January-February 2020

CATARACT

Care coordination key for patients with skin cancer near the eye


by Vanessa Caceres Contributing Writer


A large basal cell carcinoma along the lateral canthus with deep extension
Source: Tanya Khan, MD

 

With an aging population and the growth in skin cancer, comprehensive ophthalmologists are treating a larger number of patients who have skin cancer on the eyelid or around the eye but who also require eye surgery.
What special treatment, if any, do these patients require? EyeWorld asked physicians from dermatology, ophthalmology, ocular oncology, and oculoplastics for their perspective.

Common cancers around the eye

Basel cell, squamous cell, and sebaceous carcinoma are the most common kinds of skin cancers around the eyes or eyelid, in addition to melanoma, said Susan Bard, MD.
Sebaceous carcinoma is the most concerning type aside from melanoma, said Jeffrey
Fromowitz, MD, noting that sebaceous carcinoma tends to be an aggressive tumor that is harder to manage.
Skin cancer near the eye often will not affect eye surgery, but there are some exceptions. “If the lesion is large enough along the lid margin or on the eyelid itself, it may become difficult to evert the eyelids and achieve proper exposure for eye surgery,” said Tanya Khan, MD. These lesions can be a benign chalazion, a stye, an inclusion cyst, or the aforementioned carcinomas.

Surgical timing

One decision is which surgery should be performed first—skin cancer removal or eye surgery. “If the structure that’s being operated on would in any way affect or compromise the eyelids or skin with the cancer, I would address the skin cancer first,” Dr. Bard said. “If the procedure is emergent, it takes priority over the skin cancer.”
In a patient requiring cataract surgery, Dr. Fromowitz would advise having the skin cancer surgery first and waiting a couple of weeks for it to heal before cataract extraction. However, if intraocular surgery is needed for an emergent or rapidly increasing loss of visual acuity, he would recommend the eye surgery first.
Surgery timing also depends on the location of the skin lesion. “Because an extensive surgical excision and reconstruction may be required for some eyelid cancers, it is more imperative to address the eyelid pathology and investigate for any systemic involvement,” Dr. Khan said. “Additionally, an inflammatory or infectious process like a chalazion or stye should be treated in advance of the eye surgery to prevent postop eye surgery infection.”
When skin cancer is present in a patient requiring eye surgery, they should know that other specialists may get involved, including oculoplastic specialists. This can help avoid creation of a defect that affects the eye’s ability to function, such as an inability of the eyelid to close, said Amy Schefler, MD.
Oculoplastic surgeons are important partners if a skin cancer is close to or intermixed with the tear duct, said Andrew Newman, DO.
“In the rare case that it is a lesion that extends into the eye, intraocular tissues, and orbit, the patient may need to be imaged and care coordinated with other specialists,” Dr. Khan said.

Screening and prevention

Ophthalmologists and dermatologists should take the opportunity to better educate patients about skin protection for the eye, including the use of sunglasses with a UV filter and corrective lenses with a UV filter, Dr. Fromowitz said.
Other helpful recommendations include using a sunscreen with an SPF of 30 to 50 and wearing a hat, Dr. Newman said.
Patients should be careful with any dressings or eye shields after eye surgery that may adhere to or rub against the skin cancer. “Skin cancer cells do not stick together well and are friable, which can lead to ulceration, bleeding, and infection,” Dr. Bard said.
Ophthalmologists should have a low threshold to biopsy suspicious legions around the eye or refer to a dermatologist, Dr. Newman said.
“Skin cancers around the eyes can be difficult to detect, so dermatologists should pay extra attention to these areas during a skin exam,” Dr. Newman said.

About the doctors

Susan Bard, MD
Dermatologist and Mohs surgeon
Manhattan Dermatology
Specialists
New York, New York

Jeffrey Fromowitz, MD
Dermatology of Boca
Boca Raton, Florida

Tanya Khan, MD
Khan Eyelid & Facial Aesthetics
Austin, Texas

Andrew Newman, DO
Chief dermatology resident
Affiliated Dermatology
Scottsdale, Arizona

Amy Schefler, MD
Ocular oncologist
Houston Methodist
Houston, Texas

Relevant disclosures

Bard
: None
Fromowitz: None
Khan : None
Newman: None
Schefler: None

Contact

Bard
: drbard@manhattanspecialtycare.com
Fromowitz: jfromowitz@mydermgroup.com
Khan: drkhan@khaneyelidsurgery.com
Newman: anewman@affderm.com
Schefler: aewhite2@houstonmethodist.org

Care coordination key for patients with skin cancer near the eye Care coordination key for patients with skin cancer near the eye
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