Ординатура / Офтальмология / Английские материалы / Moorfields Manual of Ophthalmology_Jackson_2007
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OCULOPLASTICS 1 Chapter
Fig. 1.18: Molluscum contagiosum.
Fig. 1.19: Syringomata.
Adnexal lesions
■Lesions originating from eccrine sweat glands include sudiferous cysts, which may occur as solitary or multiple lesions on the eyelids, and syringomata (Fig. 1.19) which present as multiple small pale papules on the lower lids. Manage by surgical excision or carbon dioxide laser.
■Lesions of the apocrine glands of Moll include apocrine
hidrocystoma which presents as a small fluid-filled cyst on the |
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eyelid margin (Fig. 1.20), and cylindroma, a dome-shaped |
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Benign lid lesions
Fig. 1.20: Large cyst of Moll (apocrine hidrocystoma).
Fig. 1.21: Capillary haemangioma (strawberry naevus).
pink nodule. Extensive involvement of the scalp is described as a turban tumour. Excise intact if troublesome.
■Lesions of hair follicles include trichoepithelioma, trichofolliculoma, trichilemmoma and pilomatrixoma. All require excision biopsy.
Vascular lesions
■ Capillary haemangioma : superficial ‘strawberry naevi’ (Fig. 34 1.21) are the most common, but deeper, orbital lesions can
occur (p. 92). An oscillatory decay pattern precedes complete involution within the first decade. Larger lesions may cause astigmatism and mechanical ptosis. Where there is a risk of amblyopia, treatment (p. 92) may be required.
■Naevus flammeus (‘port wine stain’): this flat red-purple vascular lesion is formed of dilated capillaries, is usually unilateral in distribution, and does not blanch with pressure (unlike a capillary naevus). In addition, it does not involute spontaneously, and is associated with other ocular and leptomeningeal vascular lesions in the Sturge-Weber syndrome (Fig. 1.22).
■Pyogenic granuloma : occurs after trauma (Fig. 1.23). Histology shows nongranulomatous inflammatory cells, fibroblasts and blood vessels. Treatment is surgical excision.
OCULOPLASTICS 1 Chapter
Fig. 1.22: Naevus flammeus associated with Sturge- |
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Weber syndrome. |
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Benign lid lesions
Fig. 1.23: Pyogenic granuloma.
Fig. 1.24: Intradermal naevus with localized lash loss (excision biopsy required).
Pigmented lesions
■Pigmented naevi : common lesions that do not require excision in the absence of atypical features such as growth, change in pigmentation, or lash loss (Fig. 1.24). Note that basal cell carcinomas may be pigmented, and melanomata may lack pigmentation.
■Naevus of Ota (oculodermal melanocytosis): see page 392.
Xanthomatous lesions
■ Xanthelasma : presents in the medial upper and lower lids in 36 middle-aged adults (Fig. 1.25), and is associated with
hyperlipidaemia in ≈50% of cases. Treatment options include surgical excision, carbon dioxide laser, and topical trichloroacetic acid.
■Juvenile xanthogranuloma : presents within the first 2 years of life with raised nodules, typically in the head and neck region, which regress spontaneously within a few years. Associated iris involvement may cause glaucoma, uveitis and spontaneous hyphaema.
Neural lesions
■Eyelid neurofibroma : may be isolated or associated with neurofibromatosis type I. Lesions may occur as a solitary fleshy mass or diffuse lid infiltration with mechanical ptosis (plexiform neuroma) (Fig. 1.26). Complete excision is difficult to achieve and recurrence is common.
Miscellaneous
■Exophytic conjunctival granuloma : a posterior lid lesion associated with chalazia or previous posterior lid surgery (Fig. 1.27). Treat with shave excision biopsy.
■Cutaneous sarcoid granuloma : May require repeated intralesional longplus short-acting steroid injection (intralesional depomedrome 40 mg/mL, and perilesional dexamethasone 5 mg/mL).
OCULOPLASTICS 1 Chapter
Fig. 1.25: Xanthelasmata. |
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Benign lid lesions
Fig. 1.26: Neurofibroma.
Fig. 1.27: Conjunctival granuloma.
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Neoplastic Lid Lesions
Background There are no pathognomonic features of neoplasia, but a careful history may identify a gradually enlarging lid lesion, crusting, bleeding, irritation, red eye, and epiphora due to mechanical ectropion, corneal irritation, or involvement of the lacrimal drainage system. A biopsy is indicated to exclude malignancy.
Premalignant disease
■Actinic keratosis : 20% of cases may progress to squamous cell carcinoma. Lesions may be widespread and a dermatology opinion may be required. Treat by excision or cryotherapy (Fig. 1.28).
■Bowen’s disease (intraepithelial neoplasia): cellular atypia is present at the level of the basement membrane, but no deeper. Progresses to squamous cell carcinoma in 2–3% of cases; most advocate complete excision unless there is limited tissue, such as around the canaliculi (Fig. 1.29). Such cases are managed by debulking and cryotherapy, with full excision in cases of malignant transformation.
■Lentigo maligna : slowly spreading macular lesion, with irregular border. Become infiltrative in 33% of cases. Complete excision is preferable, but where this is impractical, the area needs to be monitored closely, with excisional biopsy, performed on any enlarging or suspicious areas (Fig. 1.30).
Primary eyelid malignant disease
■Basal cell carcinoma BCC accounts for >90% of all neoplastic eyelid lesions, being most prevalent in fair-skinned individuals.
OCULOPLASTICS 1 Chapter
Fig. 1.28: Actinic keratosis. |
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Neoplastic lid lesions
Fig. 1.29: Bowen’s disease.
Fig. 1.30: Lentigo maligna with focal infiltrative changes.
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Subtypes are described as nodular, ulcerative, cystic, |
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sclerosing, pigmented or morphoeiform, the latter being the |
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most difficult to manage. Lesions occur most commonly on |
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the lower lid and medial canthus (Fig. 1.31), and may be |
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raised (e.g. nodular) or flat (e.g. morphoeiform). Other features |
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include destruction of the lash follicles, a raised pearly edge |
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OCULOPLASTICS 1 Chapter
Fig. 1.31: Basal cell carcinoma.
with telangiectatic vessels, ulcerated centre, cyst formation, and pigmentation.
Complete excision with minimal sacrifice of healthy tissue is achieved by Mohs’ micrographic surgery, where available. Margin control may also be achieved with frozen section or fast paraffin. Close communication with the histologist is essential. Reconstruction may entail direct closure for small margin tumours, local sliding myocutaneous flaps, and/or fullthickness skin grafting for anterior lamella defects. Posterior lamella defects may be reconstructed with local conjunctival advancement, free tarsoconjunctival graft from the upper lid, hard palate graft, and nasal mucosal or labial mucosal grafts. Very small eyelid lesions, and those in elderly, frail patients, may be managed with cryotherapy. Local radiotherapy is not useful; subsequent lesion recurrence may be as high as 20% and may be difficult to control. Chemotherapy plays no role. Distant metastases are exceptionally rare.
■Squamous cell carcinoma SCC represent ≈5 % of all eyelid malignancies. Lesions occasionally develop from preexisting areas of actinic keratosis or Bowen’s disease. Typically present as a thickened, erythematous scaly lesion (Fig. 1.32), but may
also resemble BCC. Surface keratinization may be marked. SCC is more aggressive than BCC, with ≈5% of patients
developing local periocular recurrence despite histologically |
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complete excision. |
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Excision and reconstruction principles are similar to BCC. |
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SCC has a metastatic potential; mortality is due to local |
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Neoplastic lid lesions
Fig. 1.32: Squamous cell carcinoma.
Fig. 1.33: Sebaceous gland carcinoma.
perineural spread to the CNS ( ≈2 %). The alternative to surgical excision includes cryotherapy which is good for small lesions, particularly those close to the lacrimal drainage apparatus. Radiotherapy is effective but is preferably avoided on the upper lid, because of the risk of inducing an irritable eye from keratin production on the tarsal conjunctiva, and for lesions at the medial canthus, which may extend deeply.
■Sebaceous gland carcinoma: A rare, aggressive tumour which commonly arises from the meibomian glands (Fig. 1.33). It carries a high morbidity due to local, haematogenous, and
lymphatic spread. A history of presumed recurrent chalazion or a chronic unilateral blepharoconjunctivitis should raise
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