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Eyelid lesions (eyelid lumps and bumps) are very common and can be benign or malignant. Eyelid lesions which form a little eyelid mass, are all called eyelid tumours. Biopsy is required for the definitive diagnosis as to whether they are benign or malignant. There are five main types of benign tumours and five main types of malignant tumours. There are also rarer tumours.
Benign tumours, even though benign, often require removal and therefore must be examined carefully and the differential diagnosis of a malignant eyelid tumour considered and the method of removal planned. The lesion is examined with respect to its size, shape, colour, level in the eyelid, mobility, tethering and tenderness. The peri-orbital area is examined for additional lesions.
If a malignant tumour is suspected, full medical examination is performed and the oculoplastic surgeon works together with the dermatologist, oncologist and head and neck surgeon.
1. Pigmented lesions:
The most common type of pigmented lesion is a naevus which is usually a soft brown elevated eyelid lesion, with a low potential for growth or malignant transformation. If the naevus is an intradermal type it can be removed for cosmetic reasons, but if it is a compound type (and it is difficult to tell clinically) then it should be removed because of its malignant potential. Therefore it is best to remove all pigmented lesions around the eyelids whilst they are small. A lentigo maligna is a flat pigmented lesion which is brown or black and a proportion of these undergo malignant transformation, therefore patients with this should be kept under observation and biopsies performed.
2. Benign epithelial tumours:
These are small lumps which arise from the uppermost layer of cells in the skin, such as a pedunculated skin tag, which is also known as a squamous papilloma and is very common. Some benign epithelial tumours are pre-cancerous, such as actinic keratosis or a lesion with a cutaneous horn. Seborrhoeic keratosis is another common skin lesion on the eyelids which is soft, well circumscribed, raised and either black or brown in colour and fortunately is benign. However, it can sometimes be difficult to distinguish it from other lesions and again a biopsy is recommended. Keratoacanthoma is a benign lesion in most cases but can contain parts of it which are a squamous cell carcinoma, particularly if it does not go away spontaneously over a couple of months. The treatment is surgical excision.
3. Pre-cancerous epithelial tumours:
The main pre-cancerous epithelial tumour is actinic keratosis which appears as flat scaly lesions, sometimes lightly pigmented. These can undergo transformation to squamous cell carcinoma and should be cared for vigilantly, with biopy if suspicious for malignancy.
4. Adnexal and Cystic tumours:
These include small tumours of the sebaceous glands, the sweat glands, the hair follicles etc. They have to be removed entirely either for cosmetic reasons, or because patients fear that there may be a cancer. These are very common and appear rounded and often yellow or white coloured. If they occur near the tear duct they have to be removed very carefully under magnification.
Xanthelasma are intadermal and subdermal deposits of lipid which occur in older patients and may occasionally be associated with high cholesterol. Therefore the oculoplastic surgeon will evaluate the lipid levels. They can be removed surgically or treated with Trichlor acetic acid
1. A basal cell carcinoma:
This is the most common eyelid malignancy occurring frequently on the lower lid or medial canthus and occasionally on the upper lid and lateral canthus. It is sun related and occurs with older age but younger patients are increasingly being found with small basal cell carcinomas. See basal cell carcinoma.
2. Squamous cell carcinoma:
This is the second most common eyelid tumour but is only about a tenth as frequent as a basal cell carcinoma in Europe and North America. It can either appear as a small elevated, red, ulcerated lesion or as a rapid progressing tumour which spreads. It may, if particularly aggressive, metastasise to lymph nodes in the neck. It may also grow onto the conjunctival surface of the eyelid, or indeed arise from the conjunctival surface of the eyelid, particularly in immuno compromised patients. Surgical excision is essential.
3. Sebaceous gland carcinoma:
This only forms about 1% of malignant eyelid tumours but is a serious tumour which may behave aggressively and spread. This tumour often presents as an enlarging mass and there may be a history of previous treatment for a chalazia. It is called a mimicking tumour, as it may mimmick other more benign lesions of the eyelid, such as chalazia. The oculoplastic surgeon always has a high degree of suspicion for a sebaceous cell carcinoma if a chalazion has been treated surgically but has not gone away.
4. Malignant melanoma:
This can occur on the eyelids, either primary or in a previous lentigos maligna. Biopsy should be done to confirm the diagnosis, followed by a wide exicision. More modern treatments and monitoring of spread with sentinel node biopsy are increasingly becoming available.
Lymphoma can occur on the eyelid but more commonly on the under surface of the eyelid where it is seen as a salmon coloured, soft, fleshy elevation in the conjunctival fornix of the eye. Treatment is often non-surgical.
The majority of small lumps and bumps around the eyelids are benign and can be easily removed in their entirety. However, even a benign looking lump can be a tumour masquerading as benign and the cells have to be analysed under the microscope to exclude a malignant tumour (histopathological analysis).
The treatment of eyelid lesions depends on the diagnosis which is obtained by biopsy. Benign eyelid lesions are excised in full and ocular reconstruction performed using direct closure, flaps or grafts.
Malignant tumours may require adjuvant treatment with either radiotherapy or chemotherapy after excision, depending on their diagnosis.
Surgery of eyelid lumps and bumps can frequently be done under local anaesthetic, with the surgeon assisted by magnification, in the form of surgical loops worn on spectacles, in order to place very fine stitches which are almost invisible.
The result of the histological analysis (examination of the cells) is usually available within a week.