PIGMENTED LESIONS

FRECKLE (EPHELIS)

A freckle or ephelis is a brown, macular lesion characterized by increased amounts of melanin in the basal cell layer of the epidermis. The pigment is derived from hyperactive melanocytes that secrete their pigment into the basal cells. The freckle is usually found on areas of skin exposed to sunlight.

LENTIGO

Lentigo is clinically similar to ephelis, but it may be found on nonexposed skin, often in older people. Lentigo is characterized by increased numbers of melanocytes, as well as hyperpigmentation of the basal cell layer of the epithelium.

Lentigo maligna (melanotic freckle of Hutchinson)

Lentigo maligna is an acquired pigmented lesion which usually occurs in adults over 50 years of age. It is a brown or black, flat lesion usually appearing on the face and sometimes involving the eyelids and conjunctiva. About one-third of all lentigo maligna undergoes malignant transformation. There is a thickening or infiltration that becomes elevated into the papular nodule (91, 92).1

NEVUS

Pigmented cellular nevi are the common pigmented moles occurring on most people. They are probably derived from the melanocyte, the pigment-producing cell. The surface may be smooth or verrucous, depending on the amount of keratin present. The moles may contain few to many hairs of varying length. Those moles with large numbers of long hairs are referred to as hairy, pigmented nevi. Colors vary from fleshcolored to tan to brown to black, depending on the amount and location of melanin and pigment in the tumor. The darker-colored tumors have pigment closer to the surface.

Junctional nevus

The junctional nevus is usually flat and well circumscribed, with a uniform brown color. The name is derived because the nevus cells are located at the junction of the epidermis and the dermis. This nevus has a low potential for malignant change.

Intradermal nevus

The intradermal nevus is generally elevated and is the most common type of nevus. It is the common mole and usually has a brown to black color when pigmented. Often, it is almost flesh-colored. The intradermal nevus frequently occurs on the eyelid margin, and the eyelid cilia grow normally through the mass. This common mole also occurs on the brow, and the brow hairs also grow right through the nevus. It is felt by most authors that this nevus has no malignant potential (103–106).2–4

Compound nevus

The compound nevus combines both junctional and dermal components. The compound nevus has a low malignant potential derived from its junctional elements (107–109).

103

106 Intradermal nevus located at, and posterior to, the gray line of the right upper lid.

107 A compound nevus in the right lower lid of a 25-year-old female. The nevus, which involved the area of the punctum, was resected.The canaliculus was reconstructed with no subsequent epiphora.

Blue nevus

A blue nevus is usually flat, but it may be a well circumscribed nodule. It is blue to slate gray to black in color. The blue-black color is due to the deep location seen through the overlying skin. The nevus may be very cellular, in which case it has a low malignant potential (110).2, 5

Congenital oculodermal melanocytosis (nevus of Ota)

Congenital oculodermal melanocytosis is a type of blue nevus of the skin around the orbit associated with an ipsilateral blue nevus of the conjunctiva and a diffuse nevus of the uvea. The condition is common in Blacks and Orientals, but rare in Caucasians. This condition is potentially malignant, especially when it occurs in Caucasians.1

Treatment

Although appearance combined with history is helpful in making a clinical diagnosis, a biopsy is usually necessary to confirm the diagnosis of a nevus. An incisional biopsy may be done if the lesion is large and only a diagnosis is desired. There is no evidence that an incision of a nevus or a malignant melanoma will lead to metastasis. Excisional biopsies may also be performed if the lesion is to be removed for cosmetic reasons, as well as for confirmation of the diagnosis.

If the lesion appears on the lid margin, it can be shaved flush with the margin and the defect allowed to granulate. The epithelium will grow over the defect, and the cosmetic result is usually excellent. If the diagnosis is that of a malignant or pre-malignant lesion, then further excision can be done. If the lesion is on the lid margin and on the skin, a full thickness pentagonal section of the eyelid margin can be performed (108, 109; 196–200). Nevi which do not involve the lid margin can be removed in the same manner as removing any other skin lesion.

Nevi are not radiation-sensitive and, therefore, surgical excision is the best method for eliminating these tumors.3

INFLAMMATIONS

Some eyelid tumors may be inflammatory in nature, but nontumorous inflammations are also important because they are included in the differential diagnosis of eyelid tumors.

BLEPHARITIS

Blepharitis refers to diffuse inflammation of the eyelids which may be acute or chronic. The etiology may be allergic or infectious.

Seborrheic blepharitis

Seborrheic blepharitis is usually a chronic condition involving the lid margins, and which is often associated with dandruff of the scalp. The lid margins are hyperemic, and there are usually yellow, greasy scales on the lashes. The meibomian glands often show secretions at each orifice, and these secretions can be expressed by massaging the eyelid.

Staphylococcal blepharitis

Staphylococcal blepharitis refers to a blepharoconjunctivitis in which the eyelids, as well as the conjunctiva, are inflamed. Staphylococcus is usually recovered when these conditions are cultured. Although the etiology of staphylococcal blepharitis is not completely understood, there seems to be some allergic factor associated with the infectious component.

Treatment

Treatment consists of eyelid hygiene to remove the scales and crusts and to allow the inspissated glands to secrete normally. Scrubbing the eyelids with warm water or with a weak solution of baby shampoo is often helpful in this regard. Antibiotic drops or ointment or combinations of antibiotics with steroids can be applied locally to help decrease the inflammation and control any infectious component. Loss of lashes (madarosis), trichiasis, and some degree of ectropion can occur in association with chronic blepharitis.

Comment

Blepharitis is usually a bilateral condition which affects all four lids to some degree (111). A blepharitis which appears to be localized to one lid or a portion of one lid should suggest the possibility of underlying malignancy. For instance, a morpheaform basal cell carcinoma may be present along the lid margin without showing any nodule formation. There simply appears to be a localized inflammation of the eyelid margin. If medication does not clear such a condition in a reasonable period of time, a full thickness eyelid biopsy is usually indicated to rule out the possibility of underlying malignancy (1–3).

HORDEOLUM External hordeolum

An acute, purulent inflammation of the superficial sweat and sebaceous glands or hair follicles results in an external hordeolum or ‘stye.’ This is usually characterized by a discrete superficial, erythematous, warm, tender papule or pustule, on or near the lid margin.

Internal hordeolum

Obstruction of the duct of the meibomian gland followed by a purulent inflammation produces an internal hordeolum. Swelling, redness, and pain occur, followed by a localized area of inflammation. A circumscribed inflammatory elevation can usually be seen on the tarsal surface of the eyelid. The inflammation can sometimes spread to adjacent tissues giving a diffuse cellulitis (112).

Treatment

Warm compresses administered several times a day will increase the blood flow and tissue temperature, allowing hydrolytic enzymes to break down the tissues and form an abscess. Since the vast majority of these inflammations are associated with staphylococcus infection, use of topical antibiotics may be helpful in eliminating the infection. If the infection spreads to a cellulitis, systemic antibiotics may be indicated in appropriate doses.

If the abscess remains localized and does not drain spontaneously, surgical intervention is indicated. With a ‘pointing’ abscess, an incision with a blade may be sufficient to initiate drainage. If the condition becomes chronic, surgical treatment, as for a chalazion, might be required.

Inflammations 41

110

110 Blue nevus in the inner canthus of the right eye of a 35-year-old female.The small lesion just below the lash line in the center of the right lower lid is a previously biopsied pigmented basal cell carcinoma.

111

CHALAZION

A chalazion is a chronic inflammation of the meibomian or Zeis sebaceous glands. It may result from an internal hordeolum which does not resolve. The chalazion may enlarge to 7–8 mm (0.3 in) in diameter as the gland fills with secretions and granulation tissue. The inflammation may remain contained in the tarsus, or break through anteriorly beneath the skin, or posteriorly on the conjunctival side (113, 114). When it breaks through on the conjunctival side, it results in a rapidly enlarging, painless, polypoid mass called a pyogenic granuloma (115). Multiple or recurrent chalazia often occur in association with chronic blepharitis.

Treatment

A small chalazion with no associated inflammation may require no treatment. If the diagnosis is in doubt, an incisional biopsy can be made to diagnose the eyelid mass. Local injection of cortical steroids has been reported to be an effective form of treatment for chalazia.6

If a chalazion does not resolve with medical treatment, surgical intervention is usually effective. After injection with local anesthetic on the skin and conjunctival side of the eyelid, a chalazion clamp is placed over the lesion. A vertical incision is made, and the contents within the cyst wall are removed with a curette. The cyst wall is then completely or partially removed to prevent recurrence of the chalazion.

To reduce bleeding, radiosurgery can be used to perform the conjunctival incision. The A-8 or the Empire needle set on ‘cut/coag’ or ‘hemo’ cuts through the conjunctiva with minimal bleeding. When the cyst wall is opened, the contents can be cleaned out with a curette such as a chalazion spoon. The Empire needle can be used to remove the epithelium from the inside of the chalazion wall by using a ‘hemo’ setting, and touching the epithelium with the side of the needle.

A bipolar cautery can be used to control bleeding. An alternative method for hemostasis is to release the chalazion clamp allowing blood flow into the wound. The clamp is then tightened for several minutes. This maneuver may be repeated a second time to allow clot formation. Antibiotic drops or ointment are placed in the eye, and the eye is patched for one day. The antibiotics can be continued several times a day for 4–5 days.

Although a conjunctival approach is usually preferred, a skin approach can be used. In this case, a skin incision is made parallel to the lid margin and at least several millimeters from the lash line. The contents of the chalazion are drained, and the cyst wall is completely or partially excised. Bleeding is controlled as described above, and the skin lesion is then repaired with small sutures such as 6-0 silk or 6-0 Prolene. If the surgeon feels that a conjunctival wound might leave a scar which would result in chronic corneal irritation, a skin incision should be considered.

Comment

All material removed in chalazion surgery should be sent to the laboratory for pathological evaluation. Although this necessitates an increased expense, most patients appreciate knowing that the lesion is not malignant. Most authors suggest sending tissue for biopsy in cases of recurrent chalazia. However, this may result in patients being treated

for recurrent chalazia for several months to over a year before a biopsy is performed, and a diagnosis of, for example, sebaceous cell carcinoma made (80). The author removed what he thought was a chalazion, but the pathology report showed malignant lymphoma.

VIRAL INFLAMMATIONS Molluscum contagiosum

Molluscum contagiosum is a viral infection which produces a hypoplastic papular lesion on the lid surface or margin. This lesion usually presents as a small, dome-shaped, discrete papule with an umbilicated center. These lesions are often multiple (116).

The molluscum bodies are enlarged cells of the stratum granulosum and spinosum, which contain the cytoplasmic inclusions. If the nodule is on the lid margin, the inclusions may be liberated into the conjunctival sac, causing a follicular conjunctivitis and keratitis. These inflammations are toxic reactions to the virus, not infectious processes.

Surgical treatment of the lesion is an excellent way to manage molluscum contagiosum. Once the papule has been surgically removed, the associated inflammation clears. If the papule is located on the lid margin, it can be shaved with a scalpel blade. If it is located on the skin, it can be excised and the skin then closed with small removable sutures such as 6-0 silk or 6-0 nylon or dissolvable sutures. Other methods of treatment have also been used effectively. These include cryosurgery, incision and curettage, and the application of chemical caustics such as liquefied phenol, silver nitrate, or trichloracetic acid. Although these lesions usually have a typical appearance, biopsy of an eyelid tumor is often appropriate to rule out the possibility of carcinoma.7

Verruca (Wart)

Verruca vulgaris and verruca plana are caused by identical or closely related viruses, and both may occur on the eyelids. Verruca vulgaris is characterized by a solid elevated growth with a papillomatous surface. Verruca plana is a smoother and flatter lesion that may be pigmented.2, 8 These tumors may be similar in appearance to papillomas which are not of viral origin (117).

Complete excision of the verruca is usually the best method of treating these lesions. This surgical excision should include the base of the lesion so that a proper diagnosis can be made. In some cases, cryotherapy at the base of the lesion can be effective in preventing recurrences.9

OTHER INFLAMMATIONS

Other inflammatory or infectious conditions may give rise to cystic or solid tumors of the eyelids. The viruses of variola (smallpox), vaccinia (cowpox), varicella (chickenpox), herpes zoster (shingles), and herpes simplex (cold sore) all have bullous, pustular eruptions of similar appearance. Impetigo, which may be caused by staphylococci or streptococci, also presents as a bullous eruption. Since these conditions have multiple eruptions and are often associated with systemic manifestations, they usually do not cause confusion in a differential diagnosis of eyelid tumors.