Dr Babak Babsharif, Ophthalmologist, Subspeciality in Cosmetic Eye Surgeries (Oculoplastics), & Strabismus
Member of American Academy of Ophthalmology (AAO)
Member of European Society of Cataract & Refractive Surgery (ESCRS)
Certificate of Ophthalmology from International Council of Ophthalmology (ICO) Cambridge, UK
Medical Degree 1989
Board of Ophthalmology 1997
Subspeciality Degree 2006
Complementary Education in University of Texas, USA
• There are a number of lesions that can occur around the periorbital skin in a similar manner to any other part of the body, including seborrhoeic keratosis, actinic keratosis (note that 20% of cases may progress to squamous cell carcinoma), cutaneous horn formation, keratoxanthoma formation and melanocytic naevi.
• Papilloma - these very common lesions are derived from the squamous cells and may be broad-based (sessile) or narrow-based (pedunculated). Some are related to the human papillomavirus.
• Pyogenic granuloma - this is a pink, vascular, often pedunculated lesion growing out from the inside of the lid, which usually arises following surgery or trauma. If large or symptomatic, it can be excised.
• Capillary haemangioma (strawberry naevus) - this is rare (although one of the most common tumours of infancy) and, when it occurs around the eye, tends to form on the upper lid. The tumour usually grows rapidly in the first year of life before receding. If the vision is threatened (a large tumour may close the eye or dent the cornea, so giving rise to astigmatism ± amblyopia), treatment may be warranted. This may involve laser treatment, local steroid injection (there are a number of complications) or systemic steroids if there is associated visceral involvement. Only a few cases need surgical intervention.
• Basal cell carcinoma - accounts for >90% of all neoplastic eye lesions: look for the shiny, firm, pearly, umbilicated nodule. It most frequently occurs on the lower lid (followed by the medial canthus, upper lid and lateral canthus). There is a sclerosing, non-nodular type, which is less common and is difficult to diagnose, but look for an indurated plaque ± lid distortion and lash abnormalities. The latter may imitate chronic inflammation/scarring (eg chronic blepharitis). Younger patients predisposed to basal cell carcinoma include those with xeroderma pigmentosum and Gorlin-Goltz syndrome. Treatment is with wide local excision.
• Squamous cell carcinoma - this accounts for ~2-5% of lid malignancies and may arise from pre-existing actinic keratosis.The tumour tends to occur on the lower lid at the margin, commonly in fair-skinned elderly people with a history of sun exposure. It may be plaque-like (rough, scaly erythematous patch), nodular or ulcerating with a sharply defined base and everting borders. Both types may ulcerate, show lymphatic and perineural spread and metastasise. It can be aggressive: refer early if you suspect this.
• Sebaceous gland carcinoma - this is a rare (1-2% of lid malignancies), slow-growing but aggressive tumour usually affecting the elderly and commonly arising from the meibomian glands. In contrast to the previous two tumours, it tends to occur on the upper lid. It is aggressive and has a poor prognosis with an overall mortality rate of ~10% (going up to 67% at 5 years if there are metastases). A history of recurrent presumed chalazion or chronic unilateral blepharoconjunctivitis should raise suspicions. Depending on tumour extent, wide local excision, regional lymph node clearance and exentration may all be considered.
• Other tumours - other more rare tumours occurring around the lids include melanoma (<1% of eyelid neoplasms: irregular pigmentation, inflammation, bleeding), Kaposi's sarcoma (arising from HHV8, relatively common in people with AIDS - look for a vascular purple-red nodule) and Merckel's cell carcinoma (very rare tumour of the elderly, usually presenting as a non-tender purple nodule and often on the upper lid).