Oculoplastics

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Wills Eye Hospital

COLOR ATLAS & SYNOPSIS OF Clinical Ophthalmology Oculoplastics Oculoplastics Christopher J. Rapuano SERIES EDITOR

FOURTH EDITION

Robert B. Penne

COLOR ATLAS & SYNOPSIS OF Clinical Ophthalmology Oculoplastics FOURTH EDITION Wills Eye Hospital

EDITOR Robert B. Penne, MD Director and Attending Surgeon, Oculoplastics Service Co-Director, Ocular Cicatricial Pemphigoid Clinic Wills Eye Hospital Professor of Ophthalmology Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia, Pennsylvania

SERIES EDITOR Christopher J. Rapuano, MD

Director and Attending Surgeon, Cornea Service Co-Director, Refractive Surgery Department Wills Eye Hospital Professor of Ophthalmology Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia, Pennsylvania

COLOR ATLAS & SYNOPSIS OF Clinical Ophthalmology Oculoplastics FOURTH EDITION Wills Eye Hospital

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Copyright © 2019 Wolters Kluwer. Copyright © 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer business. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at shop.lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in the United States of America

Library of Congress Cataloging-in-Publication Data ISBN-13: 978-1-975214-87-6 ISBN-10: 1-975214-87-0 Cataloging in Publication data available on request from publisher.

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide med ical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verifica tion of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. shop.lww.com

To Devany, Daniel, Mara, Leah, Nate, Arielle, Ryan, and Laney—the source of pride and balance in my life

The goal of the series is to provide an up-to-date clinical overview of the major areas of ophthalmology for students, residents, and practitioners in all the health care professions. The abundance of large, excellent-quality pho tographs (both in print and online) and con cise, outline-form text will help achieve that objective. Christopher J. Rapuano Series Editor About the Series

T he beauty of the atlas/synopsis con cept is the powerful combination of illustrative photographs and a summary approach to the text. Ophthalmology is a very visual discipline that lends itself won derfully to clinical photographs. Whereas the seven ophthalmic subspecialties in this series—Cornea, Retina, Glaucoma, Oculo plastics, Neuro-ophthalmology, Uveitis, and Pediatrics—employ varying levels of visual recognition, a relatively standard format for the text is used for all volumes.

Preface

T his text is aimed at assisting physicians (ophthalmologists and nonophthal mologists) in recognizing the most common oculoplastic conditions. Many oculoplastic conditions can be diagnosed on simple visual examination, which makes this atlas an ideal resource to have in emergency departments and in the office. It provides a solid basis of photographic and descriptive information to

diagnose oculoplastic conditions. Once these conditions are recognized, the text describes other tests that may be needed and the differ ential diagnoses that should be considered. The management options for these conditions are also briefly described. Robert B. Penne Editor

vii

Acknowledgments surgery: Jacqueline R. Carrasco, MD; Michael P. Rabinowitz, MD; Mary A. Stefanyszyn, MD; and Alison Watson, MD.

S pecial thanks to my colleagues who have provided assistance with this book and in my practice of oculoplastic

viii

Contents

About the Series vi Preface vii Acknowledgments viii

SECTION I: EYELID 2

Chapter 1 Benign Eyelid Lesions 2 Papilloma 2 Seborrheic Keratosis 4 Cutaneous Horn 6

Epidermal Inclusion Cyst 8 Molluscum Contagiosum 10 Xanthelasma 12 Syringoma 14 Apocrine Hidrocystoma 16 Trichoepithelioma 18 Nevi (Nevocellular Nevi) 20 Hemangioma of the Eyelid (Cherry Angioma) 22

Chapter 2 Eyelid Inflammation 24 Chalazion 24 Hordeolum 26 Floppy Eyelid Syndrome 28 Chapter 3 Eyelid Neoplasms 30

Keratoacanthoma 30 Actinic Keratosis 32 Lentigo Maligna 34 Basal Cell Carcinoma 36

Squamous Cell Carcinoma 40 Sebaceous Adenocarcinoma 42 Malignant Melanoma 46 Kaposi Sarcoma 48

Chapter 4 Eyelid Trauma 50

Marginal Eyelid Laceration 50 Canalicular Eyelid Laceration 54 Dog Bites 56 Eyelid Burns 58

x Contents

Chapter 5 Eyelid Malpositions 60 Entropion 60

Acute Spastic Entropion 60 Involutional Entropion 62 Cicatricial Entropion 64 Ectropion 66 Involutional Ectropion 66 Paralytic Ectropion 68 Cicatricial Ectropion 70 Mechanical Ectropion 72 Symblepharon 74 Trichiasis 76 Ptosis 78 Congenital Myogenic Ptosis 78 Acquired Myogenic Ptosis 80 Aponeurotic Ptosis 82 Neurogenic Ptosis 84

Third Nerve Palsy 84 Myasthenia Gravis 86 Marcus Gunn Jaw-Winking Syndrome 88

Horner Syndrome 90 Mechanical Ptosis 92 Traumatic Ptosis 94

Pseudoptosis 96 Brow Ptosis 98

Dermatochalasis 100 Blepharochalasis 102 Eyelid Retraction 104

Eyelid Dyskinesis 106 Benign Essential Blepharospasm 106 Hemifacial Spasm 108 Chapter 6 Congenital Eyelid Anomalies 110 Blepharophimosis Syndrome 110 Epicanthus 112 Epiblepharon 114 Congenital Entropion 116 Congenital Coloboma 118 Congenital Distichiasis 120 Ankyloblepharon 122 Chapter 7 Miscellaneous Eyelid Conditions 124 Ocular Cicatricial Pemphigoid 124

Contents xi

SECTION II: LACRIMAL APPARATUS 128

Chapter 8 Lacrimal Obstructions 128 Congenital Obstructions 128

Congenital Nasolacrimal Duct Obstruction 128 Dacryocystocele 130 Lacrimal Fistula 132 Acquired Obstructions 134 Acquired Nasolacrimal Duct Obstruction 134 Canalicular Obstruction 136

Chapter 9 Lacrimal Infections 138 Dacryocystitis 138 Canaliculitis 140 Chapter 10 Lacrimal Sac Tumors 144 Introduction 144 Chapter 11 Orbital Infections 146 Orbital Cellulitis 146 Orbital Abscess 150 Necrotizing Fasciitis 154 Phycomycosis (Mucormycosis) 158 Aspergillosis 164 Chapter 12 Orbital Inflammation 166 Thyroid Eye Disease 166

SECTION III: THE ORBIT 146

Idiopathic Orbital Inflammation (Orbital Pseudotumor) 172 Sarcoidosis 178 Granulomatosis With Polyangiitis (Wegener’s Granulomatosis) 182

Chapter 13 Congenital Orbital Anomalies 184 Microphthalmos 184 Chapter 14 Orbital Neoplasms 188 Congenital Orbital Tumors 188

Dermoid Cysts 188 Lipodermoids 192

Vascular Orbital Tumors 194

Capillary Hemangiomas 194 Cavernous Hemangiomas 200

xii Contents

Lymphangiomas 204 Solitary Fibrous Tumor 208 Orbital Varices 212 Orbital Arteriovenous Malformations (Fistula) 216 Neural Tumors 220 Optic Nerve Gliomas 220

Neurofibromas 224 Meningiomas 226 Schwannomas 234

Mesenchymal Tumors 238

Rhabdomyosarcoma 238 Fibrous Histiocytoma 242 Lymphoproliferative Tumors 244 Lymphoid Hyperplasia and Lymphomas 244 Plasmacytoma 248 Langerhans Cell Histiocytosis 252 Lacrimal Gland Tumors 256 Epithelial Tumors of the Lacrimal Gland 256 Dacryops 262 Miscellaneous Orbital Tumors 264

Secondary Orbital Tumors 264 Metastatic Orbital Tumors 270 Chapter 15 Orbital Trauma 276 Orbital Fractures 276

Orbital Floor Fracture 276 Medial Wall Fracture 280 Orbital Roof Fracture 284 Zygomatic Fracture 286 Orbital Hemorrhage 290 Orbital Foreign Bodies 294 Mucocele 300

Miscellaneous Trauma 290

Index 302

COLOR ATLAS & SYNOPSIS OF Clinical Ophthalmology Oculoplastics FOURTH EDITION Wills Eye Hospital

CHAPTER

Eyelid Neoplasms 3

KERATOACANTHOMA K eratoacanthoma presents as an isolated lesion on the face with a unique appear ance. The lesion is dome shaped with a cen tral keratin-filled crater. It grows rapidly over weeks and may undergo spontaneous regres sion over months. Once considered benign, this is now considered a low-grade squamous carcinoma by most pathologists. Epidemiology and Etiology ● Age: Most often older than 50 years; rarely younger than 20 years ● Gender: More common in males than in females by a ratio of 2 to 1 ● Etiology: Unknown; ultraviolet radiation and chemical carcinogens may have a caus ative role. It is believed to originate from the pilosebaceous unit. History ● Rapid onset of growth over a few weeks ● The lesion is often asymptomatic except for cosmetic changes.

● There may be occasional tenderness. Examination ● Single, dome-shaped nodule with a central keratotic plug ● The lesion is firm and is slightly red to light brown in color ( Fig. 3-1 ). Special Considerations ● Once considered a benign lesion, there may still be some confusion in the liter ature about whether this is a squamous carcinoma. ● The lesion must be treated as a low-grade squamous carcinoma. Differential Diagnosis ● Basal cell carcinoma ● Hyperkeratotic actinic keratosis ● Squamous carcinoma Laboratory Tests ● Histopathology of the excised lesion ● Should be excised with frozen section guid ance or with Mohs surgery

KERATOACANTHOMA 31

Treatment ● Excision with pathologic evaluation ● These lesions will sometimes sponta neously regress over a few months to a year. ● On the eyelid, these are always excised with margin evaluation.

Prognosis ● Good

● Depending on the size of the lesion, recon struction of the defect may leave some eyelid changes.

B FIGURE 3-1. Keratoacanthoma. A. Lesion of the left upper eyelid that grew over 2 to 3 weeks. It was excised without recurrence. B. Large lesion of the left lower eyelid in a 40-year-old patient. The appearance could be that of a squamous cell carcinoma; however, the history of growth over 4 weeks and the patient’s younger age point to a keratoacanthoma. This lesion was excised without recurrence.

32 3 Eyelid Neoplasms

ACTINIC KERATOSIS T hese lesions may be single or multiple on chronically sun-exposed skin. They ap pear as dry, rough, scaly lesions that are stable but can rarely disappear spontaneously. Epidemiology and Etiology ● Age: Older than 40 years; rarely younger than 30 years ● Gender: Higher incidence in males ● Etiology: Sun exposure over time in a fair-skinned white population results in ac tinic keratosis. History ● Extensive sun exposure in youth ● Lesions present for months Examination ● Rough, slightly elevated, skin-colored or light brown lesions with hyperkeratotic scale ( Fig. 3-2 ) Special Considerations ● It is estimated that one squamous cell carci noma will develop per 1000 actinic keratoses. Synonym: solar keratosis

Laboratory Tests ● Pathologic evaluation if biopsied Pathophysiology

● Repeated solar exposure results in damage to the keratinocytes by the cumulative effects of ultraviolet radiation. Treatment ● Prevention through early and lifelong use of sunscreen ● Excise nodular lesions and submit for pathologic evaluation. ● Most flat lesions respond to liquid nitrogen or topical application of 5% 5-fluorouracil cream over a few days to weeks. ● Topical imiquimod cream has also been ap proved for the treatment of actinic keratosis. ● These three treatments (liquid nitrogen, 5-fluorouracil, and imiquimod) must be used with caution around the eye and should be avoided in lesions at or near the lid margin. Prognosis ● Some actinic keratoses may disappear spon taneously, but others remain for years unless treated. ● Incidence of squamous cell carcinoma de veloping in these lesions is unknown but has been estimated to be one squamous cell carci noma in every 1000 actinic keratoses.

Differential Diagnosis ● Squamous cell carcinoma ● Discoid lupus

ACTINIC KERATOSIS 33

Copyright © 2024 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. FIGURE 3-2. Actinic keratosis. A. Multiple actinic keratoses on the cheek and brow with signs of chronic sun damage. B. Lesion involving the lower eyelid.

34 3 Eyelid Neoplasms

LENTIGO MALIGNA L entigo maligna is a flat intraepidermal neoplasm and the precursor lesion of len tigo maligna melanoma. The lesion has strik ing variations of brown and black ( Fig. 3-3 ), often described as a “stain.” Epidemiology and Etiology ● Age: Median age is 65 years. ● Gender: Equal incidence in males and females ● Etiology: Sun exposure is a definite factor. History ● History is usually not helpful, because the exact onset of lesion is unclear. Examination ● Flat, dark brown or black color, sharply defined edges ● Often appears like a dark “stain” on the skin

Special Considerations ● This is a premalignant lesion and should be excised because of the chance of development into a lentigo maligna melanoma. Differential Diagnosis ● Seborrheic keratosis ● Actinic keratosis ● Malignant melanoma Laboratory Tests ● Histopathologic evaluation Treatment ● Excision with margins sent for pathologic evaluation Prognosis ● Excellent if excised before developing into a melanoma

LENTIGO MALIGNA 35

B FIGURE 3-3. Lentigo maligna. A. A large macule with irregular borders and different shades of brown. (Reprinted with permission from Fitzpatrick TB, Johnson RA, Wolff K, et al. Color Atlas and Synopsis of Clinical Dermatology . 4th ed. McGraw-Hill; 2001:193. Figure 9-8.) B. Recurrent lentigo maligna of the left brow.

36 3 Eyelid Neoplasms

BASAL CELL CARCINOMA B asal cell carcinoma is the most common type of skin cancer. It is locally invasive and aggressive but has very limited capacity to metastasize. If neglected, it can invade the or bit, especially if located in the medial canthal area. Most commonly, it occurs on the lower eyelid and is treated by complete surgical excision. Epidemiology and Etiology ● Age: More than 40 years. Rare cases do oc cur in the 20s and 30s. ● Gender: Males more than females ● Etiology: Sun exposure and fair skin with poor ability to tan are risk factors. Treatment with x-ray (for acne) increases the risk. ● Incidence: 500 to 1000 per 100,000 people History ● Slowly enlarging lesions in sun-exposed areas ● The lesions may be associated with bleeding. Examination ● Round or oval, firm lesions with depressed center ● The lesions are pink or red with fine thread-like telangiectasia. ● The center may be ulcerated. Basal cell car cinoma may also appear scar-like or can rarely be cystic ( Fig. 3-4A–D ). Special Considerations ● Aggressive treatment of basal cell carci noma of the medial canthal area is indicated because of the risk of orbital extension from the medial canthal area.

● Basal cell carcinomas almost never metastasize. ● Sclerosing basal cell carcinomas have poorly defined margins and may recur. ● Basal cell nevus syndrome is an autosomal dominant syndrome in which patients de velop multiple basal cells at a very young age ( Fig. 3-4E and F ). Differential Diagnosis ● Squamous cell carcinoma ● Trichoepithelioma Laboratory Tests ● Lesions are sent for pathologic evaluation. Treatment ● Complete surgical excision with pathologic evaluation ● Frozen sections or Mohs surgery is needed to ensure complete excision. ● Reconstruction of the defect is then com pleted at the same time. ● Treatment with radiation should not be used for lesions around the eye unless the pa tient is not a surgical candidate. ● Imiquimod cream can be used as a nonsur gical option if the lesion is not close to the eyelid margin. Prognosis ● Good when promptly and completely excised ● Neglected cases can invade the orbit and brain and have the potential, in rare cases, to be fatal.

BASAL CELL CARCINOMA 37

FIGURE 3-4. Basal cell carcinoma. A. Classic appearance of a basal cell carcinoma. This lesion does not involve the eyelid margin, but large lesions like this one are a challenge for reconstruction because of the chance of lower eyelid ectropion. B. Notching of the eyelid margin is a sign of an eyelid neoplasm. This basal cell carcinoma has caused a notch and demonstrates the smooth pearly borders of a basal cell carcinoma.

38 3 Eyelid Neoplasms

D FIGURE 3-4. ( continued ) C. Basal cell carcinoma may present as pigmented lesions, especially in patients with darker pigmented skin. Note the pearly edges on the inferior part of the lesion. D. A cystic lesion can be a basal cell carcinoma. This lesion is larger than most hidrocystomas and has a slightly violaceous hue. This cystic basal cell carcinoma was filled with a thick clear gel-like material, which is classic.

BASAL CELL CARCINOMA 39

Copyright © 2024 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. F FIGURE 3-4. ( continued ) E. Basal cell nevus syndrome with many basal cell carcinomas all over the face occur ring at a young age. F. Pits of the palms of the hands that are often seen in basal cell nevus syndrome.

40 3 Eyelid Neoplasms

SQUAMOUS CELL CARCINOMA

● These can present from very small to large. ● They may be crusted with bleeding or smooth ( Fig. 3-5 ). Differential Diagnosis ● Actinic keratosis ● Basal cell carcinoma ● Keratoacanthoma Laboratory Tests ● Pathologic evaluation Treatment ● Complete surgical excision with controlled margins ● Frozen sections and Mohs surgery are both appropriate options. ● Imiquimod cream can be used as a nonsur gical option if not close to the eyelid margin. Prognosis ● Excellent unless the lesion is neglected ● Squamous cell carcinoma rarely spreads via lymphatics, blood vessels, or along nerves.

S quamous cell carcinoma is a malignant tu mor of epithelial keratinocytes. It is often the result of exogenous carcinogens (ultravi olet exposure, exposure to ionizing radiation, arsenic). These lesions are much less common than basal cell carcinoma on the eyelids and are usually successfully treated with excision. Epidemiology and Etiology ● Age: Older than 55 years ● Gender: Males more commonly involved than females ● Etiology: Sun exposure and fair skin with poor ability to tan are risk factors. Treatment with x-ray (for acne) increases the risk. ● Incidence: 12 per 100,000 white males; 7 per 100,000 white females; 1 per 100,000 African Americans History ● Persistent keratotic lesion or plaque that does not resolve after 1 month must be con sidered a potential carcinoma, especially in sun-exposed areas. Examination ● Two types of lesions: ■ Differentiated lesions are keratinized, firm, and hard. ■ Undifferentiated lesions are fleshy, gran ulomatous, and soft.

SQUAMOUS CELL CARCINOMA 41

B FIGURE 3-5. Squamous cell carcinoma. A. This is a very large squamous cell carcinoma that was neglected. It now infiltrates the entire lower eyelid. Note the crusting on the lesion, which is usually present with squamous cell carcinoma and is less common with basal cell carcinoma. B. Smaller lesion of the lower eyelid that shows crusting and an irregular, erosive central area.

42 3 Eyelid Neoplasms

SEBACEOUS ADENOCARCINOMA S ebaceous adenocarcinoma is a highly ma lignant and potentially fatal tumor that arises from the sebaceous glands of the eyelid. In the early stages, this tumor can be difficult to recognize, and once it grows, it is difficult to contain, because it can have skip areas. Early recognition and aggressive excision are the keys to successful treatment. Epidemiology and Etiology ● Age: Usually older than 50 years ● Gender: More common in females than males ● Etiology: Arises from the meibomian glands, glands of Zeis, or sebaceous glands of the caruncle, eyebrow, or facial skin History ● Often starts as a chronic blepharitis or non resolving chalazion ● Patients may have a chronic red, irritated eye for months to years. Examination ● Multiple potential presentations: ■ Nodular lesion simulating a chalazion ■ Unilateral chronic blepharitis ■ Cellular membrane growing over the conjunctiva ■ Destructive, often ulcerated, lesion on the eyelid margin ( Fig. 3-6 ) ■ Occurrence in the upper eyelid is twice as common as in the lower eyelid.

Special Considerations ● This lesion is the great masquerader. Delay in diagnosis as a carcinoma and subsequent growth of the lesion add to the poor progno sis for this tumor. Differential Diagnosis ● Basal cell carcinoma ● Squamous cell carcinoma ● It is important to alert your pathologist if this sebaceous adenocarcinoma is suspected. ● Special stains have been used in the past to confirm the presence of intracytoplasmic lip ids (Oil Red O). Immunohistochemical stains are now used to confirm the diagnosis. ● Without these stains, the lesion may be misdiagnosed. Treatment ● Clinically diagnosing the lesion is often the biggest challenge. ● Biopsy of any suspicious lesion is the key. ● Once diagnosed, complete excision with wide, controlled margins is the treatment of choice. ● There can be skip areas, so careful follow-up for recurrence is needed. Prognosis ● This is a potentially lethal tumor that must be treated aggressively. ● Chronic blepharitis ● Chronic chalazion Pathophysiology

SEBACEOUS ADENOCARCINOMA 43

Copyright © 2024 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. B FIGURE 3-6. Sebaceous adenocarcinoma. A. The eyelid margin is red and inflamed with notching. B. When the eyelid is everted, there is an infiltrative lesion of the tarsal conjunctiva.

44 3 Eyelid Neoplasms

FIGURE 3-6. ( continued ) C. Left upper lid lesion with yellowish color.

SEBACEOUS ADENOCARCINOMA 45

FIGURE 3-6. ( continued ) D. Small lesion on the lateral margin is yet another way sebaceous carcinoma can appear.

46 3 Eyelid Neoplasms

MALIGNANT MELANOMA M alignant melanoma is a rare but very dangerous malignant lesion of the eye lids. Sun exposure in childhood is an etiologic factor. Despite aggressive surgical excision, this can still be a fatal tumor. Epidemiology and Etiology ● Age: Third decade and beyond ● Gender: Equal between males and females ● Etiology: Sun exposure and genetic predisposition History ● Pigmented lesion with recent growth or change in appearance Examination ● Pigmented lesion with irregular pigment deposition, irregular margins, or just increase in size ( Fig. 3-7 ) ● There may be ulceration and bleeding. Differential Diagnosis ● Nevus ● Pigmented basal cell carcinoma

Laboratory Tests ● Specimens are sent for pathologic evaluation. Treatment ● Complete excision with aggressive, con trolled surgical margins ● Frozen sections for margin control have limited value in a melanoma. ● The deeper the lesion, the wider the mar gins required. ● Sentinel lymph node biopsy is usually required. ● Melanomas are best excised via a team ap proach at centers experienced with melanoma treatment. Prognosis ● Dependent on the depth of the tumor, spread to nodes or metastasis ● Five-year survival rate is improving.

MALIGNANT MELANOMA 47

FIGURE 3-7. Malignant melanoma. A. Lesion of the right eyebrow that has grown over a few months. The lesion has irregular areas of lighter and darker pigmentation. B. Malignant melanoma of the lower eyelid.

48 3 Eyelid Neoplasms

KAPOSI SARCOMA K aposi sarcoma is a vascular neoplasia that can involve multiple systems. It is a rare lesion of the eyelids but, when present, is usu ally associated with a compromised immune system, most commonly HIV disease.

Differential Diagnosis ● Pyogenic granuloma ● Chalazion ● Hemangioma ● Melanocytic nevus Laboratory Tests

● Pathologic evaluation if biopsied ● Evaluation of the immune system if indicated Treatment ● Excision with pathologic evaluation ● Cryotherapy or intralesional chemothera peutic agents may be used for local control of the lesions. ● Radiation treatment for some large lesions Prognosis ● Patients who develop lesions associated with HIV often have a short survival and die from advancement of the HIV disease. ● Patients with primary Kaposi sarcoma may survive for years.

Epidemiology and Etiology ● Age: Any ● Gender: More common in males

● Etiology: Vascular neoplasia is often associ ated with immune compromise in the United States. History ● Rapid growth of lesion may occur. ● Patients most commonly are HIV positive, although other forms of immune compromise may predispose patients to these lesions. Examination ● Elevated dermal lesions that are red or pur ple ( Fig. 3-8 )

KAPOSI SARCOMA 49

B FIGURE 3-8. Kaposi sarcoma. A and B. Lesion of the lower lid in a patient with AIDS.

Ophthalmology

COLOR ATLAS & SYNOPSIS OF Clinical Ophthalmology Robert B. Penne, MD Oculoplastics FOURTH EDITION Wills Eye Hospital Developed at Philadelphia’s world-renowned Wills Eye Hospital, the Color Atlas and Synopsis of Clinical Ophthalmology series covers the most clinically relevant aspects of ophthalmology in a highly visual, easy-to-use format. Vibrant, full-color photos and a consistent outline structure present a succinct, high-yield approach to the seven topics covered by this popular series: Cornea, Retina, Glaucoma, Oculoplastics, Neuro-Ophthalmology, Pediatrics, and Uveitis . This in-depth, focused approach makes each volume an excellent companion to the larger Wills Eye Manual as well as a practical stand-alone reference for students, residents, and practitioners in every area of ophthalmology. The updated Oculoplastics volume includes: • Expert, state-of-the-art guidance on the differential diagnosis and treatment of the full range of oculoplastic conditions, ideal for practicing ophthalmologists, oculoplastics specialists, and residents • More than 300 high-quality images that aid in visual diagnosis and treatment planning • Information on the use of CT and MRI in diagnosing conditions and determining treatment plans • An easy-to-use format that covers Epidemiology and Etiology, History, Physical Examination, Differential Diagnosis, Laboratory and Special Examinations, Diagnosis, Prognosis, and Management Enrich Your eBook Reading Experience • Read directly on your preferred device(s) , such as computer, tablet, or smartphone. • Easily convert to audiobook , powering your content with natural language text-to-speech. SERIES EDITOR Christopher J. Rapuano, MD

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