Eyelids Flashcards
What layers do the epidermis consist of?
Keratin Layer: Stratum corneum (horny layer) consists of flat cells devoid of nuclei
Granular cell layer (stratum granulosum) typically consists of 1-2 layers of flattened cells containing keratohyaline granules.
Prickle cell layer (stratum spinosum) is approximately
five cells deep. The cells are polygonal in cross-section and have abundant eosinophilic cytoplasm. Free borders have desmosomes
Basal cell layer (stratum basale) comprises a single row of columnar-shaped proliferating cells containing melanin derived from adjacent melanocytes.
Where are sebacious glands found?
located in the caruncle and within eyebrow hairs. Tiny sebaceous glands are associated with the
thin (vellus) hairs covering periocular skin.
Where are Meibomian glands found?
modified sebaceous glands found in the tarsal plates. They empty through a single row of 20–30 orifices on each lid.
Where are Glands of Zeis found?
modified sebaceous glands associated with lash follicles.
Where are Glands of Moll found?
modified apocrine sweat glands opening either into a lash follicle or directly onto the anterior lid margin between lashes. They are more numerous in the lower
lid.
Where are eccrine sweat glands found?
distributed throughout eyelid skin and are not confined to the lid margin, in contrast to glands of Moll.
What are pilosebacious units composed of?
comprise hair follicles and their sebaceous glands
What is an incisional biopsy
involves removal of a portion of a lesion for histopathology.
What is an excisional biopsy?
performed on small tumours and fulfils both diagnostic and treatment objectives.
What is Marsupialization?
involves the removal of the top of a cyst allowing drainage of its contents and subsequent epithelialization.
What is a chalazion?
a sterile chronic granulomatous inflammatory
lesion (lipogranuloma) of the meibomian, or sometimes Zeis, glands caused by retained sebaceous secretions.
What does chalazion histopathology show?
shows a lipogranulomatous chronic inflammatory picture with extracellular fat deposits surrounded by lipid-laden epithelioid cells, multinucleated giant cells and lymphocytes
Which drug predisposes the formation of chalazia within 3 months of initiation of treatment.
Bortezomib, a proteasome inhibitor used in the treatment of multiple myeloma,
How to manage Chalazia?
Oral antibiotics- for significant bacterial infection
Conservative- 1/3rd resolve spontaneously
Hot compress
Expression (between 2 sterile cotton buds)
Steroid injections shown to be equivocal resolution rates to I&C
If surgical approach with curretage, topical antibiotic 3x/day for 5 days should be used.
Marginal lesions managed by steroid injection or curretage of deeper chalazion, by I&C via horizontal incision on conj surface or through grey line
What is cyst of Zeis?
a small, non-translucent cyst on the anterior lid
margin arising from obstructed sebaceous glands associated with the eyelash follicle
What is cyst of Moll?
(apocrine hidrocystoma) is a small retention
cyst of the lid margin apocrine glands. It appears as a round, non-tender, translucent fluid-filled lesion on the anterior lid margin
What are comedones?
plugs of keratin and sebum within the dilated
orifice of hair follicles that often occur in patients with acne vulgaris. They may be either open (blackheads), containing a darkened plug of oxidized material or closed (whiteheads).
What are milia?
caused by occlusion of pilosebaceous units resulting
in retention of keratin. They are tiny, white, round, superficial papules that tend to occur in crops
What is an epidermoid cyst?
uncommon and usually developmental,
occurring along embryonic lines of closure. It is similar in
appearance to an epidermal inclusion cyst.
What is a dermoid cyst?
usually subcutaneous or deeper and is typically attached to the periosteum at the lateral end of the brow. It is caused by skin sequestered during embryonic development.
What is Xanthelasma?
yellowish subcutaneous plaques, usually in the
medial aspects of the eyelids, commonly bilateral and
are multiple
Chalazion vs Xanthelasma histology?
fat in xanthelasmata is mainly intracellular, with lipid-laden histiocytes (foam cells) in the dermis
Treatment for Xanthelasma?
principally for cosmesis. Recurrence occurs in up to 50% and is most common in patients with hypercholesterolaemia.
*Simple excision is commonly performed where adequate
excess skin is present.
*Microdissection. Larger lesions can be raised in a flap, the fatty deposits dissected from overlying skin under a surgical
microscope using micro scissors and the skin replaced.
*Good results can be obtained using chemical
peeling with bi- or trichloroacetic acid. Laser ablation and cryotherapy have advantages but may be more prone to scarring, including pigmentary changes.
What does histology show in squamous cell papilloma?
finger-like projections of fibrovascular connective tissue covered by irregular acanthotic and hyperkeratotic squamous epithelium
What are some treatments for squamous cell papilloma?
Treatment usually involves simple excision, but other
options include cryotherapy and laser or chemical ablation.
What does histology show in seborrhoeic keratosis?
Expansion of the squamous epithelium of the epidermis by proliferating basal cells, sometimes with keratin-filled horns or cystic inclusions
What are some treatments for Seborrhoeic keratosis?
Treatment involves shave biopsy (occasionally simple excision), electrodesiccation with curettage, laser ablation, cryotherapy with
liquid nitrogen and chemical peeling.
What does histology show in Actinic Keratosis?
irregular dysplastic epidermis with hyper-
keratosis, parakeratosis and cutaneous horn formation
What are some treatments for actinic keratosis?
Treatment involves biopsy followed by excision or cryotherapy.
What is a freckle?
(ephelis, plural ephelides) is a small (generally 1–5 mm)
brown macule due to increased melanin in the epidermal basal
layer, typically in sun-exposed skin
What does histopathology of a freckle show?
hyperpigmentation
of the basal layer of the epidermis, with a normal melanocyte population.
What is a congenital melanocytic naevus?
Congenital naevi are uncommon and histologically resemble their acquired counterparts
Rare variants include a ‘kissing’ or split naevus
that involves the upper and lower eyelid and may occasionally contain numerous hairs
What is a junctional naevus?
occurs in young individuals as a uniformly brown macule or plaque
The naevus cells are
located at the junction of the epidermis and dermis and have a low potential for malignant transformation
What is a compound naevus?
occurs in middle age as a raised papular lesion. The shade of pigment varies from light tan to dark brown but tends to be relatively uniform throughout
The naevus cells extend from the epidermis into the
dermis. It has a low malignant potential related to the junctional component.
What is an intradermal naevus?
most common, typically occurs in older patients. It is a papillomatous lesion, with little or no pigmentation.
Histologically, naevus cells are confined to the dermis and have no malignant potential
What is the margin for clearance of a suspicious pigmented lesion?
Excision should be
complete in most cases, with at least a 3 mm margin if melanoma is suspected.
What is a syringoma?
benign proliferations arising from eccrine sweat
glands. They are characterized by small papules that are often
multiple and bilateral
What is a pilomatricoma?
derived from the germinal matrix cells of the hair bulb affecting children and young adults and is more common
in females. Clinically it appears as amobile purplish dermal nodule that may have a hard consistency due to calcification
Malignant change is rare. The lesion is usually removed surgically.
Histopathology shows irregular epithelial islands
exhibiting viable basophilic cells at the periphery and degenerate ‘shadow’ cells centrally
What is a capillary haemangioma?
(strawberry naevus) is one of the most common tumours of infancy. It is three times as common in girls as boys
It presents shortly after birth as a unilateral, raised bright
red lesion usually in the upper lid. A deeper lesion appears purplish
What are some characteristics of a capillary haemangioma?
The lesion blanches on pressure and may swell on crying. Ptosis is frequent and there may be orbital extension
Occasionally the lesion may involve the skin of the face and some patients have strawberry naevi on other parts of the body.
How can capillary haemangioma be treated?
regular application of a topical beta-blocker to the
affected lesion.
What does histopathology of a capillary haemangioma show?
vascular channels of varying size within the dermis and
subcutaneous tissue
What is a port wine stain?
(naevus flammeus) is a congenital malformation of
vessels within the superficial dermis, consisting histopathologically of vascular spaces of varying calibre separated by thin fibrous septa
What percentage of children with port wine stain have associated ocular or CNS involvement?
About 10% including Sturge–Weber
What are some macroscopic features of a port wine stain?
manifests clinically as a sharply demarcated soft
pink patch that does not blanch with pressure, most frequently
located on the face.
It is usually unilateral and tends to be aligned with the skin area supplied by one or more divisions of the trigeminal nerve
Darkening to red or purple
takes place with age and there is commonly associated soft tissue hypertrophy
Bleeding may occur from focal overlying lobulations
How can port wine stains be treated?
Treatment with laser (e.g. pulsed-dye) is effective in decreasing skin discoloration, particularly if undertaken early. Topical preparations such as imiquimod and rapamycin, alone or with adjuvant laser, show promise.
Soft tissue debulking is used in a small number of cases. Screening for glaucoma should begin in infancy.
Systemic investigation is considered in some patients,
particularly those with a lesion of the lumbar area.
What is Sturge Weber syndrome?
(encephalotrigeminal angiomatosis) is a
congenital, sporadic phacomatosis.
What are some features of Sturge Weber syndrome?
- Port-wine stain, extending over the area corresponding to the distribution of one or more branches of the trigeminal nerve.
- Leptomeningeal haemangioma involving the ipsilateral parietal or occipital region may cause contralateral focal or generalized seizures,
hemiparesis or hemianopia. - Ocular features may include ipsilateral glaucoma, episcleral
haemangioma, iris heterochromia and diffuse choroidal haemangioma
What is a pyogenic granuloma?
a rapidly growing vascularized proliferation of granulation tissue that is usually antedated by surgery, trauma or infection, although some cases are idiopathic
Clinically there is a painful, rapidly growing, vascular granulating polypoidal
lesion that may bleed following relatively trivial trauma.
Cutaneous lesions should be excised
What is a Neurofibroma?
benign nerve tumours, usually
nodular or pedunculated, that can be found anywhere on the
skin
if multiple lesions are present, neurofibromatosis should be excluded
Plexiform neurofibromas typically present in childhood as a manifestation of neurofibromatosis
type 1 with a characteristic S-shaped deformity of the upper
eyelid
How can Neurofibromas be treated?
Treatment of solitary lesions involves simple excision, but removal of the more diffuse plexiform lesions may be
difficult.
Which systemic conditions may result in people developing eyelid malignancies
Xeroderma Pigmentosum
Gorlin- Goltz Syndrome
Muir- Torre syndrome
Bazex Syndrome
What is Xeroderma Pigmentosum?
characterized by skin damage
on exposure to sunlight, leading to progressive cutaneous
abnormalities.
More than 90% have ocular or
periocular involvement and 65% experience photophobia
What is the inheritance pattern for xeroderma pigmentosum?
AR
What are the facial features of Xeroderma Pigmentosum?
a bird-like facial appearance and a significant propensity to the development of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma
What is the inheritance pattern for Gorlin Goltz syndrome
AD
What are some features of Gorlin Goltz syndrome?
extensive congenital deformities of the eye, face, bone and central
nervous system. Many patients develop multiple small BCC
during the second decade of life
What tumours are Gorlin Goltz syndrome associated with?
Medulloblastoma,
Breast carcinoma
Hodgkin lymphoma.
What is the inheritance pattern for Muir-Torre syndrome?
AD
What are the tumours associated with Muir Torre syndrome?
Cutaneous tumours include BCC, sebaceous gland carcinoma and keratoacanthoma. Colorectal and genitourinary carcinomas are
the most common systemic tumours.
What are the 2 distinct conditions associated with Bazex syndrome?
1) Bazex–Dupré–Christol syndrome
2) Acrokeratosis paraneoplastica of Bazex
What is the most common human malignancy affecting older individuals?
BCC
What percentage of BCC’s occur in the head and neck vs the eyelid
90% head and neck
10% eyelid
Where do BCC’s tend to occur?
Lower eyelid followed in relative frequency by medial canthus, upper lid and lateral canthus
Where are BCC’s the riskiest and pose threats to invasion?
Medial canthus- prone to invading orbits and sinuses
What does BCC histopathology show?
The tumour arises from the cells that form the basal layer of the
epidermis. The cells proliferate downward and characteristically exhibit palisading at the periphery of a tumour lobule of cells
What are clinical features of Nodular BCC
a shiny, firm, pearly nodule with small overlying dilated blood vessels. Initially, growth is slow and it
may take the tumour 1–2 years to reach a diameter of 0.5 cm
What are clinical features of Nodulo-ulcerative BCC (Rodent Ulcer)?
is centrally ulcerated with pearly raised rolled edges and dilated and irregular blood vessels (telangiectasis) over its lateral margins
What are clinical features of Sclerosing (Morphoeic) BCC?
less common and may be
difficult to diagnose because it infiltrates laterally beneath
the epidermis as an indurated plaque
The margins of the tumour may be impossible to delineate
clinically and the lesion tends to be much more extensive on palpation than inspection.
What other condition can Sclerosing BCC mimic?
a localized area of unilateral
chronic blepharitis.
Which is commoner? SCC or BCC?
BCC
Where do SCC commonly metastasise to?
regional lymph nodes in about 20%
of cases.
The tumour may also exhibit perineural spread to the intracranial cavity via the orbit.
Who is SCC commonly seen in?
Immunocompromised individuals,
such as those with acquired immunodeficiency syndrome (AIDS)
or following renal transplantation are at increased risk, as are those
with a predisposing syndrome such as xeroderma pigmentosum.
Where do SCC’s tend to occur?
Lower eyelid and lid margin
What does histopathology of an SCC show?
The tumour arises from the squamous cell layer of the epidermis.
It is composed of variably sized groups of atypical epithelial cells with prominent nuclei and abundant eosinophilic cytoplasm within the dermis. Well-differentiated tumours may show characteristic keratin ‘pearls’ and intercellular bridges
(desmosomes)
What are clinical features of Nodular SCC
a hyperkeratotic nodule that
may develop crusting, erosions and fissures
What are clinical features of Ulcerating SCC?
a red base and sharply defined, indurated and everted borders, but pearly margins and telangiectasia are
not usually present
What are clinical features of cutaneous horn?
May have underlying invasive SCC
Ostensibly benign lesions such as keratoacanthoma and
cutaneous horn may reveal histological evidence of SCC in
deeper levels of sectioning.
What is a keratoacanthoma?
rare, rapidly growing but subsequently regressing tumour that usually occurs in fair-skinned individuals with a history of chronic sun exposure.
A pink dome-shaped hyperkeratotic lesion develops, often on
the lower lid and may double or treble in size within weeks.
Growth then ceases for 2–3 months, after which spontaneous involution occurs, when a keratin-filled crater may develop.
How to treat keratoacanthoma?
complete surgical excision with a margin of at least 3 mm or utilizing Mohs surgery. Radiotherapy, cryotherapy or local chemotherapy are sometimes used.
What are histological features of Keratoacanthoma?
irregular thickened
epidermis surrounded by acanthotic squamous epithelium. A
sharp transition from the thickened involved area to normal adjacent epidermis is referred to as shoulder formation and a keratin-filled crater may be seen.
What is a sebacious gland carcinoma?
rare, slowly growing
tumour that most frequently affects the elderly, with a predisposition for females
It usually arises from the meibomian glands, although on occasion it may arise from the glands of Zeis or
elsewhere.
What does histopathology of sebacious gland carcinoma show?
lobules of cells with pale
foamy vacuolated lipid-containing cytoplasm and large hyper-
chromatic nuclei
What is pagetoid spread of a tumour?
Pagetoid spread refers to extension
of a tumour within the epithelium and is not uncommon
What are some adverse prognostic factors of sebacious gland carcinoma?
Upper lid involvement, tumour size of 10 mm or more and duration of
symptoms of more than 6 months.
Where does Sebacious gland carcioma tend to occur compared to BCC/SCC?
Upper lid.
What does yellow material within a SGC suggest?
Yellowish material within the tumour is highly suggestive of SGC.
What SGC can be mistaken for a chalazion?
Nodular SGC
presents as a discrete, hard nodule, most commonly within the upper tarsal plate and may exhibit yellow discoloration due to the presence of lipid; it can be mistaken for a chalazion
What SGC can be mistaken for blepharitis?
Spreading SGC
infiltrates into the dermis and causes a diffuse thickening of the lid margin often with eyelash distortion and loss and can be mistaken for blepharitis.
Does melanoma develop on the lids?
Melanoma rarely develops on the eyelids but is potentially lethal.
Although pigmentation is a hallmark of skin melanomas, half of lid melanomas are non-pigmented and this may give rise to diagnostic difficulty.
