5.3 Eyelid Tumours

1. Visual Acuity (best corrected)
2. General Inspection
3. Palpation and Examining the lesion
4. Examine for Invasion
5. Assessing for the risk of post-operative exposure keratopathy
6. Slit Lamp Examination

Eyelid tumours are common in clinical practice but are less common in exams as they usually proceed to surgery quickly after diagnosis. Eyelid tumour cases are commonly presented as data stations in clinical examinations.

The general principles of managing an eyelid tumour are to:

1. Form a differential diagnosis based on history and clinical examination
2. Determine the clinical extent of involvement:
   i. Macroscopic tumour size
   ii. Involvement of adjacent structures (e.g. Lacrimal canaliculus) or the orbit
   iii. Perineural spread
   iv. Regional lymph node spread
3. Confirm the diagnosis with an incisional biopsy + / - orbital and neuroimaging for tumour extension. Stage the patient formally with an oncologist if high-grade or regional / distant spread is suspected.
4. If localised, excise the tumour with clear margins if possible
5. Reconstruct a functionally and cosmetically acceptable eyelid

This is relevant for determining:

• The severity of any keratopathy
• Whether optic neuropathy (indicating orbital invasion) is present
• The viability of certain surgical repair options (such as prolonged surgical closure of the lids)

• General Inspection
  • Observe the patient’s skin for presence of sun damage
  • Look for scars and previous skin grafts on the patient’s face and head
  • Multiple skin cancers? (consider genetic predispositions e.g. Gorlin Goltz, Xeroderma Pigmentosa)
• Observe the eyelid
  • Madarosis (beware of patient with “chronic blepharitis” and consider a sebaceous gland carcinoma)
  • Eyelid thickening and effacement of the Meibomian glands
  • Involvement of the upper or lower canaliculus
  • Presence of ectropion or ptosis
  • Presence of dermatochalasis and loose skin keeping in mind excess skin for post-surgical reconstruction
• Observe the lesion
  • Type and character of the lesion (keratinized vs non-keratinized, pigmented vs non-pigmented, nodular vs. flat, assessing the borders, sessile or pedunculated)
  • Use the “ABCDE” approach in pigmented lesions to assess risk of melanoma: Asymmetry, Borders (regular vs. irregular), Colour (uniform vs. not uniform), Diameter (> 6mm), Evolving (size, shape, colour)
  • Size of the lesion in relation to the eyelid
  • Location (Upper vs. Lower lid, Medial vs Lateral canthus, location on the lid – medial, central, lateral thirds)

• Palpate the lesion
  • Determine the surface of the lesion (smooth, keratinized, “warty”)
  • Determine whether the lesion is tethered to the underlying muscular structures
• Transilluminate the lesion if large (cystic vs. solid)
• Flip the eyelids looking for invasion into the tarsal conjunctiva (sebaceous gland carcinoma)
• Palpate for skin laxity in considering a full thickness skin graft or a skin flap

These tests will determine whether orbital or further imaging modalities will be required.

• Orbital invasion
  • Assess for proptosis or dystopia (perform exophthalmometry if suspicious)
  • Assess for limitations in extraocular movements
  • Assess optic nerve function if the vision is reduced or there are other orbital signs
• Lymphadenopathy
  • Palpate the submandibular and preauricular lymph nodes
• Perineural Invasion
  • Assess CN VII and CN V1 and V2
  • Assess all the cranial nerves if suspicious for orbital apex or cavernous sinus involvement

See Section 5.1.6 Corneal Exposure Risk. The presence of two or more of these factors suggests at least moderate risk

1. All patients should have an incisional biopsy to confirm the diagnosis before undergoing extensive tissue removal surgery. A very small number of cases will not require a biopsy first
2. Confocal microscopy can be useful to differentiate lentigo maligna from lentigo malignant melanoma and can also map the extent of the disease
3. High risk malignant tumours (all except BCC) should have staging investigations performed prior to definitive treatment. Any indication of systemic spread warrants referral to an oncologist