5.3 Eyelid Tumours

Examination Outline

Introductory Comments

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

Examination Structure

1. Visual Acuity (Best Corrected)

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)

2. General Inspection

  • 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)

3. Palpation and Examining the Lesion

  • 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

4. Examine for Invasion

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
5. Assessing for the Risk of Post-operative Exposure Keratopathy

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

Investigations

  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

Blood tests

Liver function test for malignant melanoma

Imaging

  1. CT orbits without contrast for bony orbital involvement
  2. MRI orbits with gadolinium for perineural spread
  3. Neck Ultrasound for lymph node spread (more sensitive than MRI in skilled hands, and able to proceed immediately to fine needle aspiration biopsy if suspicious nodes detected)
  4. PET Scan to assess for distant metastases

Management

Treatment plans need to consider the patient as a whole. Consider the following factors which influence choice of treatment (“TAFE”).

T umour Features

  1. Includes type, location, size, growth / spread pattern
  2. State of surrounding tissues
  3. Whether primary or recurrence
  4. Any previous treatment (avoid recommending radiotherapy twice in same area)

A ge

Older patients or those with short life expectancy may be suitable for less invasive procedures with a higher recurrence risk to maximise their quality of life

F itness of patient for surgery

Tolerance of major lid reconstruction

(Other) E ye

Complex reconstructions may require occlusion of vision in the affected eye for prolonged periods which is unsuitable for patients with poor contralateral vision.

  1. Margin control
    1. Options for ensure clear margins:
        Direct excision of a clinical margin (3mm BCC, 3-5mm SCC, 5mm+ melanoma / Merkel)
      1. Intraoperative frozen section processing
      2. Rapid paraffin processing and delayed reconstruction
      3. Mohs excision (usually performed by dermatology)
    2. Consider mapping biopsies of a lesion with pagetoid spread, skip lesions, or field change (sebaceous cell carcinoma, malignant melanoma)
    3. If clear margins cannot be obtained, adjuvant therapy (radiotherapy or chemotherapy) or further surgery (including head and neck, maxillofacial, neurosurgery, ENT) needs to be considered
  2. Reconstruct the lid
    1. Consider reconstruction of the anterior and posterior lamella of the lid separately
    2. Never use a free graft for both the anterior and posterior lamella (never put a “graft on graft”)
    3. The size and location of the defect determines what kind of reconstruction is necessary (Table 1)

Small
(< 1 / 3)

UPPER LID AND LOWER LID

Direct closure

Moderate
(< 1 / 2)

UPPER LID AND LOWER LID

Direct closure (if very lax lids)
Lateral Canthotomy or Periosteal flap + skin advancement flap
Free Tarso-conjunctival graft + skin advancement flap

Large
(> 1 / 2)

UPPER LID

1. Cutler-Beard (Bridging flap)

Tarsoconjunctival Grafts + Mustarde's lid switch flap

LOWER LID

Posterior Lamellae Flap

1. Hughes Procedure + Ant lamellar graft / advancement flap
Hewes Procedure + Anterior lamellar graft

Anterior Lamellae Flap

1. Mustarde cheek rotation + posterior mucosal graft
Upper lid myocutaneous transposition flap (Tripier)
Medial forehead flap
Nasolabial flap
Lateral forehead transposition flap (Fricke)

Table 1.
Reconstruction Options for Upper or Lower Lid Full Thickness Defects, Depending on the Size of the Lesion

Figure 5.3.1 Anterior and Posterior Flap Options for the Various Locations of the Lid

  Click to zoom

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Figure 5.3.1
Anterior and Posterior Flap Options for the Various Locations of the Lid

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5.2  Entropion

          

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