The Ophthalmic Office Procedures Handbook

SECTION 3 Lids, Lashes, and Adnexa

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FIGURE 7-6 The patient is a 56-year-old male with a 6-month history of a lesion of the right lower lid. He reports no pain or bleeding. He has no history of previous trauma or skin cancer. He would like it removed. He is on 81 mg of aspirin a day. He has no known drug allergies. Clinically, the lesion is slightly raised and is about 5 mm in size. There is no ulcer or especially concerning features. It is in the periocular area, with no lash line or margin involvement. It is unclear clinically whether this is a benign or malignant lesion. The lesion has a slightly pearly appearance on the edges. Differential diagnosis would be benign seborrheic keratosis, papilloma, nevus, or a malignancy like basal cell carcinoma. Recommendation is an excisional biopsy to remove the entire identifiable lesion with clo sure with sutures due to the size with pathologic diagnosis. A shave biopsy might be acceptable as well if the specimen is still sent to pathology. There appears to be enough lax skin to remove the le sion without causing the lid to pull down. The specimen was sent to pathology. The patient underwent an excisional biopsy without complications. The final pathologic report was basal cell carcinoma with one margin not entirely cleared of malignant cells. The patient was referred to an eyelid specialist for additional surgery with mi croscopic confirmation of clear margins with no remaining tumor cells. This is immediately followed by eyelid reconstruction.

last about 10 seconds. The doctor injects with the entry site right next to the lesion but allows the tip of the needle to go just below the lesion. The local anesthetic is given slowly over 10 seconds. The area under and on either side of the lesion should balloon up. Inject ing slowly hurts the patient less than injecting fast. The needle and syringe are removed and placed sterilely on the field in case more is needed later. 9. Using a toothed forceps, the lesion is grasped and elevated. If it is small, the mass can be excised using a scissor around the base, being sure that the incision is in normal tissue below the elevated mass. It is always best to make incisions of the eyelid along the skin tension lines. The skin tension lines are the natural lines of passive tension of the skin and underlying muscle. For example, a horizontal incision is preferred to a vertical one on the eyelid. It will heal better and have less chance of a significant scar. If a scalpel is used, an elliptical incision is made along the skin tension lines to remove the mass with some sur rounding normal tissue.

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