Numerous benign and malignant cutaneous neoplasms can develop in the periocular skin, arising from the epidermis, dermis, or eyelid adnexal structures. Most lesions, whether benign or malignant, develop from the epidermis, the rapidly growing superficial layer of the skin. Although many of these lesions also occur elsewhere on the body, their appearance and behavior in the eyelids may be unique owing to the particular characteristics of eyelid skin and the specialized adnexal elements. The malignant lesions that most frequently affect the eyelids are basal cell carcinoma, squamous cell carcinoma, sebaceous cell carcinoma, and melanoma. Histologic examination of suspected cutaneous malignancies is recommended.
Clinical Evaluation of Eyelid Tumors
The history and physical examination of eyelid lesions offer important clues regarding the likelihood of malignancy. Predisposing factors in the development of skin cancer include
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a history of prior skin cancer
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excessive sun exposure, especially blistering sunburn
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previous radiation therapy
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a history of smoking
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Celtic or Scandinavian ancestry, with fair skin, red hair, and blue eyes
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immunosuppression
Signs suggesting malignancy are
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ulceration or chronic, nonhealing lesion
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bleeding, crusting, drainage
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destruction of normal eyelid margin architecture (especially meibomian orifices)
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loss of cilia (madarosis)
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heaped-up, pearly, translucent margins with central ulceration
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fine telangiectasias
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pigmentary changes
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loss of fine cutaneous wrinkles or vellus hair
Lesions near the puncta should be evaluated for punctal or canalicular involvement. Probing and irrigation may be required to exclude lacrimal system involvement or to prepare for surgical reconstruction.
Palpable induration extending beyond visibly apparent margins suggests tumor infiltration into the dermis and subcutaneous tissue. Large lesions should be assessed for evidence of fixation to deeper tissues or bone. In addition, regional lymph nodes should be palpated for evidence of metastases in cases of suspected squamous cell carcinoma, sebaceous cell carcinoma, melanoma, or Merkel cell carcinoma. Lymphatic tumor spread may produce rubbery swelling along the jawline or in front of the ear. Restriction of ocular motility and proptosis suggest orbital extension. Assessment of the function of cranial nerves V and VII can reveal deficiencies that may indicate perineural tumor spread. Perineural invasion is a characteristic of squamous cell carcinoma. Systemic evidence of liver, pulmonary, bone, or neurologic involvement should be sought in cases of sebaceous adenocarcinoma or melanoma of the eyelid. It is important to obtain photographs and measurements prior to treatment of the lesion.
For more extensive coverage, including additional clinical and pathology photographs, see BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors.
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de la Garza AG, Kersten RC, Carter KD. Evaluation and treatment of benign eyelid lesions. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 2010, module 5.
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.