Orbital Masses

Lumps and Bumps of the Eyelids and Around the Eyes

Children can present with a wide array of “lumps and bumps” of the eyelids and area around the eyes (periorbita).  Fortunately, the majority of these lesions are benign and a diagnosis can usually be made in the office. 

Dermoid

A dermoid is a collection of normal tissue in an abnormal location (choristoma) and results from a defect in skin development during fetal development.  Orbital dermoids are the most common orbital tumor of childhood and are most frequently seen at the supero-temporal (“upper-outer”) aspect of the orbit (eye socket), typically along the frontal-zygomatic suture (around the temple).  A dermoid is a skin cyst where the skin lining is facing the inside of the cyst. Just like skin elsewhere on the body, dermoids continue to produce sebum (oil), keratin, and hair, but in this case it collects in the central cavity so they enlarge over time.   Some parents notice a bump adjacent to the upper eyelid shortly after birth but it often takes several months and the loss of some baby fat for the lesion to be noticed.

While benign (i.e. – not a cancer), the contents of a dermoid cyst (sebum, keratin, and hair) are normally secreted onto the skin, not under it.  Therefore, if a dermoid ruptures it causes a lot of inflammation under the skin – as if there were an infection or foreign body.  This inflammation can mimic certain cancers and infections, and fistulas (holes to the skin) can form; there can be extensive scarring, too.  Over the long term, unruptured, growing dermoids can erode the underlying bone.  Because of the possibilities of rupture and bone erosion, it is a good idea to remove dermoids at the earliest convenience for the family, yet at an age where the risk of general anesthesia is minimal.  I prefer to remove dermoids before a child begins walking and falling (and bumping their head into table edges); in my experience, 9 to 12 months is usually a good age for surgery.  

The risks of surgery include scarring, infection, and the need for re-operation.  There is no such thing as cutting without scarring; everybody heals differently but, in my experience, the cosmetic results have been excellent with only a faint line (if any) visible.  Infection is uncommon.  A very aggressive infection could cause vision loss or systemic infection, but this is very, very rare.  To minimize infection risk, antibiotic ointments are used after surgery for the first week or so, and the patient is examined during the first week after surgery (when the risk of infection is greatest).

Second operations are very, very rare. 

Capillary Hemangioma

A capillary hemangioma is a collection of abnormal capillaries found in a normal location (hamartoma).   These are readily diagnosed by their appearance and history.  Depending on their depth within the skin, they can be purple, red, or bright red (“strawberry nevus”).

Hemangiomas tend to enlarge during the first 2 to 3 years of life then involute (go away) spontaneously.  They often become larger when the child cries, then shrink when she relaxes.   The problem with a capillary hemangioma of the eyelid is that it can cause the lid cover the pupil (ptosis) and/or pressure from the mass can distort the cornea and result in significant astigmatism – either of these can cause amblyopia.  

Any capillary hemangioma that can cause amblyopia is “visually significant” and must be treated –steroid injection or systemic steroids are needed. 

Chalazion and Stye

Within the eyelids are oil glands (Meibomian glands are located towards the back of the lid; Zeiss glands are towards the front); the oil produced by these glands is essential to normal tear film stability.  There are about 30 Meibomian glands in an upper eyelid and 20 in a lower lid; there is a Zeiss gland attached to every eyelash. 

When one of these glands becomes clogged, the oil builds up and overflows, leaking into the eyelid.  Because these oils are normally excreted to outside of the body, the immune system treats the oil trapped within the eyelid as a foreign substance.  Initially, the oil leak is surrounded by an acute immune response– the area around the foreign body becomes red and swollen, and (often) tender.  When this happens to a Meibomian gland, it is called a chalazion. 

Similarly, when a Zeiss gland extravasates oil, a hordeolum (stye) results.  Either way, there is a “pimple” within the lid – the appearance and management are the same.  (When a chalazion become chronic, a wall forms around the oil and this leaves a non-inflamed nodule under the skin that can take months or years to resorb.)

Step 1: Conservative Approach

Because the problem is an oil leak from one of our own oil glands, antibiotics play no role in treating a stye or chalazion.    What does work, however, is frequently applied hot compresses.   Hot compresses liquefy the oil and, hopefully, allow the clogged pore to open up and the oil to come out.   

If you place a towel under hot water, it will cool down very quickly.  Instead, heat a potato in the microwave and wrap a damp towel around it to create a compress that stays hot for a long time (and you can have a snack afterwards). My recommendation is to apply hot compresses 4 times a day for 5 to 10 minutes; this should be done for at least 2 to 4 weeks before saying “Well, we tried.”  Also, don’t be surprised if the eyelid skin becomes dry from the frequent compresses – apply a thin layer of AquaPhor (available over the counter) to the lid twice daily.

Step 2: Intervention

When hot compresses have been tried for a reasonable period of time, the stye/chalazion will either be gone or it won’t.  At this point, if you do nothing more the lesion will often just go away (resorb) on its own over a long period of time (months to years).  There is no danger to the eyeball from a chalazion, so leaving it alone is a perfectly reasonable option. 

However, if a chalazion is causing distress to you or your child, there are options.  Through the miracle of modern surgery, we can drain these pesky pimples and restore your child’s eyelid.  Surgery consists of flipping the eyelid over, making a small incision on the undersurface of the lid, and draining the goo out of the chalazion.  

Sometimes, the skin of the eyelid is thinned out from the chalazion and breaks open during surgery; a dissolvable suture may be needed.   The risks of this surgery are infection, occurrence of a new chalazion (or stye) in a different gland, leaving behind some of the chalazion wall (this will eventually resorb, however), and minor bleeding.