Ординатура / Офтальмология / Английские материалы / Rapid Diagnosis in Ophthalmology Series Oculoplastic and Reconstructive Surgery_Nerad, Carter, Alford_2008

Fig. 2.14 Elevated nevus of the left upper eyelid in a middle-aged patient. Note no loss of eyelid margin architecture.

Fig. 2.15 Nevus of the left upper eyelid. Note lashes growing through the nevus and spreading individual lashes apart.

Nevus

Lesions• 2 SECTIONEyelid: the of Disorders

Actinic Keratosis

Key Facts

•Most common precancerous skin lesion

•Associated with chronic sun exposure

•More common in patients with light complexion

Clinical Findings

•Lesions are scaly hyperkeratotic plaques that may flake off and reappear

•Lesions can arise on any sun-exposed skin

•Common locations:

• face • neck • forearms • ears • hands

Ancillary Testing

• Excisional biopsy

Differential Diagnosis

•Seborrheic keratosis

•Early squamous cell carcinoma appears hyperkeratotic

Treatment

•Simple excisional biopsy is a typical treatment in periocular area

•Treatment away from the periocular region usually consists of liquid nitrogen application

•Alternative treatments, especially for numerous lesions, include topical 5-flurouracil or chemical peeling

•Sunscreen recommended

Prognosis

•Excellent

•Low malignant potential

•With proper treatment, risk of progression to squamous cell carcinoma is quite low

•Other actinic lesions (e.g. basal cell carcinoma or squamous cell carcinoma) should be screened for in these patients

Fig. 2.16 Scaly plaque-like lesion on left lower eyelid.

Keratosis Actinic

Lesions• 2 SECTIONEyelid: the of Disorders

Keratoacanthoma

Key Facts

•Rapidly developing lesion (weeks)

•Affects middle-aged to older patients

•Cause unknown, possibly trauma or sunlight exposure

•Historically was thought of as a benign lesion

•May represent low-grade squamous cell carcinoma

Clinical Findings

•Rapidly growing lesion with central crater filled with keratin and with rounded margins (Fig. 2.17)

•Usually located on lower eyelid (Fig. 2.18)

•Lesions said to spontaneously involute

• Surgical removal usually performed before allowing involution

Ancillary Testing

• None

Differential Diagnosis

•Basal cell carcinoma

•Squamous cell carcinoma

Treatment

•Excision of lesion

•Send to pathology for definitive diagnosis

Prognosis

• Excellent—recurrences are rare

Lesions• 2 SECTIONEyelid: the of Disorders

Lentigo Maligna

Key Facts

•Also called Hutchinson melanotic freckle

•Lesion has varied pigmentation and irregular borders

•Progressive growth can lead to melanoma

Clinical Findings

•Presents as flat, pigmented lesion with irregular border (Fig. 2.19)

•Periocular area is common location

•Seen in older patients

•Can extend on to conjunctiva and appear as primary acquired melanosis

•Progressive growth with increasing pigmentation

•30–50% of these lesion will progress to invasive melanoma

•Malignant transformation should be suspected:

•when there are significant changes in pigmentation, borders, or thickness

•if associated with bleeding (see Cutaneous melanoma)

Ancillary Testing

• None

Differential Diagnosis

•Solar lentigo

•Lentigo simplex

•Melanoma

Treatment

•Punch biopsy for diagnosis

•Excision of lesion with controlled tissue margins (Fig. 2.20)

•Monitor patient for recurrent lesion

•Sunscreen recommended

Prognosis

•Good

•May recur

•Fewer than half of these lesions progress to melanoma

•Melanoma arising from lentigo maligna is more difficult to treat, because of diffuse spread of malignant cells

Lesions• 2 SECTIONEyelid: the of Disorders

Basal Cell Carcinoma

Key Facts

•Most common cutaneous malignancy

•Caused by ultraviolet radiation in susceptible persons

•Common in light-skinned populations

•Early diagnosis important

•Treatment by complete surgical excision

Clinical Findings

•Sun-exposed regions of lower eyelid and medial canthus are most common locations

•Characteristic findings include (Fig. 2.21):

•irregular margins

•rolled pearly margins (Fig. 2.21A)

•central ulceration

•telangiectasia

•loss of eyelid margin architecture, including eyelash loss (Fig. 2.21B)

•Several subtypes exist

•The nodular subtype is the most common (see Fig. 2.22A)

A

B

Fig. 2.21 (A) Typical nodular basal cell carcinoma with raised rolled pearly margins and central ulceration.

(B) More destructive basal cell carcinoma with loss of lid margin architecture.

A

B

Fig. 2.22 (A) Nodular subtype: clinical margins are easy to see. (B) Morpheaform subtype, with non-distinct margins typically requiring a resection larger than predicted to clear the margins.

Carcinoma Cell Basal

Lesions• 2 SECTIONEyelid: the of Disorders

Basal Cell Carcinoma (Continued)

•Morpheaform, cystic, and pigmented subtypes also exist

•The morpheaform subtype is the most aggressive and most difficult to diagnose (see Fig. 2.22B)

•Basal cell nevus syndrome (Gorlin syndrome) is a very rare autosomal dominantly inherited syndrome associated with multiple basal cell carcinomas

•Dental cysts, skeletal abnormalities, palmar pits, and nail abnormalities may accompany

Ancillary Testing

•Incisional biopsy when malignancy suspected

•If signs of orbital extension suspected on clinical examination, CT or MRI is indicated

Differential Diagnosis

• Benign cutaneous lesions do not show the features of malignancy outlined above

•Other cutaneous malignancies, especially squamous cell carcinoma, can be confused with basal cell carcinoma

•Characteristically, squamous cell carcinoma shows hyperkeratosis, whereas basal cell carcinoma does not

•If any uncertainty exists regarding whether a lesion is benign or malignant, an incisional biopsy should be performed (see Fig. 2.23)

Treatment

•Use of sunscreen and sunglasses and avoidance of sun exposure are helpful preventive measures, especially in childhood

•Excisional biopsy is the standard treatment

•Confirm free margins with frozen or permanent sections before reconstruction

•Mohs surgery is a useful technique, especially for:

•morpheaform subtypes

•canthal lesions

•recurrent tumors

•Most reconstructions offer normal or near normal function and cosmesis

•Topical 5-fluorouracil or the immunostimulant, imiquimod (Aldara), may be useful for superficial tumors, especially when numerous lesions are present

•Radiation therapy can be used as a palliative adjunct in extensive or recurrent cases

Prognosis

•Surgical cure rate is >95%

• Metastases do not occur

•Neglected tumors can grow to large size and extend into orbit

•Canthal lesions tend to have higher recurrent rate

•Patients should be observed for ≥5 years before a cure is recognized