Neil Rajan1, Deepali Varma2, Fiona Chapman2 and James A. A. Langtry3
1Department of Dermatology, Sunderland Royal Hospital, 2Department of Ophthalmology, Sunderland Eye Infirmary, and 3Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK. E-mail: drneilrajan@googlemail.com
Accepted March 7, 2007.
Sir,
Basal cell carcinoma (BCC) is the most common skin cancer, with a lifetime risk of 12% (1). Twelve to 16% of BCCs occur on the periocular skin (2, 3). It is usually a slowly enlarging tumour (4) and symptoms are rare. Pain is a very rare symptom and may represent the presence of perineural or intraneural invasion of the tumour, which is associated with a more aggressive growth pattern and high recurrence rates. We report here an unusual cause of painful eye due to an enlarging periocular BCC.
CASE REPORT
A 68-year-old woman presented to the combined oculoplastic-dermatological surgery clinic with a painless, crusted lesion on the left lower eyelid of 2 years’ duration. There was a 6×4 mm lesion on the left lower lid (Fig. 1), which incisional biopsy confirmed to be a nodular BCC. The patient was put on the waiting list for Mohs micrographic surgical (MMS) excision and lid reconstruction. At review 6 months later, she complained of soreness of the left eye of 4 weeks’ duration and a gradual increase in size of the left lower eyelid BCC (Fig. 2). Slit lamp examination showed two eyelashes displaced posteriorly and rubbing on the cornea (trichiasis). These two eyelashes were removed with fine forceps with immediate resolution of symptoms. Two months later she underwent MMS excision of the left lower eyelid BCC and reconstruction with a Hughes flap.
Fig. 1. Slit lamp photograph of eyelid basal cell carcinoma at diagnosis.
Fig. 2. Slit lamp photograph 6 months later, illustrating distortion of the free edge of the left lower lid resulting in trichiasis (circled).
DISCUSSION
BCC is an uncommon cause of trichiasis. Trichiasis may be idiopathic, associated with chronic blepharitis or cicatricial. The commonest worldwide cause is trachoma (5). MMS excision is a limited resource in the UK due to a variety of factors, including funding mechanisms. During the wait for MMS, this patient’s tumour enlarged, displacing eyelashes posteriorly to rub on the cornea, which resulted in her symptoms. The displaced eyelashes were not seen on routine examination by other physicians. This case highlights the importance of careful eye examination including slit lamp examination and the desirability of having good access to definitive treatment. Long waiting lists for MMS lead to enlargement of the tumour in the interim and therefore loss of more tissue to achieve tumour-negative surgical margins. A recent study of 342 patients with periocular BCC treated by MMS 5-year follow-up showed 0% and 7.8% recurrence rates for primary and recurrent tumours, respectively (6). MMS is the treatment of choice for most eyelid BCC, resulting in the best cure rates.
References
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