Q3 LONG ANSWER 10M ★ High-yield

Describe the benign and malignant tumours of the eyelid.

Ophthalmology · 3rd Professional

Benign Lid Tumours

Lid lesions are extremely common and the great majority are benign; the clinical task is to identify the minority that are malignant, and the features that do so are consistent across tumour types

Lesion	Features
Benign squamous papilloma (skin tag)	The commonest lid lesion; a pedunculated, flesh-coloured, raspberry-like growth. Entirely benign; excised for cosmesis
Seborrhoeic keratosis	A greasy, warty, sharply demarcated brown plaque with a "stuck-ON" appearance, in the elderly. Benign. The sudden eruption of many (LESER-TRELAT sign) is a rare marker of internal malignancy
Molluscum contagiosum	A small, waxy, umbilicated nodule on the lid margin, shedding viral particles into the tear film and causing a chronic follicular conjunctivitis that will not resolve until it is removed. Multiple lesions suggest HIV
Xanthelasma	Soft yellowish plaques of lipid-laden histiocytes, bilateral and medial on both lids. Half have normal lipids, but a fasting lipid profile should be checked, particularly in the young, and cardiovascular risk assessed
Capillary haemangioma	Of infancy: appears in the first weeks, enlarges for a year (and swells on crying), then involutes spontaneously over several years. The danger is amblyopia from ptosis covering the pupil or from induced astigmatism. Treated with oral or topical propranolol.
Port-wine stain (naevus flammeus)	A flat vascular malformation that does not involute. Involvement of the V1 dermatome raises STURGE-WEBER syndrome, with a risk of glaucoma in that eye and of intracranial angioma
Cyst of MOLL and of ZEIS	A clear (Moll, apocrine) or opaque yellowish (Zeis, sebaceous) cyst on the lid margin
Actinic keratosis	A scaly, erythematous plaque on sun-damaged skin; premalignant, progressing to squamous cell carcinoma in a small proportion, so it is treated rather than observed
Keratoacanthoma	A rapidly growing dome with a central keratin plug.

Malignant Lid Tumours

Basal cell carcinoma (BCC) accounts for 90% of malignant lid tumours. It arises on sun-exposed skin, most often on the lower lid and medial canthus
Its classical appearance is a pearly, raised nodule with rolled, everted edges and fine telangiectatic vessels over the surface.
It is locally invasive and essentially never metastasises, but a medial canthal tumour is dangerous because it can invade deeply into the orbit and along the lacrimal system, and its margins are difficult to define

Assessment and Management

Features suggesting malignancy, and any one warrants biopsy: loss of lashes (madarosis) over the lesion; ulceration; distortion or destruction of the lid margin; pearly, rolled or everted edges with telangiectasia; induration and fixation to deeper tissue; irregular pigmentation; progressive growth; bleeding or crusting; and recurrence after apparently adequate treatment
Assessment — document the size and site with photography; assess fixation, orbital extension and ocular motility; test corneal and facial sensation for perineural spread; and palpate the preauricular and submandibular nodes
Biopsy — incisional for a large lesion, excisional for a small one, and full-thickness with fresh tissue for suspected sebaceous carcinoma
Treatment — surgical excision with margin control is the mainstay. MOHS micrographic surgery or frozen-section control is preferred for medial canthal, morphoeic, recurrent and large tumours.
Reconstruction follows the lamellar principle and the size of the defect: direct closure for a defect up to about a quarter of the lid (a third in the elderly with lax lids); with a lateral canthotomy and cantholysis for a little more; a TENZEL semicircular flap for up to about half; and for larger defects a HUGHES tarsoconjunctival flap (for the lower lid, with a skin graft anteriorly) or a CUTLER-beard procedure (for the upper lid) — both of which are two-stage and occlude the eye in the interval, and are therefore avoided in a child because of amblyopia and in a patient whose other eye sees poorly
Other modalities — radiotherapy where surgery is declined or unsuitable; cryotherapy for small superficial lesions; topical imiquimod or fluorouracil for superficial basal cell carcinoma; hedgehog pathway inhibitors (vismodegib) for locally advanced or metastatic basal cell carcinoma; and exenteration for extensive orbital invasion

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