Eyelid lumps, bumps, cysts and tumours

There are many conditions that cause cysts, lumps and bumps on the eyelids. In most cases these are benign such as styes, chalazia and cysts. Occasionally they can be a sign of something more serious such as a tumour.

Over the last 25 years Mr Uddin has provided excellent care for many patients with eyelid swelling, lumps, bumps and lesions. He will rapidly reach an accurate diagnosis in order to offer an effective treatment plan.

“Many eyelid lumps & bumps are amenable to medical treatment, some need a simple excision...but one must careful to identify and treat the more sinister lesions”

Stye

A stye also known as a hordeolum is caused by a bacterial infection and inflammation affecting the eyelash follicle or oil gland in the eyelid.

What is a stye?

A stye also known as a hordeolum is caused by a bacterial infection and inflammation affecting the eyelash follicle or oil gland in the eyelid (meibomian glands and glands of Zeiss). They appear very quickly on the eyelid at the base of the eyelash as a small, red and tender spot sometimes with a yellow/white centre. They can be single or multiple or even bilateral. When they are externally visible, it's called an external hordeolum. When it is on the inside of the lid and deep to the skin, it's an internal hordeolum.

Occasionally the acute infection can be quite severe, causing significant eyelid swelling and even closure of the eye. This needs urgent assessment and treatment with oral antibiotics.

Chalazion

A chalazion is an eyelid cyst which is a more chronic inflammatory response within a meibomian gland.

What is a chalazion?

A chalazion is an eyelid cyst which is a more chronic inflammatory response within a meibomian gland (meibomian cyst). It is a common condition that is caused by a stye or blepharitis (an inflammation of the eyelids), which causes a blockage of one of the oil (meibomian) glands of the eyelids. Chalazia may become infected or inflamed again or form a hard lump.

Sometimes there is a lump under the skin, with a visible growth on the underside. This could be a condition called pyogenic granuloma which can also be removed surgically.

Can a chalazion cause blurred vision?

What are the causes or risk factors for styes?

What is Blepharitis/ Meibomian gland disease (MGD)/ “acne of the eyelids”?

Blepharitis is chronic inflammation and infection of the eyelids, centred around the meibomian glands at the base of the eyelashes. It predisposes to the development of styes and chalazia.

Symptoms of Blepharitis

red lid margins (looking like you haven't slept)
sore eyelids
dry eye symptoms and/or watery eye
gritty, flaky or crusting eyelids
sticking of the eyelids, especially in the morning
red eyes (conjunctivitis)
development of cysts/styes

Anterior blepharitis mainly affects the outer eyelid, where eyelashes grow. Normal bacteria on your skin become involved in the inflammation. Flakes and crusting are features. Sometimes skin mites (tiny parasites known as Demodex) may also cause anterior blepharitis.

Posterior blepharitis mainly affects the inner edge and inside of the eyelid which touches the eye. Oil glands (meibomian glands) produce thickened oils and become clogged, infected and inflammed. Common skin conditions like (acne) rosacea are also associated.

What treatments are available for Blepharitis?

Prevention of cysts and treatment of blepharitis

Warm compresses and careful, gentle outer eyelid base cleaning. This can be done at the end of a shower or bath (when eyelids have been warmed up. This helps to soften the thickened oils)
Omega 3 oils (found in oily fish such as sardines and salmon) or as a food supplement help skin conditions such as rosacea
Clean makeup off well and reduce eyeliner and eyelash base mascara.
Tackle stress and and any general health issues
Eye lubricants can help symptoms. Antibiotic drops and sometimes steroid eye drops can also help.
Antibiotic tablets used for acne, and rosacea such as doxycycline and lymecycline may reduce inflammation and recurrence

Treatment for Styes

Most styes will disappear after a few days using a warm compress and careful cleaning of the base of the eyelashes. Chronic or recurring styes can be treated with a course of antibiotics and lubricant eye drops.

If very swollen and painful, antibiotic tablets may be indicated.

Treatment for chalazia

A chalazion usually last a few weeks and normally disappear without any medical intervention. Similar to styes, a chalazion can be treated using a warm compress with a light massage. This reduces the swelling by softening the oils in the blocked glands and allowing them to drain. In some cases a steroid injection or a short course of antibiotics may be needed.

Incision & curettage (I&C) procedure

If the cyst is large, painful, causes blurring of vision or does not improve, it can be drained. This procedure involves making a small incision on the inner surface of the eyelid so that the contents of the cyst can be removed through incision and curettage.

A biopsy can also be performed if there is any doubt about the cause.

I &C is usually a 20 minute outpatient procedure. Local anaesthetic injection numbs the eye lid (this stings a bit). Then the procedure is usually painless. An incision is made on the undersurface of the eyelid and contents of the cyst are removed (a steroid injection can also be given at the same time).

The eye is padded, which can be removed 4 to 12 hours later. It is usually painless afterwards.

On removal of the eye pad, there is usually some discharge (which may be bloodstained). Normal washing, showering or taking a bath is allowed. Antibiotic ointment may be advised, usually about 3 times a day for 3 days.

After surgery there may be swelling which lasts about 2 to 3 days; bruising, if present can take 4-5 days to clear. Avoid driving and cycling for a couple of days, until the swelling has settled.

What are other causes of cysts, lumps and bumps?

There are many benign cysts and growths, usually slow growing and painless, which can affect the eyelids. They may cause a nuisance or eye irritation.

It is important to identify and exclude malignant growths (skin cancers), which tend to affect older people, people with sun damaged skin and people with other skin cancers

Benign Eyelid Tumours

Cyst of Moll/Zeiss/retention cysts

Sebaceous cysts (cyst of the oily glands in the skin)

Molluscum Contagiosum (a viral infection)

Xanthelasma

Seborrheic keratosis

Can an eyelid lump be a sign of cancer?

A tumour is a growth or lump. A tumour can be benign, meaning it will grow but not spread to other parts of the body. It can also be malignant or cancerous, meaning that it may grow and spread. Sometimes a condition may be precancerous, meaning although it is not cancer, there is a chance of developing cancer within it in the future.

If in doubt the lesion can be removed or a small part removed by taking a biopsy and the tissue sent for histology (examined under a microscope to make a diagnosis)

The symptoms of a malignant tumour may include

no symptoms, just a growth or distortion of the eyelid
irritating eyelid lump
progressive growth of a lump
skin/eyelid ulceration destruction and inflammation
abnormal blood vessels near the lump
loss of eyelashes (madarosis)
whitening of eyelashes (poliosis) over the bump
increased pigmentation/new dark spots
Proptosis (protrusion of the eye), double vision, reduced vision, numbness or neck swellings are potentially serious signs

These signs can be quite similar to other benign conditions affecting the eye such as conjunctivitis, chalazion or blepharitis and therefore need very careful and expert consideration.

Eyelid Tumours

This are usually slow growing and do not “destroy” tissue

Naevus

Naevus: Congenital nevi present early in childhood and may become more obvious and enlarge during puberty. They are usually well-circumscribed (meaning they have a distinct border), round/oval and with a consistent colour

Melanomas may rarely develop within nevi. Cause for concern include change in colour, increased pigmentation, irregular borders, becoming raised, itching or bleeding

Suspicious lesions should be excised entirely if possible to get an accurate diagnosis and clearance.

Warty lesions

Actinic keratosis

Squamous papilloma (warty lesions) are raised, often pedunculated,(meaning they have a small stalk). They are usually skin coloured growths. They can enlarge and can spread over time. The more serious squamous cell carcinoma may look similar, so if in doubt it will need to be biopsied (solar keratoses) are round, scaly, sometimes red/brown patches of skin which usually arise in sun damaged skin. They are premalignant and can sometimes develop into a skin cancer. They can be treated by excision and biopsy, or treated with medicated cream, freezing (cryotherapy) or photodynamic therapy (PDT). Not all treatments are suitable when close to the eye.

Basal cell carcinoma (BCC or “rodent ulcer”)

Basal cell carcinoma (BCC or “rodent ulcer”) is the most common malignant eyelid tumour in the white population. They are slow-growing skin cancers which cause distortion and destruction of the eyelid margin with the skin being slowly “gnawed away” hence the name “rodent ulcer”. They can have pearly edges, with prominent blood vessels and a central crater.

They are most commonly found on the lower eyelid or medial canthus (next to the nose) in the older people. Fair skin type and sun exposure are risk factors. They may occur in younger people if they have had significant sun exposure
They rarely spread to the rest of the body (metastasis), but damage surrounding tissues and can deeply invade the skin, this is problematic especially if they arise near the medial canthus near the nose.

There are two main types:
• Nodular BCCs are well demarcated, firm nodules with telangiectasia (blood vessels) and sometimes with a crater in the centre.
• Morphoeic BCCs are firm and flatter, distorting the skin and subcutaneous tissue. The have indistinct borders.

Squamous cell carcinoma (SCC)

SCC can be scaly, red, rough, thickened skin which may look like a wart. They can bleed. They have variable appearances often making it difficult to distinguish from other lesions without a biopsy. They are often more extensive than is obvious at first appearances.

An SCC can metastasise and invade deep tissue. It can spread within the nerves.

It may arise in premalignant lesions such as actinic keratosis or cutaneous horn.

SCCs are more common with age, sun damaged skin and fair skinned individuals.

This needs to be managed seriously, by a cancer multidisciplinary team (MDT) to check for local and distant invasion, disease elsewhere as well as any genetic predisposition.

Keratoacanthoma

Other malignant tumours

Management of malignant eyelid tumours

Full examination of the eyelid, skin and orbit should be carried out (including examining the underside of the eyelids). Checking for loss of sensation loss, additional lesions and for local and systemic signs of disease should be undertaken.

Photography is also helpful

Biopsy (Histology)

Oncology multidisciplinary teams (MDT)

Most of the above diagnoses need to be discussed in cancer MDTs to make sure the correct investigations are carried out looking for local and systemic involvement. CT or MRI scans, ultrasound and PET scans, as well as blood tests will be required

Some cases may need to be considered for sentinel node biopsy (eg melanoma and sebaceous carcinoma). Histopathologic confirmation must precede any extensive procedures.

Oncology multidisciplinary teams (MDT) form an important part of managing more servers and complex tumours and cancers. Decisions about the best investigations and management options (conservative, surgical, chemotherapy, radiotherapy, newer treatments etc.) are discussed and then considered with the patient. My Uddin is part of many excellent, long-standing MDTs where he will I put his experience and special considerations of the eye, eyelids and orbit including at Moorfields Eye Hospital, St George’s Hospital Medical School and Guys & St Thomas’ Hospital.

Treatment of malignant eyelid tumours

The treatment plan is dependent on whether the tumour is cancerous, and the type of tumour which is established with a biopsy. Mr Uddin works alongside a team of accomplished oncologists, radiologists, dermatologists and head & neck surgeons to provide compassionate, holistic, complete care.

Why choose an oculoplastic surgeon for Periocular tumours and reconstruction?

Oculoplastic surgeons are trained to look after the eye and further training relating to the eyelids, underlying orbits and periocular tissues. They also to understand the importance of the delicate anatomy, specifics of each layer and reconstructive options to provide excellent form and function around the eye.

Basal cell carcinoma

Basal cell carcinoma are largely treated with surgical excision, then checking there is clearance by histology and review. This is followed by reconstruction to restore function and aesthetics.

Sometimes MOHS surgery is recommended. This involves surgical excision with immediate histology using frozen section technique and then repeated until the tumour is cleared in one session.

Cryotherapy (freezing) and radiotherapy are used in exceptional circumstances.

Creams, such as topical imiquimod can be used if the BCC is an adequate distance away from the eye

Avoidance of sun exposure and use protective sunscreens is advocated after diagnosis of a BCC

Squamous cell carcinoma

Sebaceous carcinoma

Sebaceous carcinoma needs to be staged initially with map biopsies of the surface of the eye (conjunctiva) to look for extent of Pagetoid (diffuse). spread or deeper tumour, as well as systemic investigation.

Following this, a plan is made to excise the lid component. The conjunctival surface can be managed with excision and topical medication.

Severe, extensive disease may very rarely necessitate remove all of the eye and surrounding tissues (exenteration)

Malignant melanoma