Benign Eyelid Tumors – Nevus at the Eyelid Margin

By Paul T. Finger, MD

Description

A nevus (a benign tumor) is commonly found on the skin of other parts of the human body. A nevus can also occur on the eyelid skin. These tumors are usually pigmented and have thickness.

Symptoms

Benign Eyelid Tumors - Nevus at the Eyelid Margin
Note the relatively smooth surface, no eyelash loss, a long history of its presence, and no history of recent growth. Nevi can be melanotic “dark” like this one, or amelanotic “light-colored.” *Note* Some nevi grow during puberty.

Patients typically notice a dark spot on their eyelid that is thickened. It usually does not cause loss of eyelashes and though it can grow, most do not. When rapid (over months) growth, loss of eyelashes or discoloration of the nevus is noted, malignant melanoma is suspected.

Diagnosis

Most eyelid nevi can be diagnosed by clinical examination. A baseline photograph should be obtained for comparison with future examinations. Very suspicious or rapidly growing eyelid nevi should be biopsied to rule out melanoma. It is important to note that eyelid nevi can slowly grow, and that change is particularly common during puberty.

Treatments

Eyelid nevi are benign tumors. They can be photographed and followed for evidence of change or growth prior to consideration of biopsy or treatment. Large eyelid nevi can be a cosmetic problem that can be repaired by ophthalmic plastic surgery.

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The Nevus of Ota

By Paul T. Finger, MD

Description

Note the increased pigmentation of the eyelid and episclera. This patient was also noted to have heterochromia (different colored irides) and a darker fundus (more pigment in the choroid) by ophthalmoscopy.
Note the increased pigmentation of the eyelid and episclera. This patient was also noted to have heterochromia (different colored irides) and a darker fundus (more pigment in the choroid) by ophthalmoscopy.

Patients with the Nevus of Ota have increased amounts of melanin (pigment) and melanin producing cells (melanocytes) in and around their eyes. This includes the intraocular blood vessel layer called the uvea (choroid, ciliary body, and iris), on the white part of the eye ball (sclera), and in the eyelids.

Patients with the Nevus of Ota have been shown to be at greater risk for the development of intraocular and central nervous system malignant melanomas (e.g. choroidal melanoma). Though intraocular melanomas are more common in these patients, their lifetime risk is though to be 4%.

Patients with the Nevus of Ota should be examined at least every 6 months by an eye-cancer specialist and a neurologist.

Symptoms

The Nevus of Ota appears as increased pigmentation of one eye and its eyelids. The eyelid is darkened, pigment can be observed on the white of the eye and that iris may be darker (compared to the contralateral iris). Though none of these findings produces physical symptoms, physical asymmetry can have a psychological impact on the patient.

Ocular Melanosis is diagnosed in cases of ocular melanosis there is no eyelid involvement.

Diagnosis

Ocular Melanosis: Episcleral and uveal hyperpigmentation without eyelid skin involvement is called "Ocular Melanosis"
Ocular Melanosis: Episcleral and uveal hyperpigmentation without eyelid skin involvement is called “Ocular Melanosis”

Careful inspection of any patient with two different colored irises (heterochromia irides) may uncover the eyelid and episcleral pigmentation diagnostic of the Nevus of Ota.

Slit-lamp biomicroscopy is used to distinguish between conjunctival and episcleral pigmentation. Comparative examination of the irides can be used to evaluate coloration and surface characteristics.

Dilated ophthalmoscopy similarly demonstrates asymmetric “darker” pigmentation of the choroidal vascular layer beneath one retina.

Ophthalmic ultrasound imaging will reveal thickening of the vascular uveal layer of the eye. Examinations should include both posterior and anterior segment (UBM) imaging.

Treatments

Most patients with the Nevus of Ota have no subsequent related problems.

Less than 4% can develop choroidal melanoma in the affected eye. Fewer will develop intracranial neoplasia. Therefore, it is reasonable for all patients with the Nevus of Ota to have twice yearly eye examinations with dilated ophthalmoscopy. They should also have an initial neurology assessment, followed by periodic medical evaluations.

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Choroidal Nevus

By Paul T. Finger, MD

Description

A benign appearing choroidal nevus (eye freckle).
A benign appearing choroidal nevus (eye freckle).

Like a raised freckle on the skin, nevi can also occur inside your eye. The most common “choroidal nevus” or eye nevus are unusual and can only be seen by an eye care specialist. Like a nevus on the skin, a choroidal nevus can grow into a malignant melanoma.

A choroidal nevus rarely requires treatment. Photography is typically used to document the size of the choroidal nevus. If the choroidal nevus has orange pigmentation, if the nevus is leaking fluid, or has a thickness of 2 mm or more it may be (or become) a malignant choroidal melanoma.

Depending on its appearance, patients with a choroidal nevus should have their eyes examined (at least) every 6 months. Only your doctor can look inside your eye to see if the choroidal nevus has changed. If the choroidal nevus has orange pigment or has thickened, it should be checked more often. If a choroidal nevus is leaking subretinal fluid, this is a particularly ominous sign. Such tumors should be followed most closely for evidence of growth or malignant transformation into a choroidal melanoma.

It is reasonable to have an eye cancer specialist check to see if your choroidal nevus looks suspicious and take baseline measurements. This examination may include the use of ultrasound, specialized photography, optical coherence tomography or an intraocular angiogram. It is a good idea for each patient to keep a picture of your choroidal nevus. This picture can be compared to future examinations to help determine if the nevus has changed or stayed the same.

Symptoms

A benign choroidal nevus (eye freckle) rarely causes symptoms. However, if a choroidal nevus leaks fluid or is associated with the growth of abnormal blood vessels (neovascularization) patients can become symptomatic. Such changes can cause a localized retinal detachment/degeneration, flashing lights and loss of vision.

A typical choroidal nevus is asymptomatic or “causes no symptoms” and found by routine dilated eye examination with ophthalmoscopy.

Diagnosis

This image demonstrates how a suspicious choroidal nevus can demonstrate focal leakage on fluorescein angiography.
This image demonstrates how a suspicious choroidal nevus can demonstrate focal leakage on fluorescein angiography.

Choroidal nevus is typically a pigmented tumor of the blood vessel layer (choroid) beneath the retina. A choroidal nevus is typically gray but can be brown, yellow or variably pigmented. Your eye care professional will look to see if the choroidal nevus is raised (has thickness), orange pigment (lipofuscin), or is leaking fluid (retinal detachment). If the choroidal nevus has one or more of these findings, it is labeled a suspicious choroidal nevus that has a chance of turning into or even being a small choroidal melanoma.

A choroidal nevus can have yellow-white spots on its surface called drusen or drusenoid retinal pigment epithelial detachments (DRPED).These are signs of retinal dysfunction. The nevus may be preventing the eye from removing retinal waste products or creating microscopic leaks beneath the retina.  There are no studies that show how long it takes for drusen to form on a choroidal nevus.

Treatments

A benign choroidal nevus requires no treatment and there is no way to safely remove them. Since a choroidal nevus can turn into a choroidal melanoma, it is reasonable to have it periodically observed by your eye care professional.

Additional Info

Dr. Finger believes that since skin and conjunctival melanomas have been linked to ultraviolet exposure, and since choroidal melanomas are more commonly found in patients with blue eyes, outdoor occupations, and in Australia (where there is an ozone hole); it is reasonable to wear ultraviolet (UV) blocking sunglasses. Dr. Finger says, “Think of sunglasses as sun block for your eyes.”™

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Patient Stories

"Very well treated by Dr. Finger. He explained everything I needed to know about my issue with detail and attention, putting me at ease and giving me confidence to handle this problem for the rest of my life.”
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