Goals for Today

1. Melanosis Oculi Capillary hemangioma Xanthelasma BCC SCC Malignant Melanoma Adenocarcinoma of Meibomian Gland External Hordeolum Internal Hordeolum Chalazia Goals for Today

2. Dear Dr. G Eyes: • I love to eat. I especially love pork! Give me bacon wrapped dates. Give me honey spiraled ham. Give me pigs in a blanket. Give me bacon on a stick. El problemo is that my granddaughter is getting married in June and my wife wants me to drop 50 pounds, and have this unsightly “thing” taken off of my eyelids. • What am I suffering from? • Is it related to anything other than my eyes? • Please provide me with a detailed description of your treatment plan. • Signed: Dieting

3. Dear Dr. O Prime • I just noticed that I have this mole on the side of my face. • How can you tell if it benign or malignant? • (ABCDE, growth rate, cilia, texture..) • Signed: • Frecklie

4. Melanosis oculi • Increased pigment in uveal tract • Congenital • Differentiate from acquired (possibly malignant) melanosis

5. Types • Congenital melanosis oculi • Increased pigmentation in choroid, iris, CB, sclera, episclera • Due to increased number of melanocytes

6. Nevus of Ota (oculodermal melanosis) • Also has increased melanocytes in skin around eye • Can develop malignant melanoma

7. Characteristics of these: • Increased pigment in sclera and episclera • Increased pigment in iris • Increased pigment in fundus (choroid) • Increased pigment in skin • Management • Evaluate for uveal tract melanomas • Follow up yearly

8. Developmental Vascular Lesions Capillary Hemangioma (Strawberry Mark) • Congenital or presenting very shortly after birth • 1/3 present at birth • virtually all within 6 months • Very common (most common hemangioma) • 1/200 live births

9. Appearance/Progression • Variable course can increase in size • Usually spontaneously regress completely (most regression by age 5) • Produce flat reddish or pink lobulated lesion in skin • Color can change with venous return -straining, crying, lifting (Valsalva maneuvers) can cause redder appearance

10. Types • Capillary - most common • Flat, superficial • Congenital, early onset • Cavernous • Deeper, raised slightly • Later onset • "Spider" angioma • Not congenital

11. Racemose • Grape-like vessel clusters • "Port wine stain“ • Hemangioma on one side of face • In Sturge-Weber syndrome

12. Evaluation • Slit lamp exam • Slight pressure - easily blanches, rules out nevus, melanoma • Look for other congenital anomalies

13. Management • Photodocumentation helpful • Re-evaluate 3-6 months • Refer to dermatologist if cosmetically unappealing to patient (laser therapy is quite effective), however, remember they usually regress spontaneously, but not after adolescence • If present after adolescence recommend dermatology referral for laser therapy

14. XANTHELASMA • Common, slowly progressive skin growth • Develops in 4th and 5th decade • Variable connection with blood lipid abnormalities • Manifestation of a genetic dyslipidemia • Type IIa: elevated LDL, total cholesterol • Type IIb: elevated LDL, elevated VLDL, elevated total cholesterol

15. 50% of patients with xanthelasma have “normal total cholesterol” but LDL is abnormally high, HDL is extremely low • Longevity studies show that xanthelasma with or without hypercholesterolemia is a risk for atherosclerosis-induced mortality

16. Signs and Symptoms • Elevated yellowish discoloration of skin • Seen bilaterally on medial aspect of upper lid • Plaque-like, with a slightly granulated surface • Asymptomatic, benign, of cosmetic concern

17. Treatment • Reassurance that lesion is benign and non-cancerous • Referral for removal only for cosmetic reasons • Surgery • Electrocoagulation • Chemical cauterization (Bichloracetic Acid)

18. Basal cell carcinoma (BCC)Malignant Neoplasms of the Lid • Most common malignant neoplasm of the lids (~90% of all) • Much more common than squamous cell carcinoma • Slowly growing lesion, takes months to double in size • Usually in area of chronic exposure to sun - lid is not really common compared to other areas of exposed skin

20. Profile of most susceptible to BCC • Elderly (~80% > 50 y/o); average age ~ 65 • Usually male (due to more likely long-term chronic outdoor work than females) • Usually light complexion • Red and blonde hair have significantly higher risk • Albinos increased risk (rare in blacks and asians) • Higher incidence in areas of previous trauma, burns, physical trauma, or X-ray exposure • Controversial link to irritation caused by spectacles

21. Location of BCC • Lower lid most common (~60% of all BCC located on lids) • Medial canthus; upper lid

22. Appearance • Starts as small translucent, waxy, greyish-white nodule • Classically the center slowly ulcerates with an increase in size - tends to have darkened, ulcerated center ("rodent ulcer") • Borders tend to be smooth, pearly white with fine telangiectatic vessels • May have ulcerated center with time

24. Symptoms • Symptoms: "lump" or "growth" that "doesn't go away" or "does not heal." Chances are that it will have been there for a long time average 4 years, so long duration does not indicate benign nature. (Remember BCC - slow growth) • Slow increase in size • Does not usually metastasize • If metastasis occurs (unlikely) it will be the regional lymph node first - palpate preauricular and submandibular nodes for swelling and tenderness

25. Key points in evaluation • History • Long term growth on lid (usually lower lid) that won't go away; looks like it is bleeding • "Won't heal," etc. • History of previous damage to area • History of other growths (~60% of lid BCC accompanied by another BCC elsewhere)

26. What to evaluate? • Gross observation, palpation of lesion • Palpation of regional lymph nodes (though it spreads by direct extension, not metastasis) • Careful slit lamp examination • Look for other BCC's • If single BCC has occurred, 10-20% chance of a second within 1 year; after 2 BCC's have occurred 40% chance of another < 1 year • On trunk or back BCC may appear as an erythematous plaque

27. Management • If in medial canthal region consider consultation with oculoplastics specialist ASAP - more likely to directly extend intracranially without apparent nature when grossly observing the lesion

28. Unsure of suspicious lesion • Refer to ophthalmologist (and dermatologist) for biopsy • Consider dermatology referral - they are much more effective at picking up the other BCC's elsewhere • Surgery excision by Moh's technique, reconstruction by oculoplastic surgeon. Radiation; cryo, conventional surgery also effective

29. Legal aspects • If patient refuses biopsy - again recommend it and document in charts - document potential outcome if untreated • Worst case blindness and/or death (rare) • At least take photos and close follow-up every 3 months • If apparent growth referral • Ophthalmology • Dermatology

30. Post-op management • Careful q 3-6 months follow up by dermatologist for re-growth (recurrence rate 10-20%) and other BCC • O.D. should carefully evaluate any patient with history of BCC • Long term management • Annual exams

31. Squamous cell carcinoma (SCC) • Much, much less common than BCC • Much more rapid growth and can METASTASIZE • Profile of susceptible individual • Elderly, average age at diagnosis ~ 70 • Much exposure to sun • Exposure to irritants, chemicals or trauma - radiation, sunlight, thermal burns, chronic heat and/or irritations, organic hydrocarbons • Fair skinned most susceptible

32. Location • No typical location • Often arises from existing actinic keratosis • Can arise from cutaneous horn

33. Appearance • Various appearance - none is classic for SCC • Can be raised nodule; flat crusty area; flat scaly area; ulcerated bleeding lesion, etc. • Can be very keratotic with build up of keratin into a cutaneous horn • Numerous benign growths look like it (particularly keratoacanthoma)

34. Differential diagnosis • BCC • Actinic keratosis • Keratoacanthoma • Seborrheic keratosis

35. Management • If SCC is suspected - must refer for excisional biopsy (only definitive method). Refer now and assure compliance • Clinical evaluation is at best only ~50% correct for diagnosis of SCC - excisional biopsy is only definitive test for SCC and SCC has many appearances so great deal of suspicion is needed to detect early

36. Surgical management • Excisional biopsy if positive for SCC - Moh's technique - further excision of borders until free • Referral • Dermatology • Oculoplastics specialist

37. Follow up after surgery • Recurrence rate of previously excised lesion is higher than BCC (which is very low approx. 10%) - must carefully follow after surgery for recurrence

38. Medicolegal aspects - if patient refuses referral • Carefully explain it may be cancer, can be treated, must get opinion ASAP • Explain potential risk, blindness and/or death • Make the appointment yourself, hand information (written) to patient • Document your counseling (and info. given to patient) in the chart • Send registered, return receipt requested letter if does not keep appointment

39. Malignant Melanoma • Most malignant skin tumor (70% of all deaths due to skin cancer) • Rarely on lids • High rate of metastasis compared to other malignancies • Can metastasize in early stages • Early detection and treatment is critical • Dramatic increase in the past few years • Much less frequent than BCC and SCC but much greater mortality rate

40. Profile of susceptible patient • Those with high amount of sun exposure • Classically elderly but greatly increasing numbers of middle aged or young now get these • Those with fair skin, burn easily • Red hair 3x the risk (due to fair skin) • Family history important

41. Hutchison's freckle/lentigo malignant melanoma • Hutchison freckle is a precursor - flat, roughly circular skin discoloration • About 5% of all melanomas • Large > 3 cm flat • Usually in elderly • Tan to dark brown to black • Slowly progressive lesion - darker, larger, more elevated • Usually in sun-damaged skin of elderly • Local excision usually successful. Least aggressive melanoma

43. Superficial spreading melanoma • Most common of all melanomas - 70% of all melanomas • Flat to slightly elevated • Arises from pre-existing nevus • Irregular border, sharply defined borders • May have light halo • Regression of tumor in one area gives notched appearance • Has a pre-existing lesion, starts superficial then after 1-7 years - good prognosis if removed while superficial

45. Nodular malignant • Usually in elderly • About 15% of all melanomas in U.S. • Often from uninvolved area - no pre-existing lesion • Elevated, dark colored, sharply demarcated • Dark brown, red brown, red black • Possibly misdiagnosed as blood blister, hemangioma • Metastasizes early - poor prognosis • Most important factor is change over time - if patient complains of change in nevus looking growth - dermatology consult now

47. Adenocarcinoma of Meibomian Gland • Adenocarcinoma of meibomian glands (a sebaceous gland carcinoma in meibomian gland) • Very rare • Arises from meibomian glands • Very invasive and can rapidly invade the orbit • Also relatively likely metastasis as much as • 1/3 have metastasis

48. Management/recognition • Can mimic chalazion (BCC) • An enlarging chalazion - refer (for excision-biopsy) • Recurrent chalazion - refer (for excision-biopsy)

49. Considerations for recognition of malignant growths • 1. Fair skin patients, patients who easily burn • 2. Patients with excessive sun exposure due to job, recreation, etc. • 3. Middle aged and elderly • 4. Personal history of skin cancer • 5. Family history of skin cancer • 6. History of malignancies elsewhere

50. 7. Rapid growth of lesion (growth of what has been a quiescent lesion) • 8. Ulceration of center of lesion/erosion at the margins of lesion • 9. Bleeding from lesion which has not been traumatized • 10. Pain/irritation at site of lesion • 11. Recurrent inflammations or irritation at the site • 12. Unpredictable changes/irregular changes