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A 73-year-old African American woman was referred for the evaluation of a pigmented lesion on her left upper eyelid margin of 6 weeks’ duration. The patient first noted an erythematous, tender swelling with yellow discharge, which later evolved to the pigmented mass. Her ocular history was unremarkable. Her medical history revealed hypertension, type 2 diabetes mellitus, and hyperlipidemia.
On examination, her visual acuity was 20/40 OD and 20/30 OS. There was a sausage-shaped, darkly pigmented (black), focally ulcerated nodule involving the medial upper eyelid margin and measuring 8 × 6 × 4 mm. Associated madarosis, eyelid margin notching, and telangiectasia were noted (Figure 1). The remainder of the anterior segment and a dilated fundus examination were unremarkable.
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Pigmented basal cell carcinoma
D. Perform a full-thickness eyelid resection with intraoperative control of margins
The differential diagnosis of a pigmented eyelid lesion includes a broad spectrum of benign and malignant tumors.1,2 Diagnostic considerations include benign tumors, such as nevi, blue nevi, seborrheic keratosis, apocrine hidrocystomas, vascular malformations, and inflammatory processes (eg, a chalazion). Malignant considerations include melanoma, metastasis, pigmented squamous cell carcinoma, and pigmented basal cell carcinoma (BCC).
The original symptoms of a tender, erythematous swelling with discharge raised initial concern for an inflammatory process, such as a chalazion; however, the large, firm, pretarsal nodule with a focal madarosis suggested a neoplastic process. Thus, hot compresses and an antibiotic-steroid ointment (choice A), an incision and drainage (choice B), and a corticosteroid injection (choice C), all of which treat inflammatory chalazia, would not be appropriate management options. Surgical excision is the mainstay of treatment for most primary eyelid malignant conditions. An anterior lamellar resection is a reasonable option for anteriorly situated tumors that do not involve the tarsus or posterior lamella of the eyelid. However, in this case, the tumor was associated with madarosis, which is indicative of tarsal involvement, leading to the decision to perform a full-thickness eyelid resection with intraoperative control of margins (choice D) and a subsequent reconstruction.1 At the time of surgery, the mass was found to be temporally invasive, and final margins were clear. Pathological testing confirmed pigmented BCC of the nodular and infiltrative types, involving the anterior and posterior lamellae of the eyelid (Figure 2).
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Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (email@example.com).
Published Online: November 21, 2019. doi:10.1001/jamaophthalmol.2019.4591
Conflict of Interest Disclosures: None reported.
Funding/Support: Support was provided by the Eye Tumor Research Foundation (Dr Shields).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, and in the preparation, review or approval of the manuscript.
Additional Contributions: We thank the patient for granting permission to publish this information.
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