malignant tumors of the eyelidsshelleyeyecenter.com/files/303_-_michelle_welch.pdf · malignant...
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Management of Eyelid Neoplasms
Michelle Welch, O.D.NSU Oklahoma College of Optometry
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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