October 10, 2024 • 36 mins
One of the most common clinical presentations to ophthalmologist is 'the eyelid lesion'. While sometimes it might seem obvious what the diagnosis is, other times it's tough to make a spot diagnosis or even to decipher whether the lesion is concerning or not. So what are some helpful examination tips to help us discern the benign from the malignant? Oculoplastics specialist Dr. Lisa Jagan joins the podcast to share an effective approach on how to decide what types of eyelid lesions warrant a biopsy.
This episode is sponsored by Sun Pharma Canada - https://sunpharma.com/canada/
Check out Lid Express to help expedite a patient's referral for an eyelid lesion - https://clarityeye.ca/services/lid-express/
Become a supporter of this podcast: https://www.spreaker.com/podcast/blind-spot-the-eye-doctor-s-podcast--5819306/support.
This episode is sponsored by Sun Pharma Canada - https://sunpharma.com/canada/
Check out Lid Express to help expedite a patient's referral for an eyelid lesion - https://clarityeye.ca/services/lid-express/
Become a supporter of this podcast: https://www.spreaker.com/podcast/blind-spot-the-eye-doctor-s-podcast--5819306/support.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:11):
Hey everybody, I'm Zael Mednick and welcome to another episode
of blind Spot. This episode of blind Spot is sponsored
by Sun Pharmic Canada and we thank Sun Pharma Canada
for their support of blind Spot. Patients come in all
the time with eyelid lesions, whether it's Chilesians, pappoalomas, baso
cell carcinomas, squamous cell carcinomas, or more concerning tumors. But
(00:33):
when a patient shows you a lid lesion, it isn't
always so simple to know what it is. It isn't
always so easy to say, yes, this needs to be biopsied, No,
this doesn't need to be biopsied. And despite how common
lid lesions are, it's surprising how often patients come in
where we don't actually know what is going on and
what that lid lesion is. I'm joined today by oculoplastic
(00:53):
specialist doctor Lisa Jagan to chat about lid lesions and
an approach to bring a little bit of light into
our blinds. Doctor Jagan is an optalmologist that specializes in
oculoplastic surgery. She's published extensively in the field, contributes actively
to peer review, and is currently co authoring a procedural
oculoplastics textbook. She's the past vice president of the Toronto
(01:14):
Ophthalmology Society and the director of LID Express. She's extremely
passionate about health systems, education, and health technology and has
received significant funding from various organizations to execute projects in
these areas. Lisa, Welcome to the podcast. Thanks so much
for joining me, Thanks for having me. So we're talking
about lyd legions today, and I started in the introduction
about how like it's kind of one of those things
(01:36):
that you think is obvious. We learn in residency what
is concerning, what's not concerning, and we kind of have
this assumption that the concerning legions will be obvious to us,
and the non concerning legions will be obvious to us too,
And in a sense, that's our blind spot because then
when you get into real practice and there's nobody looking
over your shoulder, when somebody comes in with an eyelid legion,
(01:59):
you're like, oh, wait a second. If I'm the last
person who's going to say this is not concerning, I'm
a little bit more worried. And it's actually not so straightforward.
And I actually remember you were colleagues at one of
the clinics we work at. I sent you a li
lesion a few months ago, and people probably send you
lid legions all the time. I said, this looks fine, right,
And the reason I said it was because I was
(02:20):
convincing myself it looks fine. And he said, well, actually,
there's one sign on it that doesn't look one hundred
percent fine, so send it to me. And it was
just an example of it's really not as simple as
a lot of us probably think it is. So that's
kind of what them for this conversation is to unpack
(02:40):
how we can look at lid legions a little bit differently.
That's a long way of prefacing what do you think
is some of the biggest preconceptions about iselid legions.
Speaker 2 (02:51):
Yeah, Zil, I.
Speaker 3 (02:52):
Think it's exactly that.
Speaker 4 (02:54):
For the comprehensive ophthalmologist, the biggest preconception is that you
need to be able to look an eyelid lesion and
immediately know what the diagnosis is. And I understand why
you and other ophomologists might feel this way because we
rely so heavily on pattern recognition and ofphomology. For example,
(03:14):
you and I can just look at the lens and say, well,
there's a nuclear sporadic cataract, and this is the grade.
Generally there's it's a bit more black and white, but
with islid lesions they are a lot more tricky in
that one, you know, the average comprehensive optomologist isn't spending
all day every day looking at iselid lesions, so your
(03:37):
repertoire isn't as extensive to diagnose them on spec And
then two is that even for the most seasoned oculoplastic
surgeons or dermatologists, we still make the wrong call all
the time, and we rely on biobcy so much to
help us make the diagnosis. So the main goal really
then for the comprehensives should be to develop more confidence
(03:59):
in identifying which iselid lesions have worrisome features that should
prompt for the workup. And that case that you were
talking about wasn't straightforward so very reasonable, very good, good referral.
Speaker 1 (04:11):
But you're right in that a lot of the time
in optalmology we're trying to In fact, one of the
reasons people like ophthalmology, and when people ask why did
you go into optomology, people will say, including myself, is
because somebody comes in I look at their eye. I
know what the problem is, I diagnose it, and usually
it's something that we can treat. And that's not the
case with eelid lesions. But in terms of knowing exactly
(04:33):
what it is, you're correct. And with corny, I find
that a lot of times I actually will send back
and say, I don't actually know what it is, but
I know that it's not concerning, or it is concerning
enough that I do want a biopsy. So what is
your approach? Having kind of laid out that framework that
it isn't always as essential to say I know what
the diagnosis is, and maybe that's actually detrimental to our approach.
(04:56):
What is the better approach when you're looking at eelid
lesions and saying this is concerning, needs a biopsy, or
this is not concerning, does not need a biopsy, Because
that's the gist of what I'm getting from what you're saying.
Speaker 3 (05:09):
Exactly.
Speaker 4 (05:10):
Yeah, you know, every time I look at an eyelid lesion,
at minimum, I try to make three observations and those
three are lash loss eyelash loss. The second would be ulceration,
and the third is infiltration. So if you put those
things together, there's an acronym louis, so that's Lui, and
(05:34):
I'll describe those in more detail here. But l for
lash loss is essentially a distinct patch of eyelashes that's
absent along the eyelid margin. So sometimes you might see
these bumps growing and then it'll sort of display or
display the eyelashes on either side of the bump. That's
different than what I'm talking about with lash loss. In
(05:57):
this situation, there's clearly no lashes grow growing nearby, and
if I saw that, I would be suspicious for skin
cancer or malignancy.
Speaker 1 (06:07):
So for lash loss, there important important differentiation there. You're
not talking about something that's there and is like wedging
the lashes to the side. You're talking about like an
actual alesion where the lashes are not growing through it.
And that's the one that's the photo I sent you
where to me it looked really benign. I did. The
(06:27):
reason I sent it to you is because there were
no eyelashes growing right out of it. But I still thought, oh,
but this can't be anything, because because it looks it
looks so innocent. But if you see a lesion, even
if it looks normal and there's no lashes on that
margin area that is concerning.
Speaker 4 (06:43):
That is concerning, and these aren't you know, these aren't
slam dunks. It's just what's increasing your pretest probability that
something else is going on. But exactly that that, it's
the loss of the lashes completely, like there's nothing growing there.
Speaker 2 (06:58):
So the second feature that that was the ulceration for the.
Speaker 4 (07:01):
Louis acronym, and that's an area where there's tissue breakdown
or erosion. So essentially what you'd see is a depression
or a crater sort of looks like someone has scooped
out some of the tissue from the center of that
eelid bump. And if I saw ulceration happening, then again
I would be suspicious for a malignancity for ulceration.
Speaker 1 (07:24):
When we're talking about that kind of indentation. What about
when you see an area that just looks like a
little bit raw, like looks like it's a little bit red,
or looks like there's a little bit of scabbing or
bleeding there. And obviously sometimes that's pretty consistent with the
Chilesian or something active going on. But if you see
like a redness in that area that I don't know
if you'd necessarily call that ulceration. Do you put that
(07:46):
in that same bucket or umbrella?
Speaker 4 (07:49):
You know, it's it's it's a hard one to call definitively.
But oftentimes where you see that there's a scab or
some dried up blood, if you were to wet that
area with a Q tip and and remove it, you
would actually see some indentation there. It's just that we
often don't spend the time.
Speaker 2 (08:05):
To do that. If it's just sort of dried up blood.
Speaker 4 (08:08):
Without any sort of depression, which you can have in
other types of lesions, then that won't really constitute under this.
Speaker 2 (08:16):
Particular descripture ulceration.
Speaker 4 (08:19):
But I still think it's something to be worried about,
Like a lesion that scabs or bleeds often without the
patient doing something to provoke it, that would be still
concerning feature, but not one of the ones that are
in this little framework of just purely observation.
Speaker 1 (08:35):
Okay, so we have the eye in Louis.
Speaker 4 (08:38):
Yes we're onto the eye. So the eye is for infiltration.
This is this one is a bit hard, I have
to say, if you're not used to looking at eyelids
all the time. But so the eye stands for infiltration,
and essentially it means when there's abnormal tissue that's invading
or destroying the normal eyelid architecture. So if you were
(09:00):
to look at a young person's eyelid, you're often easily
able to tell that there are two sections. There's the
front part, the antier lamella, and that's where the eyelashes
grow through. And then there's the back part, which is
a post deer lamella. That's where you have the tarsus
and the my bomean glands. Often and what you should
(09:20):
be able to see is a line visible that separates
these two parts, often called the gray line, and it's
helpful to look for that line to be contiguous along
the whole breadth of the island margin because if you
find that there's an area where that line is completely
lost or distorted, then that is an indication to me
(09:41):
sort of to zoom in and more carefully examine that
area because it can be assigned for malignancy.
Speaker 1 (09:48):
Yeah, so sort of those two layers not having that
discrete gray line margin.
Speaker 4 (09:54):
Correct, Yeah, exactly. So those those are the features of
Louis acronym. That's what I tend to use just as
a base framework for every single eyelid bump that I see.
Even if I see something and in the back of
my mind I have a hune that it might be this,
or it might be that.
Speaker 2 (10:10):
I try to.
Speaker 4 (10:11):
Always use that observational framework every time and get in
the habit of it. And one thing I think important
to note is a patient doesn't have to have all
three of those features by any means. Just having one
is enough to have some suspicion. The more you have
makes you more suspicious and would really warrant to biopsy
if you were seeing all three in a given leasion.
Speaker 1 (10:33):
I love that because it's such a practical approach you're
not saying, especially especially you who's an oarchaoplastic specialist, you
do have a greater catalog of patients you've seen, right,
so there are more likely spot diagnoses you're going to
be able to make. But even you, and especially for
the general optalmologists, where we're not able to make that
spot diagnosis, the approach in many regards is probably better
(10:55):
not to try and make that spot diagnosis unless it's
leaping off the eyelid to you, keeping off the page,
so to speak, and it's better to look at those things.
And like you said, you're not saying that means it
is definitely something dangerous, but that is what's going to
guide you in either doing a biopsy or sending you
to an oculo plastic specialist to consider a biopsy.
Speaker 4 (11:13):
I really like the Louis acronym and it comes actually
from a study that was published at Queen's Queen's University,
which is where I did my oculoplastic fellowship, led by
doctor vlad Kracky vod Mercracky, And you know, the study
essentially asked an expert panel of oculo plastic surgeons to
provide descriptions of the features which made them suspicious for malignancy.
(11:38):
And these were the top three predictive features, the Louis
features that helped determine whether or not an eyelid lesion
was malignant or not. I do think it's a great
study and it does have photos that are worth looking
at to help visualize the Louis acronym.
Speaker 1 (11:53):
And when you say that it was predictive, so they
did they asked people like what are you looking at?
Then they did the biopsies and then they were able
to kind of compare which signs the oculopastic specialists reported
and correlated that with the pathology results.
Speaker 4 (12:06):
Yeah, exactly. Although they did it based on photographs of eyelids.
It was two dimensional and essentially they were looking at
about two hundred consecutive patients. But that's that's the approach
that they used.
Speaker 1 (12:20):
What are some other concerning signs for malignancy when obviously
Louis is a really good starting point and in some
situations is all you kind of need to say, Okay,
something's up here. What are some other concerning signs from malignancy? Though,
when you're examining a patient and you're just not sure.
Speaker 4 (12:39):
Right, So I think extension of the lesion to places
where we wouldn't want to see it extending. We're gon't
expect it to extend. So if it's on the outside
of the eyelid and now we're seeing it extending onto
the inner sort of tarsal conjunc taila, we're on the
sclera or you know, palpeople conjunc taiva, that would be
concerning for me.
Speaker 2 (12:59):
Also, if we.
Speaker 4 (12:59):
Start did to see that there was a loss of
important structural landmarks. So a lot of times when we
have squama cell carcinomas or basal cell carcinomas in the
medial cancel area. If you look closely, you'll actually see
that you no longer see, you know, a punctal opening,
or you're not you know, you're missing some of the
(13:20):
normal sort of infrastructure in that area.
Speaker 3 (13:23):
And then other things.
Speaker 4 (13:25):
Would just be sort of, uh, how how telanjectatic it looks?
Speaker 3 (13:30):
Pigmentation?
Speaker 4 (13:32):
Is that pigmentation, you know, really abnormal or sort of
lots of different areas of pigmentation, and that's sort of
that ABCDE But those would be other things that I
look for.
Speaker 1 (13:44):
Let's let's talk about pigmentation a little bit, because that
obviously scares people. Whenever you see pigment, you're thinking, Okay,
I just want to make sure I'm not missing a melanoma.
How what's your what's your approach to pigmented lesions? And
I guess my first question with that is HYPWK in Toronto,
where it's very cultural and there's a lot of patients
with darker pigmentation. In patients with darker pigmentation, is the
(14:05):
concern level for these pigmented lesions a lot lower? Obviously?
Speaker 4 (14:12):
For sure, it's it's definitely a lot lower. The risk
is for melanomas in particular, for pigmented lesions is way higher.
I think it's somewhere around ten ten times as high. Yeah,
you know, each study has a different report, but you know,
six to ten times as high and Caucasian patients compared
to say, in African So definitely not impossible though. And still,
(14:37):
you know, when it comes to stats like that, it's
good to have in the back of your head, but
it doesn't really change for me, you know, my approach
when I'm looking at that patients because hey, maybe this
is that one in you know, however many in front
of me. The way that I approach patients in general
when it comes to pigmented lesions is looking for other
(15:00):
areas of pigmentation that look similar on the face, and
usually patients like of Indian descent or Caribbean or so on,
you might see that they have lots of other pigmented
lesions all around their face or on their other parts
of their skin, which tends to be reassuring. There's the
ugly duckling sign that can often be used, which is
(15:20):
getting a gestalt of what the pigmented lesions look like
in other parts of the face. And then does the
one on the eyelid look a lot different than that,
or does it look like it could fit in. It's
part of the family of what we're looking at, and
I find that to be helpful. Usually, if there's a
lesion that's symmetric, like for example, a lot of times
(15:40):
in patients with some sort of you know, pigmented complexion,
you will see along the eyelid margin some changes where
it looks more brown or more black. But you'll see
that in many areas on both sides. And so once
you start seeing that show up on both sides, then
that's really reassuring. And although we say we look for
(16:02):
things that change over time as a concerning feature, I
do think for sure as pigmented patients get older, those
pigmented changes can become more noticeable. So it's a really
tough one. In general, I think that pigmented eyelid lesions
are a challenge for even the most seasoned oculoplastic specialist.
(16:25):
For the most part, my spiel to patients is, hey,
you know, the likelihood of this being melanoma or being
something serious is very low, but if it is something
like melanoma, then that can be quite serious. And we
don't want to miss it. So we have a couple
of options. Option one is that my suspicion is very low,
(16:47):
so I can monitor you and see you back in
say six months, and then again in one year, and
we can take serial photographs to see if it starts.
Speaker 3 (16:55):
To look different or change.
Speaker 4 (16:57):
The other option is that we just sort of byop
see it from the get go to get an indication
of what it might be at this stage, and you
can leave it in the patient's court because some people
just want that reassurance. Other people are just totally not
worried and they don't want to go through that process,
and you're just empowering them to make that decision.
Speaker 1 (17:16):
And I kind of jumped the gun there by going
to kind of patients who are pigmented and making it
a little bit more of a challenging situation in somebody
who's Caucasian. What are some of the signs you're looking
at that are going to prompt you, because that's where
when I see somebody with a pigmented lesion, I'm really
more concerned specifically because if you do look at both eyelids,
(17:36):
that symmetry often isn't there that they have that pigmented complexion.
I know that the ABCD acronym is used for general
skin lesions that we learn in med school. Does that
apply to the eyelids? And what's your approach in Caucasians?
Speaker 4 (17:53):
For sure, that's a really good question. I do have
a much lower threshold for pushing for biopsy. I almost
always would push for a biopsy if there was a
newly pigmented lesion around the eyelid and it's you know,
one one bump and there's nothing else there, you do
We do still use the abc D. I think it's helpful.
(18:14):
And so just to review, A is for asymmetry, so it's.
Speaker 3 (18:18):
Not you know, symmetric on both sides.
Speaker 4 (18:22):
B is for the borders, so irregular borders. C would
be color variations, so different you know, levels of pigment.
And remember you can also have melanomas that are not pigmented.
They can just look flesh colored. D is for the diameter,
and then E is for evolving or changing. So I
would say that those come into play. But realistically, any
(18:46):
new lesion that a Caucasian patient has that is a
pigmented lesion, even if they're young in their you know,
twenties or thirties because it can present at that age.
For sure, I would be pushing for a biopsy. The
other thing I wanted to is just that family history
plays an important role when it comes to melanomas. So
I always ask whenever you see a pigmented lesion around
(19:07):
the eyelets, I ask if the patient has a family
history of melanoma. And if they have even a remote
family history, that's definitely pushing me in the direction of
doing a biopsy.
Speaker 1 (19:17):
In terms of the history, that obviously is really important
with melanoma, and with a lot of these lesions. Patients
often explain their allegions, and I remember you told me
once that you can kind of get false reassurance from patients.
What are some of the things that you want to
be weary of or not weary of, But what are
some factors on history that reassure you, and what are
(19:37):
some factors on history that alarm you a little bit more?
Even if the patient might think that they're trying to
convince you, oh no, no, no, no, it's fine, I've had
this for X amount of time.
Speaker 4 (19:47):
Right, So if a patient says that they've had an
eyelid lesion that keeps resolving and then recurring in the
same spot, then that's definitely something that alerts me to
some maybe being suspicious there. If they say that it's
bleeding and scabbing and it's not healing within a few weeks,
(20:09):
then I would be suspicious. Other things would be you know,
just how they feel. So sometimes lesions can be painful
or like extremely itchy. That can actually also push me
in the direction of considering doing a biopsy for that.
And then the family history is a big one, so
particularly for the melanomas, their personal.
Speaker 3 (20:30):
History is important.
Speaker 4 (20:31):
So if they say I've had a basal cell carcinoma
removed from my back or my scalp, then that will
push me in the direction of doing something. And then
there are some more obscure ones like having history of
radiation or ammno suppression, things that are likely to increase
the risk of developing these. So with a lot of
the biologics, there is a higher risk of developing sort
(20:54):
of these skin malignancies. And I had a patient actually
who can coming in with all of these recurring basil
cell carcinomas on the eyelid, and we kept going through
the process of biopsying and removing. But after going back
and doing a medication review, we saw that they were
on a type of medication that can increase that risk,
(21:15):
and so it is important to still look at that history.
Speaker 1 (21:19):
Yeah. And the reason I in a previous conversation when
that came up with us, when you said, kind of
the history can be a little bit misleading, I guess
would be those cases where they say, oh, no, I've
had this for a while, it comes, it goes, it
comes and goes, and initially our reaction right be oh,
basically that's just under the bucket of they've had this
for a long time, nothing to worry about, but coming
(21:39):
and going changing that is obviously different. And if you
actually parse down that history, that will make you concerned,
is what you're saying.
Speaker 4 (21:48):
Yeah, exactly, because we're always taught to do history first,
but I would say that for eyelid lesions, I like
to do the you know, use the Louis observational framework
first for last law ulceration infiltration, because the history can
be such a bias and it's so easy for patients
to say, oh, I was told this was a chlazy
(22:09):
and it's fine, but you know, they might have been
told that at a walk in clinic, and that diagnosis
just gets propagated. So it's almost better to have that
framework where you're looking at it and then you ask
the secondary historical questions that will actually change whether or
not you do the biopsy or push you in one direction.
Speaker 3 (22:28):
Or the other.
Speaker 1 (22:30):
Before we get to some of the management and biopsy techniques,
which we'll touch on briefly, I just want to ask
I've been harping on what are the things we need
to be concerned about? Are there any things that, in
granted we want to err on the side of being
more concerned than we want than the other side of
not being concerned, But are there any things when you
look at an eyelid lesion that actually can provide some
(22:52):
reassurance that this is a benign lesion? Obviously there are
some sort of spot diagnoses that we know more likely
that innoculo plastic diagnosis, will feel more comfortable making them.
But what are some things One of them, obviously based
on Louis is if you saw lashes growing through a
lesion that would be reassuring. Are there other things when
looking at eelid lesions that an ophthalmologist can say, Okay,
(23:15):
you know what I'm a little bit more reassured here.
Speaker 4 (23:18):
Yeah, I do think for sure there are some that
have a very classic appearance, for example apocrine hydrosystemas. But
essentially those are dome shape lesions. If you held a
pen light up to that lesion, you would see that
it transilluminates and they tend to be located in the
canthi like the medial or lateral can thi. That would
(23:40):
be that symmetry again, so the symmetry piece. If you're
seeing a lesion that looks the same in the same
area on both eyelids, that's reassuring. You mentioned the lashes
growing through bumps. I think that's for sure a big one.
Especially I get a lot of referrals for intradermal nev
that you know, patients will have had since their teenage years,
(24:02):
and they.
Speaker 2 (24:03):
Do look a bit funny.
Speaker 4 (24:04):
But the lashes growing right through the center of it
is it's a very.
Speaker 3 (24:08):
Reassuring piece for me.
Speaker 4 (24:10):
And then things that you know, for example inclusion cists.
You might see a epidermal inclusion sist. It almost looks
like there's this semi solid white material inside of the
dome shape lesion, and it's all very symmetric. One piece
that I'll mention here, and doctor Kracky was the one
who had taught this technique. But it's to use a
(24:32):
Q tip and then sort of lightly almost push or
kind of use a horizontal motion on the top of
the cyst and see whether you can see a wrinkle
in the skin above the cyst. Because when it comes
to basal cell carcinomas, for example, you can almost get
a nodule at times, but when you use a Q
(24:53):
tip on top, the skin is so distorted that you
won't see this wrinkling effect.
Speaker 2 (25:00):
It's hard to describe.
Speaker 1 (25:01):
Over the wrinkling effect is reassuring.
Speaker 4 (25:04):
The wrinkling effect is reassuring.
Speaker 1 (25:06):
Yeah, one thing you've talked a lot about is symmetry,
and I know that one thing that's important is doing
a gross examination and not just necessarily going straight to
the slit lamp and looking, because a lot of these things,
in terms of symmetry or in terms of the general appearance,
could be missed if you just look straight through the
slit lamp and aren't looking globally, just in the room
(25:26):
at the patient's face.
Speaker 4 (25:28):
Definitely, I think it's so important to spend that five
seconds and take a look at the patient where you're
seeing them with both of their eyes open, with you know,
natural light from the window or just the light in
the room. One of the issues with looking at bumps
under the slit lamp is that if the light is
on you know, too high of illumination, you're just washing
(25:50):
out a lot of the effect. I like to use
like a broader light if I am going to use
something and quite you know, almost more dim But for sure,
just just generally looking at the patient straight on with
that ambient light makes a huge difference for diagnosis.
Speaker 1 (26:06):
So let's say we've now gone through the process. We've
looked at an ilid lesion, We've referred to the appropriate person.
We've decided okay, by we, I mean you, you've decided okay,
this needs to be biopsied. Walk me through the process
of how some of these biopsies work. Obviously, some of
them are easier to take off than others, where you
just do an excisional biopsy because it's not too big,
and you send it to pathology and you get the result.
(26:28):
But then we hear a lot about things like frozen
sections and mos and those are terms that we probably
should know more about, but we probably don't know as
much about it as we as we should. Can you
describe a little bit about what those processes are and
what it's, what the differences when you would do them,
and what it entails.
Speaker 3 (26:46):
Right?
Speaker 4 (26:48):
So okay, So basically what you're saying is, we have
a patient. We took a sample of their eyelid lesion,
like we did an initial biopsy, and it came back
as cancer. So basically our next goal is to remove
it an entire and to understand the frozen section or
mose micrographic surgery. I do think it's helpful to understand
(27:09):
the more old school approach, which is what you were
talking about. I would say that's not used as often.
There are definitely situations where it is still the go
to depending on the community you live in and resources.
But essentially in the past, let's say that the patient
in front of me has a basal cell carsonoma and
(27:30):
I want to remove this, then I would be cutting
out the lesion with a margin of say three to
four millimeters all around it, and I'm trying to remove
it with this normal healthy margin all the way around it.
There are guidelines on how much to remove to feel
confident that you're getting rid of the entire skin cancer.
(27:53):
Then in real time, right away, after I've removed that bump,
I would go ahead and suture and repair the eyelid.
I'd still then have to send over that specimen so
the pathologists can look at it. That would probably take
two weeks, and then they'd get back to me and say, yeah, Lisa,
you got all of it.
Speaker 2 (28:10):
Good job, or it's possible.
Speaker 4 (28:12):
They might say, you know what, actually there was some
cancer left behind. But the downside here with that approach
is that I've already repaired the eyelid, so I can't
really know where to go back and try to cut
out more. So those patients would end up maybe getting
serial follow ups to make sure that there's no recurrence.
Another sort of downside to that classic approach that you're
(28:33):
describing is that I've just gone ahead and just chose
I've selected this margin that's quite a wide margin. But
the eyelid, unlike other parts of the body, there's not
a lot of skin to work with, and so we
really want to choose an approach that can preserve as
much skin as possible for the eyelid to preserve the function.
Speaker 1 (28:53):
Of the eyelid.
Speaker 4 (28:55):
So that's where the frozen section and the MOSE comes
in compared to like this old school classic approach, which
again still has its role, it's not out the window,
but with both frozen section and MOS, what we're doing
here is trying to keep as much eyelid tissue as
we can, and the way that we do that is
(29:16):
during the surgery, we remove what we see for that
eyelid bump, and then we send it to the pathologist.
In the case of a frozen section, the pathologist tells
us right there and then hey, like, you need to
take a little bit more from this side. There's still
some cancer cells on this side. So then we know
and we can go back and just selectively take a
little bit of a wider margin from that side before
(29:39):
we do the reconstruction. And again we would send what
we took off and the pathologists would read it and
get back to us. Usually so it takes it might
take like one or two iterations.
Speaker 2 (29:49):
Which is a long day for the patient.
Speaker 4 (29:51):
But the upside here is that we're getting our answer
right away and we feel more confident before we proceed
to do the actual reconstruction.
Speaker 3 (29:58):
Enclosure.
Speaker 4 (30:00):
The difference between a frozen section and Moe's it has
to do with the way that the original excision is
done and the way that that tissue is sort of
looked at under the microscope. So that is a little
bit technical and I don't think it's necessary to know,
but oculoplastic surgeons often use a frozen section technique. That
(30:22):
means that we have to arrange our surgery with a
pathologist who's ready to receive the specimen we send them
and we have that communication. Whereas Moe's surgery is done
all by dermatologists, so they're actually specially trained to do
most surgery where once they remove the malignant lesion, they
(30:42):
the dermatologists will himself or herself look under the microscope
and say, okay, I know I need to take out
more here and so on. So slightly different scopes, but
similar overall idea in preserving eyelid skin.
Speaker 1 (30:59):
It's a great exception. So it's they're both just as
opposed to doing an excisional biopsy where you're getting rid
of potentially everything you don't even know. If you're getting
rid of everything, you're doing it more slowly and preserving
more eelid tissue to help with a more efficient repair
which you can do on the spot exactly. Yeah, before
(31:20):
we finish up, I feel like a chat about eyelid
lesions isn't complete without talking about some of the really
concerning eyelid legions and like sebacious cell tumors, mercle cell
that kind of stuff. Will those be caught if you're
doing the Louis approach or what are some other things
that you want to be aware of for some of
(31:42):
these diagnoses that again might be spot diagnoses to oculopastic specialists,
but are really really important that we don't miss.
Speaker 3 (31:51):
Right.
Speaker 4 (31:52):
Louis does encapsulate some of these. I would say that
one that can tend to maybe evade the Louis The
acronym might be the sabacious an'te or sabacious ato carcinomas
because they're they're known to be the great masqueraders or mimickers.
They can present very differently to other types of islid lesions,
(32:14):
so we we're on alert for them. In situations like
a chelasian that seems to recur in the exact same
location every time, and that can come and go over
the course of several months or even years. Sometimes we
can see it as presenting like a unilateral.
Speaker 3 (32:31):
Bluff ro conjunctiveitis.
Speaker 4 (32:33):
So there's not even a focal area that we're necessarily
seeing as a lesion, but that eyelid skin is chronically
inflamed in a way that looks like blufferitis. But the
other eyelid is completely normal, and there's no explanation for that.
But most of the sebacious carsonomas that I've seen have
had some element of Louis. I think it's just hard
(32:56):
because they're much more rare, so we don't have as
much data to go on in terms of what to expect.
They do tend to be a bit yellowish in color,
a tough one, a tough one to pick up. Still
use the Louis acronym. Another lesion that I wouldn't want
to miss would be the Merkele cell carcinoma. And I
know I said you can't necessarily rely on pattern recognition,
(33:18):
but if there was one eyelid lesion to use pattern
recognition for, it would be this one. It has essentially
this violaceous red appearance. It's very chalanjectatic, and it grows
really quickly and you know, in the course of months
it can be massive. The reason it's so important to
identify it. It is because it's extremely aggressive and it
(33:40):
has a high rate of metastases, so there's only a
fifty percent survival rate in five years, which is really low.
You don't want to miss it, so you google image
Merkle cell carcinoma. That would be one one to take
away with you.
Speaker 1 (33:54):
Lisa, this has been such a great conversation, really practical,
which is what I love about it. Louis lash loss, ulceration, infiltration.
It's something we can all look for and it takes
some of the burden away from us of trying to
actually diagnose it. It's more, as in many things in
ophalmology and in medicine, is this concerning? Is it not concerning?
And that is a really really useful framework, and you've
(34:17):
provided so many other practical tips here. What are some
final thoughts yet for people who are listening to this.
Speaker 4 (34:22):
I would say that a part, yeah, for sure, the
Louis acronym. I hope that you can take away with
you and try to use it every time. But also
just remembering when making referrals, how helpful it is to
have a description for the oculo plastic surgeon. It's much
more helpful and easier for me to triage a patient
(34:43):
if I have an idea of the size, the location,
if there's an important family history of eyelids cancer or melanoma,
for example, those things affect how quickly we see the
patients because there's just so many referrals for eyelid abumps.
If I know that an ilid bump is located in
the medial canthas, I'm going to get that patient in
(35:05):
much more quickly because all the important structures that can
lead to invasion into the orbit are usually coming from
a lesion that's in the medial canthas, So something as
simple as that can make.
Speaker 3 (35:17):
A big difference for patients.
Speaker 4 (35:19):
So please, yeah, if you can try to add in
even just a few descriptors is helpful.
Speaker 1 (35:25):
Well, doctor Lisa Jagan, thank you so so much for
joining me. It's been a real delight chatting with you,
and we're going to have you back for another episode
at some point. Talk about a program you're doing called
LID Express, which is a really cool initiative to help
expedite some of these referrals and make it easier for
both patient and doctor to screen eelid lesions and we're
(35:45):
going to talk about that. Thank you so much for
joining me.
Speaker 3 (35:48):
This has been great, This is yeah, really fun.
Speaker 1 (35:51):
Thanks so and thanks everybody for listening to another episode
of blind Spot. Have a great day
Speaker 4 (36:01):
Pasting past
Hey everybody, I'm Zael Mednick and welcome to another episode
of blind Spot. This episode of blind Spot is sponsored
by Sun Pharmic Canada and we thank Sun Pharma Canada
for their support of blind Spot. Patients come in all
the time with eyelid lesions, whether it's Chilesians, pappoalomas, baso
cell carcinomas, squamous cell carcinomas, or more concerning tumors. But
(00:33):
when a patient shows you a lid lesion, it isn't
always so simple to know what it is. It isn't
always so easy to say, yes, this needs to be biopsied, No,
this doesn't need to be biopsied. And despite how common
lid lesions are, it's surprising how often patients come in
where we don't actually know what is going on and
what that lid lesion is. I'm joined today by oculoplastic
(00:53):
specialist doctor Lisa Jagan to chat about lid lesions and
an approach to bring a little bit of light into
our blinds. Doctor Jagan is an optalmologist that specializes in
oculoplastic surgery. She's published extensively in the field, contributes actively
to peer review, and is currently co authoring a procedural
oculoplastics textbook. She's the past vice president of the Toronto
(01:14):
Ophthalmology Society and the director of LID Express. She's extremely
passionate about health systems, education, and health technology and has
received significant funding from various organizations to execute projects in
these areas. Lisa, Welcome to the podcast. Thanks so much
for joining me, Thanks for having me. So we're talking
about lyd legions today, and I started in the introduction
about how like it's kind of one of those things
(01:36):
that you think is obvious. We learn in residency what
is concerning, what's not concerning, and we kind of have
this assumption that the concerning legions will be obvious to us,
and the non concerning legions will be obvious to us too,
And in a sense, that's our blind spot because then
when you get into real practice and there's nobody looking
over your shoulder, when somebody comes in with an eyelid legion,
(01:59):
you're like, oh, wait a second. If I'm the last
person who's going to say this is not concerning, I'm
a little bit more worried. And it's actually not so straightforward.
And I actually remember you were colleagues at one of
the clinics we work at. I sent you a li
lesion a few months ago, and people probably send you
lid legions all the time. I said, this looks fine, right,
And the reason I said it was because I was
(02:20):
convincing myself it looks fine. And he said, well, actually,
there's one sign on it that doesn't look one hundred
percent fine, so send it to me. And it was
just an example of it's really not as simple as
a lot of us probably think it is. So that's
kind of what them for this conversation is to unpack
(02:40):
how we can look at lid legions a little bit differently.
That's a long way of prefacing what do you think
is some of the biggest preconceptions about iselid legions.
Speaker 2 (02:51):
Yeah, Zil, I.
Speaker 3 (02:52):
Think it's exactly that.
Speaker 4 (02:54):
For the comprehensive ophthalmologist, the biggest preconception is that you
need to be able to look an eyelid lesion and
immediately know what the diagnosis is. And I understand why
you and other ophomologists might feel this way because we
rely so heavily on pattern recognition and ofphomology. For example,
(03:14):
you and I can just look at the lens and say, well,
there's a nuclear sporadic cataract, and this is the grade.
Generally there's it's a bit more black and white, but
with islid lesions they are a lot more tricky in
that one, you know, the average comprehensive optomologist isn't spending
all day every day looking at iselid lesions, so your
(03:37):
repertoire isn't as extensive to diagnose them on spec And
then two is that even for the most seasoned oculoplastic
surgeons or dermatologists, we still make the wrong call all
the time, and we rely on biobcy so much to
help us make the diagnosis. So the main goal really
then for the comprehensives should be to develop more confidence
(03:59):
in identifying which iselid lesions have worrisome features that should
prompt for the workup. And that case that you were
talking about wasn't straightforward so very reasonable, very good, good referral.
Speaker 1 (04:11):
But you're right in that a lot of the time
in optalmology we're trying to In fact, one of the
reasons people like ophthalmology, and when people ask why did
you go into optomology, people will say, including myself, is
because somebody comes in I look at their eye. I
know what the problem is, I diagnose it, and usually
it's something that we can treat. And that's not the
case with eelid lesions. But in terms of knowing exactly
(04:33):
what it is, you're correct. And with corny, I find
that a lot of times I actually will send back
and say, I don't actually know what it is, but
I know that it's not concerning, or it is concerning
enough that I do want a biopsy. So what is
your approach? Having kind of laid out that framework that
it isn't always as essential to say I know what
the diagnosis is, and maybe that's actually detrimental to our approach.
(04:56):
What is the better approach when you're looking at eelid
lesions and saying this is concerning, needs a biopsy, or
this is not concerning, does not need a biopsy, Because
that's the gist of what I'm getting from what you're saying.
Speaker 3 (05:09):
Exactly.
Speaker 4 (05:10):
Yeah, you know, every time I look at an eyelid lesion,
at minimum, I try to make three observations and those
three are lash loss eyelash loss. The second would be ulceration,
and the third is infiltration. So if you put those
things together, there's an acronym louis, so that's Lui, and
(05:34):
I'll describe those in more detail here. But l for
lash loss is essentially a distinct patch of eyelashes that's
absent along the eyelid margin. So sometimes you might see
these bumps growing and then it'll sort of display or
display the eyelashes on either side of the bump. That's
different than what I'm talking about with lash loss. In
(05:57):
this situation, there's clearly no lashes grow growing nearby, and
if I saw that, I would be suspicious for skin
cancer or malignancy.
Speaker 1 (06:07):
So for lash loss, there important important differentiation there. You're
not talking about something that's there and is like wedging
the lashes to the side. You're talking about like an
actual alesion where the lashes are not growing through it.
And that's the one that's the photo I sent you
where to me it looked really benign. I did. The
(06:27):
reason I sent it to you is because there were
no eyelashes growing right out of it. But I still thought, oh,
but this can't be anything, because because it looks it
looks so innocent. But if you see a lesion, even
if it looks normal and there's no lashes on that
margin area that is concerning.
Speaker 4 (06:43):
That is concerning, and these aren't you know, these aren't
slam dunks. It's just what's increasing your pretest probability that
something else is going on. But exactly that that, it's
the loss of the lashes completely, like there's nothing growing there.
Speaker 2 (06:58):
So the second feature that that was the ulceration for the.
Speaker 4 (07:01):
Louis acronym, and that's an area where there's tissue breakdown
or erosion. So essentially what you'd see is a depression
or a crater sort of looks like someone has scooped
out some of the tissue from the center of that
eelid bump. And if I saw ulceration happening, then again
I would be suspicious for a malignancity for ulceration.
Speaker 1 (07:24):
When we're talking about that kind of indentation. What about
when you see an area that just looks like a
little bit raw, like looks like it's a little bit red,
or looks like there's a little bit of scabbing or
bleeding there. And obviously sometimes that's pretty consistent with the
Chilesian or something active going on. But if you see
like a redness in that area that I don't know
if you'd necessarily call that ulceration. Do you put that
(07:46):
in that same bucket or umbrella?
Speaker 4 (07:49):
You know, it's it's it's a hard one to call definitively.
But oftentimes where you see that there's a scab or
some dried up blood, if you were to wet that
area with a Q tip and and remove it, you
would actually see some indentation there. It's just that we
often don't spend the time.
Speaker 2 (08:05):
To do that. If it's just sort of dried up blood.
Speaker 4 (08:08):
Without any sort of depression, which you can have in
other types of lesions, then that won't really constitute under this.
Speaker 2 (08:16):
Particular descripture ulceration.
Speaker 4 (08:19):
But I still think it's something to be worried about,
Like a lesion that scabs or bleeds often without the
patient doing something to provoke it, that would be still
concerning feature, but not one of the ones that are
in this little framework of just purely observation.
Speaker 1 (08:35):
Okay, so we have the eye in Louis.
Speaker 4 (08:38):
Yes we're onto the eye. So the eye is for infiltration.
This is this one is a bit hard, I have
to say, if you're not used to looking at eyelids
all the time. But so the eye stands for infiltration,
and essentially it means when there's abnormal tissue that's invading
or destroying the normal eyelid architecture. So if you were
(09:00):
to look at a young person's eyelid, you're often easily
able to tell that there are two sections. There's the
front part, the antier lamella, and that's where the eyelashes
grow through. And then there's the back part, which is
a post deer lamella. That's where you have the tarsus
and the my bomean glands. Often and what you should
(09:20):
be able to see is a line visible that separates
these two parts, often called the gray line, and it's
helpful to look for that line to be contiguous along
the whole breadth of the island margin because if you
find that there's an area where that line is completely
lost or distorted, then that is an indication to me
(09:41):
sort of to zoom in and more carefully examine that
area because it can be assigned for malignancy.
Speaker 1 (09:48):
Yeah, so sort of those two layers not having that
discrete gray line margin.
Speaker 4 (09:54):
Correct, Yeah, exactly. So those those are the features of
Louis acronym. That's what I tend to use just as
a base framework for every single eyelid bump that I see.
Even if I see something and in the back of
my mind I have a hune that it might be this,
or it might be that.
Speaker 2 (10:10):
I try to.
Speaker 4 (10:11):
Always use that observational framework every time and get in
the habit of it. And one thing I think important
to note is a patient doesn't have to have all
three of those features by any means. Just having one
is enough to have some suspicion. The more you have
makes you more suspicious and would really warrant to biopsy
if you were seeing all three in a given leasion.
Speaker 1 (10:33):
I love that because it's such a practical approach you're
not saying, especially especially you who's an oarchaoplastic specialist, you
do have a greater catalog of patients you've seen, right,
so there are more likely spot diagnoses you're going to
be able to make. But even you, and especially for
the general optalmologists, where we're not able to make that
spot diagnosis, the approach in many regards is probably better
(10:55):
not to try and make that spot diagnosis unless it's
leaping off the eyelid to you, keeping off the page,
so to speak, and it's better to look at those things.
And like you said, you're not saying that means it
is definitely something dangerous, but that is what's going to
guide you in either doing a biopsy or sending you
to an oculo plastic specialist to consider a biopsy.
Speaker 4 (11:13):
I really like the Louis acronym and it comes actually
from a study that was published at Queen's Queen's University,
which is where I did my oculoplastic fellowship, led by
doctor vlad Kracky vod Mercracky, And you know, the study
essentially asked an expert panel of oculo plastic surgeons to
provide descriptions of the features which made them suspicious for malignancy.
(11:38):
And these were the top three predictive features, the Louis
features that helped determine whether or not an eyelid lesion
was malignant or not. I do think it's a great
study and it does have photos that are worth looking
at to help visualize the Louis acronym.
Speaker 1 (11:53):
And when you say that it was predictive, so they
did they asked people like what are you looking at?
Then they did the biopsies and then they were able
to kind of compare which signs the oculopastic specialists reported
and correlated that with the pathology results.
Speaker 4 (12:06):
Yeah, exactly. Although they did it based on photographs of eyelids.
It was two dimensional and essentially they were looking at
about two hundred consecutive patients. But that's that's the approach
that they used.
Speaker 1 (12:20):
What are some other concerning signs for malignancy when obviously
Louis is a really good starting point and in some
situations is all you kind of need to say, Okay,
something's up here. What are some other concerning signs from malignancy? Though,
when you're examining a patient and you're just not sure.
Speaker 4 (12:39):
Right, So I think extension of the lesion to places
where we wouldn't want to see it extending. We're gon't
expect it to extend. So if it's on the outside
of the eyelid and now we're seeing it extending onto
the inner sort of tarsal conjunc taila, we're on the
sclera or you know, palpeople conjunc taiva, that would be
concerning for me.
Speaker 2 (12:59):
Also, if we.
Speaker 4 (12:59):
Start did to see that there was a loss of
important structural landmarks. So a lot of times when we
have squama cell carcinomas or basal cell carcinomas in the
medial cancel area. If you look closely, you'll actually see
that you no longer see, you know, a punctal opening,
or you're not you know, you're missing some of the
(13:20):
normal sort of infrastructure in that area.
Speaker 3 (13:23):
And then other things.
Speaker 4 (13:25):
Would just be sort of, uh, how how telanjectatic it looks?
Speaker 3 (13:30):
Pigmentation?
Speaker 4 (13:32):
Is that pigmentation, you know, really abnormal or sort of
lots of different areas of pigmentation, and that's sort of
that ABCDE But those would be other things that I
look for.
Speaker 1 (13:44):
Let's let's talk about pigmentation a little bit, because that
obviously scares people. Whenever you see pigment, you're thinking, Okay,
I just want to make sure I'm not missing a melanoma.
How what's your what's your approach to pigmented lesions? And
I guess my first question with that is HYPWK in Toronto,
where it's very cultural and there's a lot of patients
with darker pigmentation. In patients with darker pigmentation, is the
(14:05):
concern level for these pigmented lesions a lot lower? Obviously?
Speaker 4 (14:12):
For sure, it's it's definitely a lot lower. The risk
is for melanomas in particular, for pigmented lesions is way higher.
I think it's somewhere around ten ten times as high. Yeah,
you know, each study has a different report, but you know,
six to ten times as high and Caucasian patients compared
to say, in African So definitely not impossible though. And still,
(14:37):
you know, when it comes to stats like that, it's
good to have in the back of your head, but
it doesn't really change for me, you know, my approach
when I'm looking at that patients because hey, maybe this
is that one in you know, however many in front
of me. The way that I approach patients in general
when it comes to pigmented lesions is looking for other
(15:00):
areas of pigmentation that look similar on the face, and
usually patients like of Indian descent or Caribbean or so on,
you might see that they have lots of other pigmented
lesions all around their face or on their other parts
of their skin, which tends to be reassuring. There's the
ugly duckling sign that can often be used, which is
(15:20):
getting a gestalt of what the pigmented lesions look like
in other parts of the face. And then does the
one on the eyelid look a lot different than that,
or does it look like it could fit in. It's
part of the family of what we're looking at, and
I find that to be helpful. Usually, if there's a
lesion that's symmetric, like for example, a lot of times
(15:40):
in patients with some sort of you know, pigmented complexion,
you will see along the eyelid margin some changes where
it looks more brown or more black. But you'll see
that in many areas on both sides. And so once
you start seeing that show up on both sides, then
that's really reassuring. And although we say we look for
(16:02):
things that change over time as a concerning feature, I
do think for sure as pigmented patients get older, those
pigmented changes can become more noticeable. So it's a really
tough one. In general, I think that pigmented eyelid lesions
are a challenge for even the most seasoned oculoplastic specialist.
(16:25):
For the most part, my spiel to patients is, hey,
you know, the likelihood of this being melanoma or being
something serious is very low, but if it is something
like melanoma, then that can be quite serious. And we
don't want to miss it. So we have a couple
of options. Option one is that my suspicion is very low,
(16:47):
so I can monitor you and see you back in
say six months, and then again in one year, and
we can take serial photographs to see if it starts.
Speaker 3 (16:55):
To look different or change.
Speaker 4 (16:57):
The other option is that we just sort of byop
see it from the get go to get an indication
of what it might be at this stage, and you
can leave it in the patient's court because some people
just want that reassurance. Other people are just totally not
worried and they don't want to go through that process,
and you're just empowering them to make that decision.
Speaker 1 (17:16):
And I kind of jumped the gun there by going
to kind of patients who are pigmented and making it
a little bit more of a challenging situation in somebody
who's Caucasian. What are some of the signs you're looking
at that are going to prompt you, because that's where
when I see somebody with a pigmented lesion, I'm really
more concerned specifically because if you do look at both eyelids,
(17:36):
that symmetry often isn't there that they have that pigmented complexion.
I know that the ABCD acronym is used for general
skin lesions that we learn in med school. Does that
apply to the eyelids? And what's your approach in Caucasians?
Speaker 4 (17:53):
For sure, that's a really good question. I do have
a much lower threshold for pushing for biopsy. I almost
always would push for a biopsy if there was a
newly pigmented lesion around the eyelid and it's you know,
one one bump and there's nothing else there, you do
We do still use the abc D. I think it's helpful.
(18:14):
And so just to review, A is for asymmetry, so it's.
Speaker 3 (18:18):
Not you know, symmetric on both sides.
Speaker 4 (18:22):
B is for the borders, so irregular borders. C would
be color variations, so different you know, levels of pigment.
And remember you can also have melanomas that are not pigmented.
They can just look flesh colored. D is for the diameter,
and then E is for evolving or changing. So I
would say that those come into play. But realistically, any
(18:46):
new lesion that a Caucasian patient has that is a
pigmented lesion, even if they're young in their you know,
twenties or thirties because it can present at that age.
For sure, I would be pushing for a biopsy. The
other thing I wanted to is just that family history
plays an important role when it comes to melanomas. So
I always ask whenever you see a pigmented lesion around
(19:07):
the eyelets, I ask if the patient has a family
history of melanoma. And if they have even a remote
family history, that's definitely pushing me in the direction of
doing a biopsy.
Speaker 1 (19:17):
In terms of the history, that obviously is really important
with melanoma, and with a lot of these lesions. Patients
often explain their allegions, and I remember you told me
once that you can kind of get false reassurance from patients.
What are some of the things that you want to
be weary of or not weary of, But what are
some factors on history that reassure you, and what are
(19:37):
some factors on history that alarm you a little bit more?
Even if the patient might think that they're trying to
convince you, oh no, no, no, no, it's fine, I've had
this for X amount of time.
Speaker 4 (19:47):
Right, So if a patient says that they've had an
eyelid lesion that keeps resolving and then recurring in the
same spot, then that's definitely something that alerts me to
some maybe being suspicious there. If they say that it's
bleeding and scabbing and it's not healing within a few weeks,
(20:09):
then I would be suspicious. Other things would be you know,
just how they feel. So sometimes lesions can be painful
or like extremely itchy. That can actually also push me
in the direction of considering doing a biopsy for that.
And then the family history is a big one, so
particularly for the melanomas, their personal.
Speaker 3 (20:30):
History is important.
Speaker 4 (20:31):
So if they say I've had a basal cell carcinoma
removed from my back or my scalp, then that will
push me in the direction of doing something. And then
there are some more obscure ones like having history of
radiation or ammno suppression, things that are likely to increase
the risk of developing these. So with a lot of
the biologics, there is a higher risk of developing sort
(20:54):
of these skin malignancies. And I had a patient actually
who can coming in with all of these recurring basil
cell carcinomas on the eyelid, and we kept going through
the process of biopsying and removing. But after going back
and doing a medication review, we saw that they were
on a type of medication that can increase that risk,
(21:15):
and so it is important to still look at that history.
Speaker 1 (21:19):
Yeah. And the reason I in a previous conversation when
that came up with us, when you said, kind of
the history can be a little bit misleading, I guess
would be those cases where they say, oh, no, I've
had this for a while, it comes, it goes, it
comes and goes, and initially our reaction right be oh,
basically that's just under the bucket of they've had this
for a long time, nothing to worry about, but coming
(21:39):
and going changing that is obviously different. And if you
actually parse down that history, that will make you concerned,
is what you're saying.
Speaker 4 (21:48):
Yeah, exactly, because we're always taught to do history first,
but I would say that for eyelid lesions, I like
to do the you know, use the Louis observational framework
first for last law ulceration infiltration, because the history can
be such a bias and it's so easy for patients
to say, oh, I was told this was a chlazy
(22:09):
and it's fine, but you know, they might have been
told that at a walk in clinic, and that diagnosis
just gets propagated. So it's almost better to have that
framework where you're looking at it and then you ask
the secondary historical questions that will actually change whether or
not you do the biopsy or push you in one direction.
Speaker 3 (22:28):
Or the other.
Speaker 1 (22:30):
Before we get to some of the management and biopsy techniques,
which we'll touch on briefly, I just want to ask
I've been harping on what are the things we need
to be concerned about? Are there any things that, in
granted we want to err on the side of being
more concerned than we want than the other side of
not being concerned, But are there any things when you
look at an eyelid lesion that actually can provide some
(22:52):
reassurance that this is a benign lesion? Obviously there are
some sort of spot diagnoses that we know more likely
that innoculo plastic diagnosis, will feel more comfortable making them.
But what are some things One of them, obviously based
on Louis is if you saw lashes growing through a
lesion that would be reassuring. Are there other things when
looking at eelid lesions that an ophthalmologist can say, Okay,
(23:15):
you know what I'm a little bit more reassured here.
Speaker 4 (23:18):
Yeah, I do think for sure there are some that
have a very classic appearance, for example apocrine hydrosystemas. But
essentially those are dome shape lesions. If you held a
pen light up to that lesion, you would see that
it transilluminates and they tend to be located in the
canthi like the medial or lateral can thi. That would
(23:40):
be that symmetry again, so the symmetry piece. If you're
seeing a lesion that looks the same in the same
area on both eyelids, that's reassuring. You mentioned the lashes
growing through bumps. I think that's for sure a big one.
Especially I get a lot of referrals for intradermal nev
that you know, patients will have had since their teenage years,
(24:02):
and they.
Speaker 2 (24:03):
Do look a bit funny.
Speaker 4 (24:04):
But the lashes growing right through the center of it
is it's a very.
Speaker 3 (24:08):
Reassuring piece for me.
Speaker 4 (24:10):
And then things that you know, for example inclusion cists.
You might see a epidermal inclusion sist. It almost looks
like there's this semi solid white material inside of the
dome shape lesion, and it's all very symmetric. One piece
that I'll mention here, and doctor Kracky was the one
who had taught this technique. But it's to use a
(24:32):
Q tip and then sort of lightly almost push or
kind of use a horizontal motion on the top of
the cyst and see whether you can see a wrinkle
in the skin above the cyst. Because when it comes
to basal cell carcinomas, for example, you can almost get
a nodule at times, but when you use a Q
(24:53):
tip on top, the skin is so distorted that you
won't see this wrinkling effect.
Speaker 2 (25:00):
It's hard to describe.
Speaker 1 (25:01):
Over the wrinkling effect is reassuring.
Speaker 4 (25:04):
The wrinkling effect is reassuring.
Speaker 1 (25:06):
Yeah, one thing you've talked a lot about is symmetry,
and I know that one thing that's important is doing
a gross examination and not just necessarily going straight to
the slit lamp and looking, because a lot of these things,
in terms of symmetry or in terms of the general appearance,
could be missed if you just look straight through the
slit lamp and aren't looking globally, just in the room
(25:26):
at the patient's face.
Speaker 4 (25:28):
Definitely, I think it's so important to spend that five
seconds and take a look at the patient where you're
seeing them with both of their eyes open, with you know,
natural light from the window or just the light in
the room. One of the issues with looking at bumps
under the slit lamp is that if the light is
on you know, too high of illumination, you're just washing
(25:50):
out a lot of the effect. I like to use
like a broader light if I am going to use
something and quite you know, almost more dim But for sure,
just just generally looking at the patient straight on with
that ambient light makes a huge difference for diagnosis.
Speaker 1 (26:06):
So let's say we've now gone through the process. We've
looked at an ilid lesion, We've referred to the appropriate person.
We've decided okay, by we, I mean you, you've decided okay,
this needs to be biopsied. Walk me through the process
of how some of these biopsies work. Obviously, some of
them are easier to take off than others, where you
just do an excisional biopsy because it's not too big,
and you send it to pathology and you get the result.
(26:28):
But then we hear a lot about things like frozen
sections and mos and those are terms that we probably
should know more about, but we probably don't know as
much about it as we as we should. Can you
describe a little bit about what those processes are and
what it's, what the differences when you would do them,
and what it entails.
Speaker 3 (26:46):
Right?
Speaker 4 (26:48):
So okay, So basically what you're saying is, we have
a patient. We took a sample of their eyelid lesion,
like we did an initial biopsy, and it came back
as cancer. So basically our next goal is to remove
it an entire and to understand the frozen section or
mose micrographic surgery. I do think it's helpful to understand
(27:09):
the more old school approach, which is what you were
talking about. I would say that's not used as often.
There are definitely situations where it is still the go
to depending on the community you live in and resources.
But essentially in the past, let's say that the patient
in front of me has a basal cell carsonoma and
(27:30):
I want to remove this, then I would be cutting
out the lesion with a margin of say three to
four millimeters all around it, and I'm trying to remove
it with this normal healthy margin all the way around it.
There are guidelines on how much to remove to feel
confident that you're getting rid of the entire skin cancer.
(27:53):
Then in real time, right away, after I've removed that bump,
I would go ahead and suture and repair the eyelid.
I'd still then have to send over that specimen so
the pathologists can look at it. That would probably take
two weeks, and then they'd get back to me and say, yeah, Lisa,
you got all of it.
Speaker 2 (28:10):
Good job, or it's possible.
Speaker 4 (28:12):
They might say, you know what, actually there was some
cancer left behind. But the downside here with that approach
is that I've already repaired the eyelid, so I can't
really know where to go back and try to cut
out more. So those patients would end up maybe getting
serial follow ups to make sure that there's no recurrence.
Another sort of downside to that classic approach that you're
(28:33):
describing is that I've just gone ahead and just chose
I've selected this margin that's quite a wide margin. But
the eyelid, unlike other parts of the body, there's not
a lot of skin to work with, and so we
really want to choose an approach that can preserve as
much skin as possible for the eyelid to preserve the function.
Speaker 1 (28:53):
Of the eyelid.
Speaker 4 (28:55):
So that's where the frozen section and the MOSE comes
in compared to like this old school classic approach, which
again still has its role, it's not out the window,
but with both frozen section and MOS, what we're doing
here is trying to keep as much eyelid tissue as
we can, and the way that we do that is
(29:16):
during the surgery, we remove what we see for that
eyelid bump, and then we send it to the pathologist.
In the case of a frozen section, the pathologist tells
us right there and then hey, like, you need to
take a little bit more from this side. There's still
some cancer cells on this side. So then we know
and we can go back and just selectively take a
little bit of a wider margin from that side before
(29:39):
we do the reconstruction. And again we would send what
we took off and the pathologists would read it and
get back to us. Usually so it takes it might
take like one or two iterations.
Speaker 2 (29:49):
Which is a long day for the patient.
Speaker 4 (29:51):
But the upside here is that we're getting our answer
right away and we feel more confident before we proceed
to do the actual reconstruction.
Speaker 3 (29:58):
Enclosure.
Speaker 4 (30:00):
The difference between a frozen section and Moe's it has
to do with the way that the original excision is
done and the way that that tissue is sort of
looked at under the microscope. So that is a little
bit technical and I don't think it's necessary to know,
but oculoplastic surgeons often use a frozen section technique. That
(30:22):
means that we have to arrange our surgery with a
pathologist who's ready to receive the specimen we send them
and we have that communication. Whereas Moe's surgery is done
all by dermatologists, so they're actually specially trained to do
most surgery where once they remove the malignant lesion, they
(30:42):
the dermatologists will himself or herself look under the microscope
and say, okay, I know I need to take out
more here and so on. So slightly different scopes, but
similar overall idea in preserving eyelid skin.
Speaker 1 (30:59):
It's a great exception. So it's they're both just as
opposed to doing an excisional biopsy where you're getting rid
of potentially everything you don't even know. If you're getting
rid of everything, you're doing it more slowly and preserving
more eelid tissue to help with a more efficient repair
which you can do on the spot exactly. Yeah, before
(31:20):
we finish up, I feel like a chat about eyelid
lesions isn't complete without talking about some of the really
concerning eyelid legions and like sebacious cell tumors, mercle cell
that kind of stuff. Will those be caught if you're
doing the Louis approach or what are some other things
that you want to be aware of for some of
(31:42):
these diagnoses that again might be spot diagnoses to oculopastic specialists,
but are really really important that we don't miss.
Speaker 3 (31:51):
Right.
Speaker 4 (31:52):
Louis does encapsulate some of these. I would say that
one that can tend to maybe evade the Louis The
acronym might be the sabacious an'te or sabacious ato carcinomas
because they're they're known to be the great masqueraders or mimickers.
They can present very differently to other types of islid lesions,
(32:14):
so we we're on alert for them. In situations like
a chelasian that seems to recur in the exact same
location every time, and that can come and go over
the course of several months or even years. Sometimes we
can see it as presenting like a unilateral.
Speaker 3 (32:31):
Bluff ro conjunctiveitis.
Speaker 4 (32:33):
So there's not even a focal area that we're necessarily
seeing as a lesion, but that eyelid skin is chronically
inflamed in a way that looks like blufferitis. But the
other eyelid is completely normal, and there's no explanation for that.
But most of the sebacious carsonomas that I've seen have
had some element of Louis. I think it's just hard
(32:56):
because they're much more rare, so we don't have as
much data to go on in terms of what to expect.
They do tend to be a bit yellowish in color,
a tough one, a tough one to pick up. Still
use the Louis acronym. Another lesion that I wouldn't want
to miss would be the Merkele cell carcinoma. And I
know I said you can't necessarily rely on pattern recognition,
(33:18):
but if there was one eyelid lesion to use pattern
recognition for, it would be this one. It has essentially
this violaceous red appearance. It's very chalanjectatic, and it grows
really quickly and you know, in the course of months
it can be massive. The reason it's so important to
identify it. It is because it's extremely aggressive and it
(33:40):
has a high rate of metastases, so there's only a
fifty percent survival rate in five years, which is really low.
You don't want to miss it, so you google image
Merkle cell carcinoma. That would be one one to take
away with you.
Speaker 1 (33:54):
Lisa, this has been such a great conversation, really practical,
which is what I love about it. Louis lash loss, ulceration, infiltration.
It's something we can all look for and it takes
some of the burden away from us of trying to
actually diagnose it. It's more, as in many things in
ophalmology and in medicine, is this concerning? Is it not concerning?
And that is a really really useful framework, and you've
(34:17):
provided so many other practical tips here. What are some
final thoughts yet for people who are listening to this.
Speaker 4 (34:22):
I would say that a part, yeah, for sure, the
Louis acronym. I hope that you can take away with
you and try to use it every time. But also
just remembering when making referrals, how helpful it is to
have a description for the oculo plastic surgeon. It's much
more helpful and easier for me to triage a patient
(34:43):
if I have an idea of the size, the location,
if there's an important family history of eyelids cancer or melanoma,
for example, those things affect how quickly we see the
patients because there's just so many referrals for eyelid abumps.
If I know that an ilid bump is located in
the medial canthas, I'm going to get that patient in
(35:05):
much more quickly because all the important structures that can
lead to invasion into the orbit are usually coming from
a lesion that's in the medial canthas, So something as
simple as that can make.
Speaker 3 (35:17):
A big difference for patients.
Speaker 4 (35:19):
So please, yeah, if you can try to add in
even just a few descriptors is helpful.
Speaker 1 (35:25):
Well, doctor Lisa Jagan, thank you so so much for
joining me. It's been a real delight chatting with you,
and we're going to have you back for another episode
at some point. Talk about a program you're doing called
LID Express, which is a really cool initiative to help
expedite some of these referrals and make it easier for
both patient and doctor to screen eelid lesions and we're
(35:45):
going to talk about that. Thank you so much for
joining me.
Speaker 3 (35:48):
This has been great, This is yeah, really fun.
Speaker 1 (35:51):
Thanks so and thanks everybody for listening to another episode
of blind Spot. Have a great day
Speaker 4 (36:01):
Pasting past
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