At the completion of this article, the reader should be able to improve their identification and referral of eyelid lesions, including:
- Distinguish between benign and malignant eyelid lesions.
- Apply the ‘ABCDE’ rule for melanoma assessment.
- Identify the most common
eyelid malignancies, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), sebaceous gland carcinoma and malignant melanoma. - Know when to refer a patient to an ophthalmologist for further evaluation.
eyelid malignancies, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), sebaceous gland carcinoma and malignant melanoma.
Dr Helen Garrott
MBBS (Hons) BMedSci, FRANZCO
Lid, lacrimal, orbital surgery
Bayside Eye Specialists, Victoria.
Optometrists play a vital role in detecting eyelid malignancies during routine exams and are often the first to identify suspicious lesions. With Australia experiencing peak summer UV exposure, this is a critical time to raise awareness about recognising malignancies, writes DR HELEN GARROTT.
As front-line providers of eyecare, optometrists play a crucial role in early detection of ocular and periocular abnormalities, including eyelid malignancies. Recognising potential malignancies can help reduce morbidity and in some cases save lives by facilitating early diagnosis and referral to an ophthalmologist. This article will guide optometrists in identifying the main types of eyelid malignancies, recognising warning or ‘red flag’ signs, and understanding when a referral is necessary.
Understanding Eyelid Malignancies
Most eyelid malignancies are skin cancers deriving from the skin of the eyelids or in some cases the eyelid margin. The most common malignancies, in order of frequency, are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), sebaceous gland carcinoma and malignant melanoma. Each type presents unique characteristics, risks and levels of aggressiveness.
Basal Cell Carcinoma
The most common form of eyelid cancer, BCC accounts for 85-95% of malignancies. It is slow-growing with minimal risk of metastatic disease but can cause significant local tissue destruction. It often occurs on the lower eyelid, the medial canthus, and less commonly, the upper eyelid. Owing to its slow growth and low metastatic potential, BCC is rarely life-threatening.
Squamous Cell Carcinoma
Although less common, SCC is more aggressive than BCC as evidenced by its more rapid growth and metastatic potential. It occurs more frequently on the lower lid than the upper lid and typically presents as a crusting and bleeding lesion. As a result of its tendency to metastasise over time, SCCs require more aggressive and more urgent management than BCCs.
Sebaceous Gland Carcinoma
This is a rare and highly aggressive cancer originating from oil glands in the eyelids. It may originate either from the meibomian glands or Glands of Zeiss. It has a high mortality rate and can mimic benign conditions such as styes. The diagnosis must therefore be considered in a non-resolving chalazion in an elderly patient. It is often mistaken for chronic blepharitis and sebaceous gland carcinoma, so it must be considered in cases of so-called ‘unilateral blepharitis’.
Malignant Melanoma
Although rare, eyelid melanoma is extremely aggressive and can metastasise quickly. These usually present as new or changing pigmented lesions of the eyelid, with or without bleeding. Malignant melanoma requires urgent referral and management to minimise morbidity and improve survival.
Recognising Warning Signs
Knowing what to look for can make a significant difference in identifying potential malignancies and guiding urgency of referral. Here are some key warning signs for each type:
Basal Cell Carcinoma
• A persistent ‘sore’ that does not heal
• A raised pearly nodule with telangiectatic vessels
• Focal loss of eyelashes
• Raised, ulcerated lesions, sometimes with crusting
• Bleeding or oozing spontaneously or with minimal trauma
• An unexplained eyelid margin notch
Squamous Cell Carcinoma
• Rough, scaly, thickened patches
• Wart-like growths or lumps that bleed easily
• A ‘sore’ that does not heal
Sebaceous Gland Carcinoma
• Persistent eyelid swelling or thickening, often misinterpreted as a stye
• Yellowish nodules, particularly on the upper eyelid
• A non-resolving or recurrent chalazion, particularly in an elderly person
• Diffuse thickening of the eyelid margin, often mistaken for ‘unilateral blepharitis’
Malignant Melanoma
• Dark, irregularly pigmented lesions
• Asymmetry in shape, irregular borders or colour variation
• Pigmented lesions that change shape, size or colour over time
• Presence of new ‘moles’ around the eyelid
Using the ‘ABCDE’ rule for melanomas
For optometrists assessing pigmented eyelid lesions, the ‘ABCDE’ rule can be helpful in assessing the risk of melanoma:
• Asymmetry: Melanomas tend to be asymmetrical, unlike benign lesions. This means that one half of the lesion does not match the other half.
• Border: Irregular blurred or notched borders may suggest malignancy. This means that the edge of the lesion is not well defined.
• Colour: Multiple colours within the same lesion, such as brown, black, red or blue, are warning signs.
• Diameter: Larger lesions >6mm are more likely to be malignant.
• Evolving: Any change in size, shape, or colour should be viewed with caution. Essentially if the patient thinks that a pigmented lesion is changing in any way, or there is evidence of any change in the characteristics of the lesion on serial follow up, this should prompt urgent referral for assessment. Patients may notice that the edges of the lump are changing, that it is becoming thicker, progressively enlarging, or that there is new bleeding, oozing or itching.
Differential diagnosis: benign vs malignant lesions
It is important for optometrists to distinguish between benign and potentially malignant lesions, as many benign conditions can resemble malignancies. Here are some common benign eyelid lesions:
Chalazion
A common, benign swelling of the meibomian glands, typically self-limiting and treatable with warm compresses, but occasionally requiring surgical drainage with incision and curettage.
Stye
An acute infection of the meibomian glands, usually tender red and located at the eyelid margin. Usually rapidly self-limiting but can evolve into a more chronic chalazion.
Xanthelasma
Yellowish plaques within the skin, most commonly in the superior medial canthus, due to cholesterol deposits. Usually bilateral but may be asymmetrical. In some cases, associated with raised serum lipid levels.
Naevi
Benign pigmented moles that remain stable in appearance over time, without change in size, shape of pigmentation.
Cyst of Moll
Benign sweat gland cyst usually close to the eyelid margin. Typically transilluminates.
Cyst of Zeiss
Benign oil gland cyst usually at the base of an eyelash. Typically presents as a discrete opaque whitish yellow spot or lump.
Seborrhoeic keratosis
A waxy, often pigmented lesion with a ‘stuck-on’ appearance, but alternatively can be lobulated or pedunculated.
Below are some reassuring features that a lesion is benign:
• Longstanding
• Not growing or changing
• Not bleeding
• Lashes are growing through it
When a lesion does not fit the typical characteristics of these benign conditions or fails to improve with treatment, it is essential to consider the possibility of malignancy.
When to Refer
Optometrists should refer any suspicious eyelid lesion to an ophthalmologist, ideally with expertise in oculoplastic surgery. Prompt referral is warranted for the following:
• Persistent or growing nodules or sores that do not heal, or that bleed or ooze.
• Eyelash loss
• Telangiectatic vessels
• Central ulceration
• Lesions that recur in the same location after prior resolution (e.g. recurrent chalazion)
• Any new lesion in a patient with a history of skin cancer
• History of immunosuppression
• Pigmented lesions that are irregular in colour, size or shape, particularly if they meet any ‘ABCDE’ criteria
Patient education
Optometrists should routinely examine for lesions around the eye in their patients and enquire as to whether the lesions are new or longstanding. In particular, patients should be asked about whether there is any growth, bleeding or crusting of the lesion, all of which should prompt referral to an ophthalmologist, preferably with subspecialist oculoplastic training. Even in cases in which an optometrist has a low suspicion for malignancy, they should advise the patient to monitor for any warning signs which should trigger repeat examination and/or referral, namely: growth, bleeding, crusting or any significant change in the lesion.
Optometrists should advise general sun protection including sunglasses, hats and sunscreen, particularly in those with a history of skin cancers. In cases where an optometrist feels a referral to an ophthalmologist is warranted for a suspicious lesion, they should explain to the patient that it is always sensible to get an opinion from an expert for any new or changing skin lesions and that the same principle applies to eyelid lesions.
Conclusion
Understanding the warning signs for eyelid malignancies allows optometrists to play a key role in early diagnosis, prompt referral and subsequent treatment, which in turn significantly improves patient outcomes. A timely referral can make the difference between preventing local invasion, metastasis, and potential vision and eye loss.
More reading
Combining myopia treatment with UV protection
Paediatric optometry beyond myopia
Glaucoma: Integrating OSD management with peri-operative optometric care
References
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2. Sun MT, Rajak S, Selva D, Smith H. Periocular basal cell carcinoma: a comprehensive review. Expert Rev Ophthalmol. 2017; 12 (3): 221-232.
3. Moran JM, Phelps PO. Periocular skin cancer: Diagnosis and management. Dis Mon. 2020 Oct; 66 (10): 101046.
4. Rana H, Stokkermans TJ, Purt B, et al. Malignant eyelid lesions. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Available from: https://www.statpearls.comw
