Practice 10-Minute Consultation

Eyelid lumps and lesions

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3029 (Published 19 May 2014) Cite this as: BMJ 2014;348:g3029
  1. Anjali Gupta, specialist trainee 2 ophthalmology1,
  2. Simon Stacey, general practitioner2,
  3. Kwesi N Amissah-Arthur, specialist trainee 7 ophthalmology1
  1. 1Birmingham and Midland Eye Centre, Birmingham B18 7QH, UK
  2. 2Westrop Surgery, Highworth, Swindon SN6 7DN, UK
  1. Correspondence to: A Gupta Birmingham and Midland Eye Centre, Dudley Road, Birmingham, United Kingdom, B18 7QH anjaligupta{at}doctors.org.uk
  • Accepted 5 March 2014

A 65 year old roofer presents to his GP with a slow growing lower lid lump of several months duration. It is not tender but there is involvement of his lid margin.

What you should cover

Eyelid lumps have a variety of causes, ranging from innocuous cysts to malignant lesions. Although sinister pathology is rare, early identification and referral are essential to ensure a good outcome.

History

Is it chronic?—Chronic lesions include papillomas (viral warts), naevi, sebaceous cysts, and molluscum contagiosum. These all have the same appearance as elsewhere on the body. Molluscum near the lid margin can cause a persistent follicular conjunctivitis.

Chalazia (figure 1) are the commonest chronic eyelid lumps. They are caused by a blocked meibomian gland. Chalazia are entirely benign; however, it is important to be suspicious of a recurrent chalazion in the same position as this might represent a malignancy.

Figure1

Fig 1 Lower lid chalazion of the left eye. The lid margin is not distorted and there is no madarosis (loss of eyelashes), suggesting a non-sinister lesion

Is it tender?—Tender eyelid lumps and lesions are often acute and associated with infection. Hordeolum externum (a stye) arises from a staphylococcal infection of a lash follicle, presenting as a tender, erythematous, pus filled lesion near the eyelid margin. Hordeolum internum (an infected chalazion, figure 2) presents similarly, but is located away from the lid margin.

Figure2

Fig 2 Left upper lid internal hordeolum with limited cellulitis

Dacryocystitis (figure 3), an infection of the lacrimal sac caused by a blocked nasolacrimal duct, is another periocular tender swelling. It is located beneath the medial canthus, and patients will often give a history of a watery eye.

Figure3

Fig 3 Acute dacryocystitis of the left medial canthal area with abscess formation and localised cellulitis

Is it evolving?—As with skin lesions elsewhere, always consider malignancy. Is there a history of excessive sun exposure, immunosuppression, or skin conditions such as actinic keratosis? These are all risk factors for squamous cell carcinoma (figure 4).

Figure4

Fig 4 Ulcerating squamous cell carcinoma of the right upper lid. Note the madarosis and the irregularity of the lesion

More specific points to ascertain from the history include the following questions. Is there discharge from the eye? (a possible sign of an infective process), and is there blurring of vision? This might indicate an internal lid lesion causing corneal compression or increased tear secretion.

Examination

Location—Although chalazia, basal cell carcinomas, and squamous cell carcinomas can occur on the upper or lower lid, chalazia are more common on the upper lid, whereas basal cell carcinomas and squamous cell carcinomas are more common on the lower lid because of exposure to sunlight. Basal cell carcinomas also have a predilection for the medial canthus.

Surface features—Any ulcerating lesion should raise concern. A squamous cell carcinoma is typically an ulcerating or hyperkeratotic lesion (figure 4). Of the many types of basal cell carcinomas, the most common is nodular (figure 5). It exhibits a pearly edge with surface telangiectasia, which might have central ulceration.

Figure5

Fig 5 Nodular basal cell carcinoma of the right lower lid. Note the distorted lid margin, pearlescent rolled edge, and telangiectactic surface vessels

Appearance of the surrounding skin—Erythema might indicate a focal infection such as an external hordeolum, internal hordeolum, or dacryocystitis. Diffuse erythema suggests an associated cellulitis.

Mobility of lesion—Mobile lesions include papillomas. Immobile lesions include sebaceous cysts, which are often found at the medial canthus.

Colour/pigmentation—Seborrhoeic keratoses (figure 6) and cutaneous naevi are common benign pigmented periocular lesions. Eyelid melanomas are rare but lethal. A spreading pigmented lesion of the eyelid should raise concern. However, half of eyelid melanomas are clinically non-pigmented, which can raise diagnostic uncertainty. The mnemonic ABCDE (Asymmetry, irregular Border, Colour variegation, large Diameter, Elevation) is a useful aid to remember features suggestive of a malignant melanoma.

Figure6

Fig 6 Right lower lid non-pigmented seborrhoeic keratosis. Note the presence of eyelashes over the lesion and the regularity of the lid margin suggesting a benign lesion

Yellow plaques, commonly bilateral and located medially, are likely to be xanthelasma.

Translucency—Suggestive of a cyst of Moll (figure 7), a benign fluid filled swelling arising from an obstructed sweat gland

Figure7

Fig 7 Cyst of Moll of the right lower lid involving the punctum. The lesion is regular and fluid filled

Size—Itis essential to document the size of the eyelid lump or lesion to aid monitoring of the lesion. Serial photographs can assist in documenting a change in size.

If possible, evert the lower and upper lid because lesions that seem small might have a large component hidden from direct view. Also, examine the regional lymph nodes when suspecting a squamous cell carcinoma—20% of lesions spread to these nodes.

Red flags

  • Distortion of the lid margin

  • Loss or whitening of eyelashes

  • Recurrent “chalazia” in the same position

  • Skin ulceration or bleeding

  • Diplopia

  • Proptosis

These red flags might represent a malignancy. The latter two indicate orbital invasion.

What you should do

Conservative management

  • Warm compresses applied to closed eyelids might be helpful for small chalazia, internal and external hordeola. The role of topical antibiotics is debatable. Oral antibiotics should be used if there is an associated cellulitis.

  • Xanthelasma are unlikely to resolve spontaneously. It is important to check the levels of serum lipid because half of all xanthelasma are associated with raised levels of lipids.

  • Reassure patients about papillomas; they are harmless and might resolve spontaneously.

  • Ask patients to self monitor naevi and to re-present if there is growth or any change.

  • Lubricants might alleviate symptoms from a follicular conjunctivitis associated with molluscum.

Routine referral

Potentially, persistent chalazia, sebaceous cysts, cysts of Moll, and seborrhoeic keratoses can be excised at a local minor operations clinic either in the community or in the hospital, depending on the local contractual arrangement. If no sinister features are present, and the patient does not want cosmetic removal, self observation by the patient is advised.

Urgent referral

Refer urgently to a specialist if any of the red flags are present or there is a suspicion of malignancy.

Useful reading

Notes

Cite this as: BMJ 2014;348:g3029

Footnotes

  • This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs

  • Acknowledgements: The authors thank Simon Madge, consultant ophthalmologist at Hereford County Hospital, for assistance with obtaining the images.

  • Contributors: All three authors (AG, KAA, and SS) fulfil the four criteria as authors. AG contributed to the design and writing of the paper and its subsequent revisions. SS contributed to the redesign of the paper, after the initial draft, and writing of the subsequent revisions. KAA had the initial idea of the paper and contributed to its design and assisted in writing the paper and its subsequent revisions. KAA is guarantor. All the authors approved the final version to be published and are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Simon Madge contributed to the paper by helping to acquire the images in the article.

  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare no competing interests.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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