Oculoplastics Case of the Month: " I think my eye doctor is trying to scare me"


For our October Oculoplastics Case of the month we present an interesting common problem that we see in our practice. Often both myself and Dr Popham perform 7-8 eyelid biopsies a week with roughly 2-3 eyelid cancer case.

October 2017 Case

A 68 year old female presents from her optometrist with an “Eyelid growth that has been there for years”. She was referred by her optometrist who had noticed loss of lashes around the growth on slit lamp examination. The patient denied that the lesion bled spontaneously or any history of skin cancer. Her doctor had referred her for a consultation and biopsy because of the eyelash loss which she felt “I think he was just trying to scare me”. On further questioning it was found the lesion was roughly 2-3 years old in the patient's memory. She had a sister who had a basal cell on the cheek. They had both grown up in Evergreen.


Pathology

A biopsy was performed which revealed after a long discussion with the patient. The slide review by the pathologist Dr Jason Hicks revealed crests of blue (basaloid) cells in the eyelid skin consistent with basal cell carcinoma of the eyelid.


The patient underwent Mohs surgery with a resultant defect in the eyelid. The eyelid margin was closed using vertical sutures which were removed in 10 days.


The patient returned after 3 months with resolution of the basal cell carcinoma of the eyelid.


Basal Cell Carcinoma of the eyelid

Basal cell carcinoma is a common malignant tumor in Colorado. Because of the intense exposure to UV light, Colorado residents are particularly at risk. In particular risk are those patients who may have grown up in higher elevation counties such as Pitkin, Summit and Gunnison county. UV rays are hypothesized to increase mutagenic changes in the skin. The lower eyelid is the most common location for basal cell carcinoma followed by the medial canthus. 90% of malignant eyelid lesions are basal cell carcinoma. The average age at diagnosis is between 60 and 80 though in our practice we have seen patients in Colorado as young as 15.

Presentation

Often basal cell carcinoma presents as a painless growing mass on the eyelid. It typically has an ulcerated appearance.


Some of the particularily high risk signs of a growing lesion include

  1. Eyelash loss

  2. Spontaneous bleeding

  3. Architectural disruption

Differential Diagnosis

Basal Cell Carcinoma

Squamous Cell Carcinoma

Amelanotic Melanoma

Chalazion

Epithelial inclusion cyst

Apoicrine Hydrocystoma

Treatment

Treatment for basal cell carcinoma in the eyelid primarily consists of excision and repair. The two most common techniques used are Mohs surgery and Frozen sections. Mohs surgery involves a dermatologist removing the cancer and sending the patient to the oculoplastic surgeon for reconstruction. Frozen section involves the work of an oculoplastic surgeon with a pathologist “on call” to make sure the cancer is gone.

Nonsurgical treatment for basal cell carcinoma includes topical imiquimod which is applied once a day, 5 days a week for 4 months. This is used primarily in locations where it cannot infiltrate into the eye. It can have treatment success of 100% in lesions under 1 centimeter. Unfortunately it can be damaging to the cornea and is generally avoided around the eye.

Radiation is another option for large lesions especially in patients who are not surgical candidates. Side effects include loss of hair and surrounding damage to tissue. Radiation retinopathy, optic neuropathy have been described in patients and it has not had favor around the eye.

Vismodegib, a hedgehog pathway inhibitor is an oral pill which is used to shrink large basal cell lesions and treat patients with Multiple Basal Cell Syndrome (Gorlin Syndrome). The cost of this medication is roughly $40,000 a month and may be not the treatment of choice for small lesions.

Risk factors for recurrence after excision of basal cell carcinoma include size and subtype of the carcinoma. Morpheaphorm basal cell can have recurrences up to 4%.

Treatment considerations for the eye doctor

The key for lowering morbidity of basal cell carcinoma patients is early detection and treatment. Anterior segment examination of the eyelids are the mainstay of treatment. Additionally, after eyelid reconstruction there can be irritation and keratitis of the cornea as the newly reconstructed eyelid is rubbing against the eye. The optometrist serves as a key player in monitoring these patients after surgery to make sure that the eyelid is functioning properly against the surface of the eye after surgery.

Summary

Basal cell carcinoma is a common entity that eye doctors encounter in their practice. Early intervention is useful for patients to reduce their morbidity and risk of direct extention into the orbit. Patients often are unaware of growing lesions in their periocular area. The optometrist can be critical in ocular surface monitoring and maintenance after excision as the surgical site is healing.


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