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Growths on the eyelid are very common. Probably the most common oculoplastic consultation I see is to evaluate a growth on the eyelid. They can be single or multiple and involve one or more of the eyelids. Multiple growths tend to be benign. Single growths raise more suspicion. Fortunately, benign eyelid growths tend to be more common, especially in the younger patient (Figures 12 & 13).
What should I do if I notice a growth on my eyelid?
It is best to have an ophthalmologist (MD) or oculoplastic specialist evaluate any eyelid growth. These physicians can best examine your eyelids under magnification to better define the problem. A complete history is very important in deciding how to treat these lesions (Figure 14). Some growths are treated with observation, antibiotics or biopsy (see below). One of the most common infections in the eyelid is a chalazion. People often mistake a chalazion for a “stye”. Initial treatment is with warm compresses and antibiotics.
Some chalazions will eventually need to be surgically removed.
What historical information and physical findings are important for evaluation?
1. Your eye physician will want to know if any infection preceded the growth. Some eyelid
infections will persist as cysts once treated.
2. The length of time that the growth has been present is important.
3. Is pain present? Does it hurt to touch the growth?
4. Has there been growth- and over what period of time? (Figure 15)
5. Has the growth ever ulcerated and bled?
6. Did you or do you spend a lot of time in the sun?
7. Have you ever had any growths like this in the past?
8. Are your eyelashes missing?
9. Does the growth have irregular margins and irregular shapes? Remember that malignancies tend to destroy normal tissue
10. Are there any color changes?
Based on the history and physical examination, if your eye physician is suspicious that the growth may be malignant, a biopsy will be suggested. In general benign growths have a uniform color with regular shapes and borders. Most pigmented growths are benign such as a nevus (commonly called a mole). Making sure a lid growth is not a malignancy is the main goal of the evaluation. Biopsies can be either incisional (removing a portion of the tumor) or excisional (removing the entire tumor). Some patients will frequently ask, “why not just remove the entire growth if you suspect it may be malignant”? The reason is that if the biopsy confirms malignancy, the surgical resection needs to be more extensive to insure complete removal. If it is benign, why remove unnecessary healthy tissue? In addition, there a number of surgical options and techniques available that needs to be discussed.
If a malignancy is determined by biopsy, what are my options?
Further surgery is definitely indicated. Almost all forms of eyelid skin cancer can be cured by complete removal. The most common form of eyelid skin cancer is a basal cell carcinoma (Figure 16). Basal cell carcinomas comprise more than 90% of malignant eyelid growths. These are caused by excessive exposure to sunlight and are usually seen after the age of sixty. I have, however, been seeing these cancers in younger patients in there forties and fifties. They tend to be more common in lighter skinned individuals with light skin and blue eyes. The second most common type of eyelid skin cancer is a squamous cell carcinoma (less than 5%). Squamous cell carcinoma is a more serious form because it can spread to distant sites and metastasize. A premalignant lesion called actinic keratosis occurs on sun damaged areas. Actinic keratosis can be a precursor to squamous cell carcinoma or a basal cell carcinoma. Actinic keratosis usually feels gritty to touch on the skin. Actinic keratosis needs to be treated. This is usually done by a dermatologist (doctor who specializes in the skin). Basal cell carcinomas tend only to spread locally. However, basal cell carcinomas if left untreated can spread behind the eye and to the brain. Another less commonly seen malignant eyelid tumor is a meibomian gland or sebaceous cell carcinoma. This can be a very dangerous malignancy resulting in distant
spread and death. Meibomian gland carcinoma often will masquerade as different eyelid growths. A high index of suspicion is necessary for making this diagnosis. A full thickness
eyelid biopsy (which involves all layers of the eyelid) is the only way with special fat stains. Alerting the pathologist (the doctor who examines the biopsy) to this possibility is very important. I am also very suspicious of pigmented growths of the eyelid (Figure 17). Because I am worried about a deadly cancer called malignant melanoma, I do not hesitate to biopsy pigmented lesions. Fortunately most pigmented growths are not melanomas. Remember that any skin growth may be pigmented.
After the biopsy returns as positive, I usually have an extensive discussion with my patients regarding their options. One thing is for certain. Further surgery with complete excision is now indicated and is the goal. The diagnosis will determine how much further tissue needs to be removed. In surgical lingo, this is know as “margin control”.
The first option to consider is a technique called Moh’s chemosurgery. This is performed by a specially trained dermatologist. The Moh’s surgeon carefully removes the entire tumor trying to preserve as much normal tissue as possible (Figure 18). In conjunction with the Moh’s surgeon, an oculoplastic surgeon will then do the eyelid reconstruction. That is, the plastic surgery to repair the defect created by the tumor removal.
The other method to consider is called frozen section controlled removal of the malignancy. This technique involves removing the main specimen and then taking pieces around the defect and examining to see if any tumor remains. Surgery continues until all tissue is free of tumor. Reconstruction proceeds as described for Moh’s surgery.
The literature states that with Moh’s surgery the cure rate is between 95%-98% for most basal cell carcinomas and between 95%-96% for excision with frozen section control.
It is the oculoplastic surgeon who is skilled in repairing all eyelid defects and restoring the eyelid back to a normal function and acceptable appearance. I always tell patients that there are three goals in malignant eyelid tumor surgery in this order. First, we need to get the entire tumor out to insure a low recurrence rate. Second, my job as an oculoplastic surgeon is to make the eyelid function again. It must be remembered that both the upper and lower eyelids serve a very important function in protecting the eye. And third, I use all my skills to make the eyelid appear as normal as possible. Sometimes with large defects this is not always possible. The final result can take up to six months before the eyelid reconstruction is fully healed.
Eyelid tumors can occur in children at any age and are handled in a similar manner. It is somewhat more difficult because removal usually necessitates a general anesthetic.