malignant tumors of the eyelidsshelleyeyecenter.com/files/303_-_michelle_welch.pdf · malignant...

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1 Management of Eyelid Neoplasms Michelle Welch, O.D. NSU Oklahoma College of Optometry [email protected] Malignant Tumors of the Eyelids “Pearls” Most periocular tumors are derived from epidermis or adnexae Main goal – rule out malignancy Identify characteristics of malignancy (HABCDs) BIOPSY ALL SUSPICIOUS LESIONS! Characteristics of Epithelial Malignancies Ulceration – benign lesions do not ulcerate Induration – malignant lesions often very firm Irregularity – malignancies have irregular shapes and borders Characteristics of Epithelial Malignancies Tenderness – malignant lesions are not painful Telangectasias – focal telangectasia suggests malignancy Pearly borders, rolled, translucent margins – think basal cell CA Epithelial Malignancies Basal cell carcinoma Most common malignancy of the eyelid (90%+) Types Nodular Ulcerative Sclerosing, morpheaform Basal Cell Carcinoma Rarely metastasize Medial canthal area most dangerous Mortality rate unknown, quoted 1-3% Orbital invasion Iowa series (1992) 1.7% Mayo clinic series 2.4% Extenteration necessary 1.4 – 3.8% of cases

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Page 1: Malignant Tumors of the Eyelidsshelleyeyecenter.com/files/303_-_Michelle_Welch.pdf · Malignant Tumors of the Eyelids ... {Hordeolum zTender zMay have discharge Differential Diagnosis

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Management of Eyelid Neoplasms

Michelle Welch, O.D.NSU Oklahoma College of Optometry

[email protected]

Malignant Tumors of the Eyelids

“Pearls”Most periocular tumors are derived from epidermis or adnexaeMain goal – rule out malignancyIdentify characteristics of malignancy (HABCDs)BIOPSY ALL SUSPICIOUS LESIONS!

Characteristics of Epithelial Malignancies

Ulceration – benign lesions do not ulcerateInduration – malignant lesions often very firmIrregularity – malignancies have irregular shapes and borders

Characteristics of Epithelial Malignancies

Tenderness – malignant lesions are not painfulTelangectasias – focal telangectasia suggests malignancyPearly borders, rolled, translucent margins – think basal cell CA

Epithelial Malignancies

Basal cell carcinomaMost common malignancy of the eyelid (90%+)Types

NodularUlcerativeSclerosing, morpheaform

Basal Cell Carcinoma

Rarely metastasizeMedial canthal area most dangerousMortality rate unknown, quoted 1-3%Orbital invasion

Iowa series (1992) 1.7%Mayo clinic series 2.4%Extenteration necessary 1.4 – 3.8% of cases

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BASAL CELL CARCINOMA BASAL CELL CARCINOMA

PIGMENTED BASAL CELL Nodular Basal Cell Carcinoma

Ulcerative Basal Cell Carcinoma Epithelial Malignancies

Squamous cell carcinomaRelatively rare, Wilmer series 4.2% (Doxanas 1987)Small tendency to metastasize (0.23 –0.25%)Frequently misdiagnosed clinically

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Squamous Cell Carcinoma

Confused with:Sebaceous cell carcinoma, basal cell carcinomaSeborrheic keratosis, inverted follicular keratosis, papilloma

If rapid onset and inflammation present, think of:

Keratoacanthoma, pseudoepitheliomatous hyperplasia

Squamous Cell Carcinoma

Photo Courtesy of Ellman Int’l.

Squamous Cell CarcinomaCharacteristics of Pigment Cell

Malignancy (Melanoma)

New onset or recent changeAsymmetric shapeIrregular marginsColor change or multiple colorsLarge size - > 5mm

Pigmented Lesions Pigmented Lesions: Melanoma

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MALIGNANT MELANOMA

Differential Diagnosis

verruca molluscum

Basal cell carcinoma Squamos cell carcinoma

Pick your lesion carefully!

Chalazion Molluscum

Verruca

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Pick your lesion carefully!

Basal Cell CarcinomaSquamos Cell Carcinoma

Pick your lesion carefully!

Biopsy Techniques

Shave Biopsy

Excisional Biopsy

Excision Mechanism Options

Excision with ScalpelExcision with ScissorsExcision with Radiofrequency

Papilloma Removal

IndicationsRisks and complications

RecurrenceScarringInfectionRisks associated with injection of anesthetic

Excision with Scalpel

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Excision Techniques Excision Techniques

Excision Techniques Excision Techniques

Excision Techniques Excision Techniques

If excising lesion try to put incision in same direction as natural skin lines.

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Papilloma Removal Excision with Radiofrequency

Advantages of RadiosurgeryQuick and easy (to do and to learn)Nearly bloodless fieldMinimal Post-op painRapid healingFine control with variety of tipsNo muscle contractions or nerve stimulation from radiowaves (Farradayeffects)

ContraindicationsDo NOT perform shave excision on pigmented lesion unless certain is not melanoma!!!Don’t use in presence of flammable fumes/liquidsPacemaker

“Do not work near the heart and place the antenna (or grounding) plate well away from the heart. Use the least power possible. Activate the handpiece intermittently rather than continuously. The cutting mode is the most risky, so avoid it if possible. Use another form of treatment if it is an option. The pacers are purportedly “shielded” and the current in the ESUs should not affect them, but all things are not perfect! Therefore caution is needed. Asystole and tachycardia are potential adverse outcomes.”

Pfenninger and Fowler's Procedures for Primary Care, 3rd Edition. John L. Pfenninger, MD, FAAFP and Grant C. Fowler, MD

Electromagnetic Spectrum

Ellman Unit Excision Techniques

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Feathering Technique Instruments

Yeager Plate

AsepsisAseptic technique

sterile equipmentscrub handssterile gloves

Asepsis

Bloodborne Pathogens

Universal Precautions:Do not recap contaminated needlesNeedle stick safetyNeedle stick policyYou will have to be aware of these things if doing procedures in your office

Informed Consent

Indications for treatmentDescription of treatment in layman’s termsAlternatives to treatmentRisks and benefit of treatmentExpected and unexpected outcomesPatient must request procedure

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Pre-Operative Activities

check patient allergiescheck vital signs (pulse, respiration, BP)informed consenthandling patient fearset up equipmentInspection of equipmentInspection of medication - discard if cloudy, expired, or container damagedPhotodocument lesion

Procedure Technique

Pre-op (photos, consent, BP and Pulse, VA)Anesthetize (infiltrative usually)Clean area, drape if needed

Betadine needs 3 mins on skin!

Turn on Ellman unit: warm up for at least 30 secondsChoose appropriate waveformChoose initial power setting (will often need to adjust depending on tissue response to energy level chosen)

Procedure Technique

Have assistant turn on/position vacuum unit – USE vacuum and masks!

Have isolated HPV and HIV in smokePlace yourself in comfortable/stable position to do procedureBrace your handpiece wrist on patient for stability

Procedure Technique

Electrode tip should be applied perpendicularly to allow even distribution of energyPress footplate activator when ready to begin procedureMove in expeditious but controlled fashion: always keep electrode moving when contacting tissue

Procedure TechniqueKeep surgical site moist (saline gauze) to avoid tissue drag; also wipe energized tip to remove tissue stuck to itFor removing mass lesions, use loop electrode/grab with opposite hand forceps/have specimen jar ready for lab submissionWhen feathering down a lesion with a loop, keep perpendicular---remove until healthy tissue seen (particularly helpful with lesions on gray line)Can use forceps closed tips to touch end of area of bleeding, touch electrode to forceps to transfer energy to area to stop bleeding

Procedure Technique

Clean area of betadineApply antibiotic ungDon’t let patient jump and run as you sit them up!Blood pressure and pulse post-opWrite op report in chart along with patient instructions on wound care and follow-up schedule

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Chalazion Presentation

Patient complaints

Non-tender lesion (may have started as a tender lesion)Size variesLength of time present variesLocation varies

www.redatlas.com

Chalazion Presentation

Exam SignsLesion within tarsus – not easily moveableNo lash lossNon-tender, no discharge upon palpation

Differential Diagnosis

HordeolumTenderMay have discharge

Differential Diagnosis

Sebaceous Gland Carcinoma

Must r/o in any recurrent chalazionMay be lash lossAppearance can be varied – be cautious

Chalazia Management Options

Give each patient all options for treatment!

Conservative ApproachHot compress with digital massageCan add Doxycycline if not contraindicated

Intralesional Steroid InjectionIncision and Curettage

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Conservative Approach

IndicationsSmall lesion (< 6 mm)Less present less than 6 monthsLesion in medical aspect of lid where would not want to perform I & CPatient choice of treatment

ContraindicationsDoxycycline allergy, liver and/or kidney dz

Risks and ComplicationsNo resolution of lesion

Intralesional Steroid InjectionIndications

Over 6 months oldLarge (4 – 6 + mm)Located in medial aspect of lid (won’t be able to do I & C)Patient choice

ContraindicationsAllergy/sensitivity to steroid

Risks and ComplicationsDepigmentationInfectionNo resolution of lesion

Intralesional Steroid Injection TechniqueMultiuse Vial

Alcohol topPut air in syringePush air into vialLoad syringe with medAlcohol top of vialDilute kenalog 40 to 20 or 10

Instruments

Chalazion Clamp

Instruments

Curette

Intralesional Steroid Injection Technique

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Intralesional Steroid Injection Technique Chalazion Incision and Curettage

IndicationsSame as for injection plus:Failure of injection to resolve lesion

ContraindicationsAllergy/Sensitivity to anesthetic

Risks and ComplicationsIncomplete removalInfectionRisks associated with injection of anestheticIf recurs in same spot will need biopsy could be sebaceous gland carcinoma!

Chalazion Incision and Curettage Chalazion Incision and Curettage

Chalazion Incision and Curettage Trichiasis Treatment

IndicationsPatient comfortDecrease risk of infection from abrasion

Risks and ComplicationsRisk associated with injection of anestheticRecurrenceInfection

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Trichiasis Procedure TechniqueCut offending lashesAnesthetize +/-Grab lash with forcepUse microinsulated needle Put needle beside lash shaft into follicle until cannot go furtherLowest power setting, CoagTouch and let off immediately of footplateGently tug lash – if comes out smooth are doneIf not treat quickly again

EntropionInward turn of eyelid – usually lower lidFor mild entropion, repair by suture is a viable option

Lid Anatomy Structural Changes Upon Suture Placement

Patient Education

May be small amount of bruisingCan use ice pack if needed

Pain ReliefUse same meds use to alleviate headache

Keep area clean and dryDon’t wash for 24 hrsNo make up, lotions, powders for 5 – 7 days

Use medication as directedUsually topical antibiotic ungThin film over area for 4 – 5 days

Keep moist – don’t want hard dry scabs

Patient EducationWatch for signs of infectionAs scab forms, don’t rub, scrub or pick – keep moist. Don’t use agents that will dry it - alcohol, peroxide, etc.Discuss suture removal timelineLimit exposure to sunlight Long term moisturizer use (with spf)

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Websites for Lesions or Diseases

www.rootatlas.comwww.redatlas.orgwww.kellogg.umich.edu/theeyeshaveit/index.htmlwww.atlasophthalmology.com/dro.hs.columbia.edu/www.gonioscopy.org

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