2020–2021 BCSC Basic and Clinical Science Course™
7 Oculofacial Plastic and Orbital Surgery
Part II: Periocular Soft Tissues
Chapter 10: Classification of Eyelid Disorders
Benign Adnexal Lesions
In this context, the term adnexa refers to skin appendages that are located within the dermis but communicate through the epidermis to the surface. They include oil glands, sweat glands, and hair follicles. The eyelids contain both the specialized eyelashes and the normal vellus hairs found on skin throughout the body. Periocular adnexal oil glands include
the meibomian glands within the tarsal plate
the glands of Zeis, associated with eyelash follicles
normal sebaceous glands that are present as part of the pilosebaceous units in the skin hair
Sweat glands in the periocular region include the eccrine sweat glands, which have a general distribution throughout the body and are responsible for thermal regulation, and the ciliary glands with apocrine secretion (the glands of Moll), which are located in the eyelid margin.
Lesions of oil gland origin
Chalazion and hordeolum
These common eyelid lesions are discussed earlier in this chapter in the section Acquired Eyelid Disorders.
Sebaceous gland hyperplasia presents as multiple small yellow papules that may have central umbilication (Fig 10-29). They tend to occur on the forehead and cheeks and are common in patients older than 40 years. These lesions are sometimes mistaken for basal cell carcinoma because they may have central umbilication and fine telangiectasias. Patients with multiple acquired sebaceous gland adenomas, adenomatoid sebaceous hyperplasia, or basal cell carcinomas with sebaceous differentiation have an increased incidence of visceral malignancy (Muir-Torre syndrome [MTS]) and should be evaluated accordingly.
This rare tumor appears as a yellowish papule on the face, scalp, or trunk and may mimic a basal cell carcinoma or seborrheic keratosis. As noted above, sebaceous adenoma may be associated with MTS.
Tumors of eccrine sweat gland origin
Eccrine hidrocystomas are common cystic lesions 1–3 mm in diameter that occur in groups and tend to cluster around the lower eyelids and canthi and on the face. They are considered to be ductal retention cysts, and they often enlarge in conditions such as heat and increased humidity, which stimulate perspiration. Treatment consists of surgical excision.
Figure 10-29 Sebaceous hyperplasia of the right lower eyelid.
(Courtesy of Cat N. Burkat, MD.)
Figure 10-30 Syringomas.
(Courtesy of Robert C. Kersten, MD.)
Benign eccrine sweat gland tumors found commonly in young females, syringomas present as multiple small, waxy, elevated nodules 1–2 mm in diameter on the lower eyelids (Fig 10-30). Syringomas can also be found in the axilla and sternal region. They become more apparent during puberty. Because the eccrine glands are located within the dermis, these lesions are too deep to allow shave excision. Removal requires complete surgical excision.
A less common variant, chondroid syringoma, occurs most commonly in middle-aged men and can enlarge to 3 cm. It is composed of sweat gland components within a mixed cartilaginous stroma.
This rare benign tumor occurs most commonly in the head and neck region and may involve the eyelids (Fig 10-31). Histologically, the tumor is identical to pleomorphic adenoma of the salivary and lacrimal glands (discussed in Chapter 5). Treatment is complete surgical excision.
Figure 10-31 Pleomorphic adenoma (benign mixed tumor) of the left eyebrow.
(Courtesy of Bobby S. Korn, MD, PhD.)
Tumors of apocrine sweat gland origin
A very common, smooth cyst arising from the glands of Moll along the eyelid margin, apocrine hidrocystoma is considered to be an adenoma of the secretory cells of Moll rather than a retention cyst (Fig 10-32). These lesions are typically translucent or bluish, and they transilluminate. They may be multiple and often extend deep beneath the surface, especially in the canthal regions. Treatment for superficial cysts is marsupialization. Deep cysts require complete excision of the cyst wall.
Cylindromas (eccrine spiradenomas) are rare tumors that can be solitary or multiple and may be dominantly inherited. Lesions are dome-shaped, smooth, flesh-colored nodules of varying size that tend to affect the scalp and face (Fig 10-33). They may occur so profusely in the scalp that it is entirely covered with lesions, in which case they are called turban tumors. Treatment is surgical excision, which may be difficult if multiple lesions involve a large surface area.
Tumors of hair follicle origin
Several rare benign lesions may arise from the eyelashes, eyebrows, or vellus hairs in the periocular region.
These lesions are small, flesh-colored papules with occasional telangiectasias that occur on the eyelids (Fig 10-34) or forehead. Histologically, trichoepitheliomas appear as basaloid islands and keratin cysts with immature hair follicle structures. If keratin is abundant, these lesions may clinically resemble an epidermal inclusion cyst. The individual histologic picture may be difficult to differentiate from that of basal cell carcinoma. Simple excision is curative.
A trichofolliculoma is a single, sometimes umbilicated lesion found mainly in adults. Histologically, it represents a squamous cystic structure containing keratin and hair shaft components (Fig 10-35).
Figure 10-32 Apocrine hidrocystoma of the right lower eyelid.
(Courtesy of Cat N. Burkat, MD.)
Figure 10-33 Cylindroma (eccrine spiradenoma) of the left lower eyelid.
(Courtesy of Stephen R. Klapper, MD.)
Figure 10-34 Trichoepithelioma.
(Courtesy of Jeffrey A. Nerad, MD.)
Figure 10-35 Trichofolliculoma of the right upper eyelid.
(Courtesy of Cat N. Burkat, MD.)
Another type of solitary lesion that occurs predominantly in adults, trichilemmomas resemble verrucae. Histologically, they show glycogen-rich cells oriented around hair follicles.
Also known as pilomatrixoma, this lesion most often affects children and young adults. It usually occurs in the eyebrow and central upper eyelid as a nontender, reddish purple subcutaneous mass attached to the overlying skin (Fig 10-36). Pilomatricomas may become quite large, measuring up to 5 cm or more. The tumor is composed of islands of epithelial cells surrounded by basophilic cells with shadow cells. Multiple lesions or familial cases may be associated with Gardner syndrome, familial adenomatous polyposis, Turner syndrome, myotonic dystrophy, and Rubinstein-Taybi syndrome. Excision is usually curative, and recurrence is rare.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.