As in many areas of medical diagnosis, the clinician evaluating an eyelid tumor is presented with a history and a physical finding. Proper evaluation of these signs and symptoms is important in correctly diagnosing an eyelid tumor. Misjudgment at this stage can often result in a malignant process going undiagnosed and, therefore, causing further local destruction or spreading to cause systemic morbidity or even death. In this portion of the text, the various signs and symptoms of eyelid tumors are evaluated.

OCULAR DISCHARGE

The eye responds to an irritant by forming a discharge of mucus. The irritant may be an infectious agent, a foreign body, or simply a dry cornea related to exposure or lack of tear production. However, an eyelid malignancy, such as basal cell, squamous cell, or sebaceous cell carcinoma which involves the mucocutaneous junction, can act as an irritant and give rise to a constant mucoid discharge.

EYELID MARGIN INFLAMMATION

The common types of eyelid margin inflammation are blepharitis and meibomianitis. Trichiasis may or may not be associated with these inflammatory conditions. True

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blepharitis, as well as meibomianitis, will usually be bilateral. These conditions often involve the entire length of the eyelid. If a meibomianitis or loss of eyelashes is limited to one portion of one lid, a malignancy in the area of the inflammation should be considered. Basal cell carcinoma, squamous cell carcinoma, lymphoma, and sebaceous cell carcinoma can present in this way (1–3).

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1 A 64-year-old female who had been treated for chronic blepharitis for longer than one year. Although there was no obvious tumor mass, the loss of lashes and the fact that the disorder appeared to be localized to the right lower lid were factors suggesting malignancy.The blue line indicates the extent of the nodular basal cell carcinoma. Complete resection necessitated repair with a modified Hughes procedure.

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INFLAMMATORY MASS

Inflammation from the superficial glands (sweat and sebaceous) and hair follicles of the eyelids often presents as a localized swelling on or near the lid margin. This is an external hordeolum (stye) (112). An internal hordeolum results from an acute purulent inflammation of the meibomian glands within the tarsal plate. It usually presents as a diffuse, deep, tender, warm, erythematous area involving much of the eyelid.

A chronic inflammation of the meibomian glands or the glands of Zeis is referred to as a chalazion. The chalazion

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is usually less erythematous than the hordeolum or it may not be erythematous at all (113). A chalazion may spontaneously rupture or may remain quiet as a hard, painless nodule in the eyelid. If a chalazion ruptures through the tarsal conjunctiva, granulation tissue may form around it resulting in a painless polypoid mass referred to as a pyogenic granuloma. Although quite rare, a meibomian cell carcinoma may present as a chronic chalazion and must be considered when evaluating what appears to be a localized inflammatory mass. Other malignant tumors with necrotic centers can also be mistaken for chalazia (4–9).

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NONINFLAMMATORY MASS

The majority of ‘lumps and bumps’ which present on the eyelid are benign. However, the physical characteristics of these many lesions vary tremendously. The clinician must decide which ones are benign, which ones are malignant, and which treatment is appropriate for each.

Lesions with smooth skin overlying a liquid or semiliquid substance are usually cysts. A cyst may stretch the skin surface so that one sees the underlying fluid. However, the skin may be normal in appearance; therefore, the presentation may be that of a subcutaneous mass. An evaluation by ultrasound may differentiate the cyst from a solid tumor (10–13; 150).

Subcutaneous nodules appearing in the center of the upper lid may be inclusion cysts (120) or tumors such as lymphomas, neurofibromas (155, 156), or sweat gland tumors. Some of these tumors may be localized to the lid,

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Noninflammatory Mass 9

and others may continue into the orbit.

Smooth subcutaneous masses that appear in the area of the lateral brow in children are usually dermoid cysts (128, 129). However, congenital dermoid cysts may also appear in the medial aspect of the brow or in the medial canthal area.

Other firm subcutaneous masses in the medial canthal area include lacrimal sac tumors and enlarged lacrimal sacs filled with mucoid material secondary to nasolacrimal obstruction. In a patient with nasolacrimal duct obstruction, the lacrimal sac often fills with a mucoid material that cannot be expressed via the canaliculi because a valve in the area of the common canaliculus is forced shut by the fluid within the lacrimal sac. Inflammation may not be present, and the patient simply presents with a firm mass in the area of the lacrimal sac. This may be present for months without giving the patient any significant discomfort, but in some cases, the sac is so distended that there is pain involved (14).

On occasion, hard contact lenses have been retained within eyelid tissues and have become encysted.

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These unusual inclusion cysts must be considered in a differential diagnosis of smooth eyelid tumors.1

Orbital disease may present as eyelid swelling. The change may be inflammatory or noninflammatory. Dacryoadenitis and a mucus-secreting adenocarcinoma are two such examples (15–17).

Elevations of the surface epithelium may be benign or malignant (18, 19). A papilloma is an elevation on a stalk. Papillomas may be manifestations of actinic keratosis, verruca vulgaris, or seborrheic keratosis. These same skin abnormalities may also appear as flat raised areas instead of papillomas. Some skin malignancies, such as basal cell carcinoma, meibomian cell carcinoma (76), squamous cell carcinoma, and Merkel cell tumor (11), may also appear as smooth, raised areas. Umbilicated tumors may represent benign conditions, such as molluscum contagiosum, or

malignant tumors, such as basal cell (42) and squamous cell carcinomas, keratoacanthoma type (60).

Melanotic lesions can appear on the skin surface, the lid margin, or the conjunctival surface of the eyelid. They may be raised or flat. Usually, these lesions are nevi. An intradermal nevus has essentially no malignant potential. However, a junctional nevus or a compound nevus does have some malignant potential (20–23). Nevi may be amelanotic. When these lesions appear at the lash line, the cilia are usually not interrupted. If a lesion appears at the lash line with loss of cilia, the possibility of malignancy increases (24–26). An excisional biopsy can be done for diagnostic and cosmetic reasons, but an incisional biopsy is usually appropriate to rule out the possibility of malignancy or potential for malignancy.