Clinical DD of various lid lesion. Surgical approaches lid defects (post-excision / post-trauma / or congenital coloboma defect).

1. Eyelid lesions
Samhaa Mohammed Abd Elmoneim
Zagazig Ophthalmic Hospital 2018

2. Epidermis
Keratin layer
Granular layer
Brickle cell layer
Basal layer
Dermis
Bl vs
Lymphatics
Fibroblast, CT
Macrophage
Mast cells
Adnexa
deep in dermis
& tarsus

3. Histological terminology
 Atypia: abnormal appearance of individual cells
(abnormal mitosis).
 Dysplasia: alteration in size, morphology &
organization.
 Hyerkeratosis (increased keratin layer).
 Dyskeratosis: keratinization other than epidermis.
 Acanthosis: thickened brickle cell layer.
 Parakeratosis: retension of nuclei in keratin layer.
 Carcinoma in situ (intraepidermal carcinoma, Bowen
disease).

4. General consideration
• Epidermal, adenxal or dermal lesion.
• Benign lesions (less induration, ulceration,
limited growth, uniform color, preservation of
lid margin structure, regular outline.
• Biopsy is required if it is suspicious.
• Incisional/ excisional biopsy.
• Excision/ marsuplialization/ laser, cryo
ablation.
• Suspicion neads total excision with safety
margin 3mm

5. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid)
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus)
Adenxal (syringoma,
pilomatricoma)
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma)
Malignant
BSC
SCC, kerato acanthoma.
SGC
Site
Size
Surface
Surrounding
Edges
LN

6. Small non translucent at ant
margin, from lash follicle,
obstructed sebaceous gland.
(cyst of zeis)
Cystic translucent non tender at
ant. lid margin.
(apocrine hydrocystoma,
cyst of Moll)

7. Epidermis implantation into
dermis, 2ry to trauma,
surgery. Firm, nodular SC
containing keratin.
(Epidemal inclusion cyst)
Sequestrated skin during
embryonic development,
typically attached to
periosteum at lateral brow
at suture fusion.
(Dermoid)

8. Tiny, white round papules.
Retention of keratin due to
blockage of pilosebaceous unit.
(Milia)
Lipogranuloma, meibomian cyst.
Rosacea, blepharitis are
association.exclude EOR in
children & malignancy in eldery.
(Chalazion)
Keratin plugs within dilated
orifice of follicles in acne .
Fulgaris. open (backhead),
closed (whitehead)
(Comedones)

9. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid) √
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus)
Adenxal (syringoma,
pilomatricoma)
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma)
Malignant
BSC
SCC, keratoacanthoma
SGC
Site
Size
Surface
Surrounding
Edges
LN

10. Peduculated, sessile,
hyperkeratotic cutaneous
horn. Acanthosis,
hyperkeratosis. Slowly
progressive increase in
eldery. HPV. B.
(squamous cell papilloma)

11. Proliferation of basal layer of
epithelium with expansion of
squamous epith. Pigmentd ̎ stuck
on ̎ appearance. Shave biopsy é cyo,
laser, chemical peeling can be done.
(Seborrheic keratosis (basal cell
papilloma)
Slowly progressing in sun damaged
skin. Nodular, wart or cutaneous
horn. Low potential of malignancy to
SCC (carcinoma insitu). Excision or
cryo.
(Actinic keratosis)
Insitu = no penetration of
basment membrane of epi
thelium / demis

12. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid) √
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
√
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus)
Adenxal (syringoma,
pilomatricoma)
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma)
Malignant
BSC
SCC, keratoacanthoma
SGC
Site
Size
Surface
Surrounding
Edges
LN

13. Increase melanin in epidermal
basal layer, increase with sun
exposure.
(Freckle)
Uncommon usually small. Rare
variant is kissing/ split naevus,
may contain numerous hair.
Large one (giant hairy naevus )
has malignant transformation
15%.
(Congenital melanocystic
naevus)

14. Uncommon usually small. Rare
variant is kissing/ split naevus,
may contain numerous hair.
Large one (giant hairy naevus )
has malignant transformation
15%.
(Congenital melanocystic
naevus)

15. Junctional
(low malignant
potential)
Compound
(lower)
Intrademal
(No)
Acquired
melanocytic naevi

16. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid) √
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
√
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus) √
Adenxal (syringoma,
pilomatricoma)
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma)
Malignant
BSC
SCC, keratoacanthoma
SGC
Site
Size
Surface
Surrounding
Edges
LN

17. Hair bulb proliferation.
Mobile purple hard nodule
with/out calcification.
(Pilomatricoma)
From eccrine sweat gland.
Multiple bilateral papules.
(Syringioma)

18. Unilateral mobile raised bright red
lesion, increase with strain. Blanch.
Involved skin with strawberry
appearance. Systemic association if
multiple?. Resolve at 1y. Ttt with
steroid injection, BB topical &
systemic, surgery.
(Capillary haemangioma)
Congenital malformation of dermal
bl vs. 10% with systemic association
as SWS. Well defined facial pink
patch. Not blanch. Unilateral with 5th
n. Darken with age. Glaucoma
screening. Early ttt with laser.
(Potwine haemangioma)

19. Bl vs, granulation
tissue. Tender
rapidly growing.
Trauma, infection,
surgery, idiopathic.
(Pyogenic
granuloma)
Isolated NF in
normal
individual,
plexiform in NF1,
S-shaped ptosis.
Difficult excision.
(plexiform NF)
Intracellular
lipid. Bil
yellowish SC
plaques, at
medial aspect.
(Xanthelasma)

20. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid) √
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
√
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus) √
Adenxal (syringoma,
pilomatricoma) √
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma) √
Malignant
BSC
SCC, keratoacanthoma
SGC
Site
Size
Surface
Surrounding
Edges
LN

21. Nodular Ulcerative Sclerosing
• The most common skin malignancy, 90% in
head & neck. The most common lid
malignancy. Locally malignant.
• Inferior, medial, superior, lateral. Medial is
the worst.
• Arise from basal layer of epith.., extend
downward with pallisade arrangemnt of
lobules.
(BCC)
Locally malignant= arise from BM
of epi dermis/thelium. Extend
downward with surrounded
pallisade cell pattern

22. • Fair skin, immunesuppresion, eldery.
• Rapidly growth, with keratinization,
LN.
• Well defined DD: BSC.
• Actinic keratosis, carcinoma in situ
(Bowen), keratoacantoma DD.
(SCC)
Nodular Ulcerative Cutaneous
horn

23. • Rare tumor, from meibomian gland, zeis
gland.
• 5-10% mortality rate.
• More in UL
• Pale foamy vaculated lipid containing
cytoplasm, large hyperchromatic nuclei.
• Nodular (DD chalazion).
• Pagetoid (DD chronic post blepharitis)
(SGC)
Nodular Pegatoid

24. • Fair skin with sun exposure.
• Rapidly growing then regressed over
3m.
• Keratin filled crater.
• Definte ttt is required.
(Keratoacanthoma)

25. • Lentigo maligna (melanoma in situ).
• MM invading dermis.
• Rapidly growing, variable
pigmentation, ill defined, ulceration.
(lentigo maligna & melanoma)
Lentigo
maligna
Nodular
melanoma
MM

26. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid) √
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
√
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus) √
Adenxal (syringoma,
pilomatricoma) √
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma) √
Malignant
BSC √
SCC, keratoacanthoma √
SGC √
Site
Size
Surface
Surrounding
Edges
LN

27. Describe
DD
(B/ M, melanotic/ non) (how to think ??):
• Age (BCC, SCC, SGC, MM, KA)
• Race (BCC, SCC, actinic Keratosis, basal cell
papilloma
• Rapid growth, ulcer (BCC, SCC, KA, SGC,
MM)
• Papillomatous surface (BCC, SCC, SCP, BCP,
KA)
• Color (pigmented in BCC, BCP, MM)
• LN (SCC, SGC, MM)
Ulcerative
BCC
Rare Pdf :
• Xeroderma pigmentosa
(AR, BCC, SCC, SGC, sun
exposed skin damage
bird like facies.
• Gorlin-Goltz $ (AD, eye,
bone, skin, face
deformities,
medulloblastoma,
breast c, lymphoma.
• Muir-Torre $ skin, GIT
malignancy.

28. Describe
DD (how to think ??):
• Age (BCC, SCC, SGC, MM, KA)
• Race (BCC, SCC, actinic Keratosis, basal cell
papilloma
• Rapid growth, ulcer (BCC, SCC, KA, SGC,
MM)
• Papillomatous surface (BCC, SCC, SCP, BCP,
KA)
• Color (pigmented in BCC, BCP, MM)
• LN (SCC, SGC, MM)
Rare Pdf :
• Xeroderma pigmentosa
(AR, BCC, SCC, SGC, sun
exposed skin damage
bird like facies.
• Gorlin-Goltz $ (AD, eye,
bone, skin, face
deformities,
medulloblastoma,
breast c, lymphoma.
• Muir-Torre $ skin, GIT
malignancy.

29. Describe
DD
(Benign/Malignant,
melanotic/not)
Ulcerative
BCC
Keratoacanthoma

30. Merkel cells are for light
touch sensation. Rare
highly malignant
violaceous/ red nodule
with intact skin.
Difficult Dx. Excision ttt.
(Merker cell tumour)
Dermal vascular
malignant tumour, in HIV
& AIDS pt. Associated
systemic dis., bluish or
red in color. Excision,
radiotherapy + ttt cause.
(Kaposi sarcoma)

31. Describe
DD (B/M,
melanotic/ not)
Pyogenic
granuloma
Amelanotic
melanoma

32. Describe
DD (B/M,
melanotic/ A)
Ulcerative
BCC
Keratoacanthoma

33. BCC
SCC

34. Nodular
BCC
Squamous
cell
papilloma

35. Sebaceous
cyst
Cyst of
moll

36. Benign
Cysts (chalazion, zeis, moll, sebaceous ,
milia, comedone, epidermal inclusion,
dermoid) √
Epidermal (squamous papilloma,
seborhoeic keratosis, actinic keratosis)
√
Pigmented (freckle, congenital naevus,
acquired melanocytic naevus) √
Adenxal (syringoma,
pilomatricoma) √
Miscellaneous (capillary hgoma,
portwine, pyogenic granuloma, NF,
xanthelasma) √
Malignant
BSC √
SCC, keratocanthoma √
SGC √
Site
Size
Surface
Surrounding
Edges
LN

37. Lid defect surgical protocol
Partial thickness
defect
(direct closure, Z, V/Y
plasty, flap or graft)
Anterior lamellar
Posterior lamellar
defect
Full thickness defect
Small defect < 1/3 lid
( direct closure +/-
canthyolysis )
Moderate 1/3 -1/2 lid
( Tenzel rotational
myocutaneous flap )
Severe > 1/2 lid
( Hughes for LL, Cutler-
Beard bridge for UL )
V Severe
( Mustrade cheek
rotational flap )

38. Surgical videos