treatment plan

A Bothersome Lid Bump

BY WILLIAM L. MILLER, OD, PHD, FAAO

Infrequently, we come across lesions on the eyelids that require us to determine whether they are benign or malignant. A 10-item decision-making list can be useful in determining whether a lesion around the skin adnexa is in fact neoplastic or malignant.

First look at the size of the lesion — anything larger than 5mm should be held with suspicion. As with other lesions, the lesion should not have changed in color, lost hair/lashes/brow, or become asymmetric. All of these can be signs of malignancy. A malignant lesion also exhibits ulceration and is immobile with digital massage. Also, if the lesion exhibits focal telangiectasia or tends to bleed, this would be another indication that it may be malignant. Finally, if the lesion has irregular borders or has become multicolored, this could point to malignancy.

If any of these 10 observations holds true, it would be wise to seek an oculoplastic or dermatologic consult. If none are observed, then you can reasonably assume that the lesion is benign.

Benign Lesions

A more frequently encountered set of benign lesions includes sebaceous and sudoriferous cysts. The former more commonly occur away from the eyelid margin whilst the latter are very near the anterior eyelid margin. Rarely do they cause problems, but when they do it's usually because of an irritative sensation or cosmetic awareness.

A sudoriferous cyst can be described as a retention cyst of Moll and represents an apocrine hydrocystoma. They are typically clear fluid-filled cysts with sizes ranging between 2mm and 4mm in diameter. They are usually non-inflamed and avascular.

A sebaceous cyst, however, is a sebaceous gland retention cyst or steatocystoma (Figure 1). Sebaceous cysts are usually well-demarcated and take on a creamy appearance due to sebum retention. They are larger than sudoriferous cysts, around 10mm, although smaller (0.6mm) intracutaneous versions known as milia exist. A careful evaluation of this lesion using the 10-item decision-making process is essential to rule out a sebaceous gland carcinoma or other malignancies.

Figure 1. Sebaceous cyst prior to opening with sterile needle.

Cyst Treatment

Treatment of both cysts is similar and will be addressed together. Prior to treatment, clean the cyst and the area surrounding the cyst with alcohol. Both types will be ultimately expressed using sterile cotton-tipped applicators after the cysts have been opened with a 25/27 gauge sterile needle or scalpel. I prefer a needle attached to a syringe for maximum control; however you can also use a singular needle. Opening the cyst with a needle will likely require a topical xylocaine gel; however, depending on the cyst's size, you may skip this step. If you use a scalpel, local infiltrative Lidocaine injection is recommended. Score the cyst with the scalpel blade in a motion away from the globe. Depending on the invasiveness of your technique, you can stop the eventual bleeding with gauze compression or, in more severe cases, cautery. Disposable cautery units are available from multiple sources for use with these infrequent cysts.

After the procedure you should cover the area with an antibiotic ointment and prescribe a similar ointment for the patient to use four times a week for one week. CLS

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Optometric Association and serves on its Journal Review Board. You can reach him at wmiller@uh.edu.