Pigmented Lesions of the Eyelid Treatment & Management

The benign pigmented lesions of the eyelids do not require any medical therapy. However, any benign lesion that affects vision should be excised with primary reconstruction. Vision can be affected in various ways, most commonly by a mechanical blepharoptosis (with occlusion of the visual axis) or by induction of astigmatism. In the first 10 years of life, this can lead to amblyopia and permanent reduction of vision if not treated in a timely fashion. Malignant lesions require surgical excision.

For patients with primary periocular basal cell carcinoma, Moesen et al found that cryotherapy using a nitrous oxide probe has certain advantages over surgical removal of tumors in the periocular region, but careful follow-up is advisable. ^[7]

Surgical therapy may be performed for cosmetic reasons or suspicion of malignancy in benign pigmented lesions.

The procedure of choice for treatment of cutaneous malignant melanoma of the eyelid is wide surgical excision with 1 cm of skin margins confirmed by histology. Regional lymph node dissection should be performed for tumors greater than 1.5 mm in depth and/or for tumors that show evidence of vascular or lymphatic spread.

Surgical excision always should be performed with attention placed toward obtaining clean surgical margins. At the present time, 2 forms of analysis currently are performed to obtain this goal, as follows: frozen sectioning and Mohs micrographic surgery. Mohs surgery is a specialized technique and is not offered in many rural areas. Although both modalities achieve the same endpoint, it has been postulated that Mohs surgery provides a more definitive result. This does not mean that frozen section analysis is in any way inadequate or inferior, as frozen section analysis does yield excellent results. At the current time, surgeon preference dictates pathological processing. If possible, frozen sections of pigmented malignant lesions should be confirmed with permanent sections of margins. Any suspicion of a positive margin with a pigmented malignancy should prompt reoperation with a new biopsy or a wider excision.

A retrospective survey of the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the European Society of Ophthalmic Plastic and Reconstructive Surgery by Esmaeli and colleagues yielded 44 cases. ^[8] The patients' age, sex, date of diagnosis, histologic classification of melanoma, Breslow thickness, Clark level, location of melanoma, size of margins of excision, and findings of local or regional recurrence or distant metastasis were recorded in each case.

According to this study, patients were stratified on the basis of margins of excision: less than or equal to 5 mm; greater than 5 mm but less than 10 mm; and greater than or equal to 10 mm. Patients were also stratified by Breslow thickness. The main outcome measures were the incidences of local and regional recurrence and distant metastasis as a function of margins of excision and Breslow thickness.

Most patients in this study for whom reliable information was available had excision margins of less than or equal to 5 mm. The Breslow thickness of most of the tumors was less than or equal to 1 mm.

Eleven patients (25%) had local recurrence. Five patients (11%) had regional lymph node metastasis. All patients with regional nodal metastasis were men. Distant metastasis developed in 3 patients (7%), that is, 2 men and 1 woman. The follow-up times ranged from 10-108 months (mean, 34 months; median, 21 months). The incidence of local recurrence was higher among patients with melanomas at least 2-mm thick and margins of excision less than or equal to 5 mm than among those patients with melanomas at least 2-mm thick but with margins of excision greater than or equal to 10 mm; however, this difference was not statistically significant because very few patients had melanomas at least 2-mm thick.

Breslow thickness was the only statistically significant predictor of local, regional, and distant metastasis. Margins of excision did not have a statistically significant effect on local, regional, or distant recurrence. ^[8]

Laser can be used for certain eyelid pigmented lesions; a recent study has shown a case of bilateral uveitis after intense pulsed light therapy for eyelid pigmented lesions. ^[9]

In general, biopsy should precede all extensive tumor resections, even if the clinical diagnosis seems apparent. There is debate as to the danger of incising into a melanoma for biopsy. Biopsies of pigmented lesions that are highly suggestive of malignancy probably should be a complete excision (excisional vs incisional) and clear margins confirmed on permanent section from the primary excision.

On malignant melanoma, excisional surgery with regional lymph node dissection should be performed, if warranted.

A metastatic evaluation is recommended for patients who have malignant lesions.

Benign lesions should be observed. Epithelial lesions that display painless growth, irregular borders, ulceration, induration, or telangiectasia should raise suspicion of malignancy. Signs that show malignant change in pigmented lesions include irregular borders, asymmetric shape, color change or presence of multiple colors, recent changes, or diameter greater than 5 mm. As with all malignant lesions of the eyelid, madarosis (loss of eyelash cilia) and meibomian gland destruction also should increase suspicion significantly.

From the study by Esmaeli and colleagues, Breslow thickness appears to be the most important prognostic indicator for eyelid skin melanomas. ^[8] A 5-mm margin of excision may be adequate for thin melanomas of the periocular skin; however, because of the small number of patients in this series who had margins of excision greater than 5 mm, a definitive comparison of outcome with larger margins of excision cannot be made. For melanomas greater than or equal to 2 mm, wider margins of excision may be prudent, and careful surveillance for local and regional recurrence is indicated. ^[8]

Benign lesions rarely have malignant transformation; therefore, a biopsy or excision should be performed on lesions suggestive of malignancy that demonstrate irregular growth or appearance. ^[10]

Nevus of Ota can present with malignant degeneration with the choroid at the site of involvement. Periodic fundus examination and follow-up care for glaucoma are recommended.

Metastasis is linked to the depth of invasion from malignant melanoma.

Most benign lesions have an excellent prognosis. The treatment varies according to site, diagnosis, and systemic evolution. The prognosis and metastatic potential from melanoma are related to the depth of invasion, as described by Breslow. ^[6]

The current literature is not extensive enough to draw any conclusions regarding definitive treatment of malignant melanoma of the eyelid. At the current time, treatment of eyelid melanoma is extrapolated from data reported on melanoma treatment in other areas of the body. Further studies are warranted.