NORTHERN MINDANAO MEDICAL CENTER

DEPARTMENT OF OPTHALMOLOGY

CASE PRESENTATION

BASAL CELL CARCINOMA

THEA SELINA L. UMBAC

Post Graduate Intern
 OBJECTIVES
GENERAL OBJECTIVES
• To present a case of mass on the lower eyelid mass
SPECIFIC OBJECTIVES
• To discuss a brief anatomy of the eyelid
• To discuss basal cell carcinoma of the lower lid
▫ Etiology
▫ Risk Factors
▫ Pathology
▫ Differential Diagnosis
▫ Management
▫ Prevention
▫ Prognosis
▫ Follow-up
IDENTIFYING DATA
• JMF
• 79 year old
• Female
• Widow
• Filipino
• Retired
• Roman Catholic
• From Lanitu-on CDO
• Admitted for the first time at NMMC last July 2, 2019 at 9:06AM
• Chief complaint – Mass on the lower eyelid, right
• Informant – Patient
• % Reliability – 95%
 A
2 YEARS PTA 1 MONTH PTA
MASS MASS

Lower eyelid, right Progrressive enlargement

Small
Hyperpigmented (-) discharges
(-) vision changes
(-) discharges (-) pain
(-) vision changes (-) itchiness
(-) pain (-) history of trauma
(-) itchiness
(-) history of trauma Consult done with another
specialist and was
Consult done with diagnosed with:
a specialist and was advised Melanoma vs Basal Cell
for excision but failed to follow Carcinoma
up Advised for surgery
PAST MEDICAL HISTORY
• Known Hypertensive – 2000 – compliant to antihypertensive
medications
• Noted to have CVD – 2003, left sided weakness

FAMILY HISTORY
• (-) HPN, DM, BA, Cancer

PERSONAL-SOCIAL HISTORY
• Retired
• Non-alcoholic and non-smoker
• No allergies to food or medication
 REVIEW OF SYSTEMS
• General: (-) fever, fatigue, weight loss
• Skin: (-) rashes, jaundice
• HEENT: (-) pain, lesions, headache, dizziness, blurring of vision, eye discharges, hearing
difficulty, fullness, pain, discharges, congestion, discharge, cyanosis, odynophagia,
dysphagia
• Neck: (-) stiffness, masses
• Respiratory: (-) cough, difficulty of breathing
• Cardiac: (-) chest pain, palpitation
• Gastrointestinal: (-) diarrhea, vomiting
• Urinary: (-) dysuria, hematuria, frequency, urgency
• Genitalia: (-) bleeding, masses, pain
• Peripheral Vascular: (-) intermittent claudication, edema
• Musculoskeletal: (-) joint and muscle pain
• Hematologic: (-) easy bruising, bleeding
• Neurologic: (-) seizures, tremors, paralysis
• Endocrine: (-) heat/cold intolerance, polyphagia, polydipsia
• Psychiatric: (-) behavioral changes, depression, anxiety
OCULAR EXAMINATION
VISUAL ACUITY
OD 20/80 20/40
OS 20/80 20/50

ADNEXAE

Hyperpigmented mass
TR: 2.5 cm
AP: 1.3 cm
CC: 2 cm
 OCULAR EXAMINATION

TONICITY FUNDOSCOPY
OD Soft OD (+) ROR CM DDB
OS Soft OS (+) ROR CM DDB

EXTRAOCULAR MUSCLES SLIT LAMP

PHYSICAL EXAMINATION
• General Survey: Conscious, coherent, not in respiratory
distress
• Skin: Warm to tough, senile turgor
• HEENT: No masses , no lesions; anicteric sclerae, pinkish
palpebral conjunctivae; no nasal discharges, non-tender
sinuses, septum at midline; pink, moist lips; non-edematous
tonsils
• Neck: Supple, trachea at midline, no lymphadenopathy, no
masses
PHYSICAL EXAMINATION
Chest & Lungs Heart
Equal chest expansion, no retractions PMI at 5th ICS LMCL
Resonant lung fields No heaves or thrills
Equal tactile fremitus Regular rhythm, no murmurs
Clear breath sounds

Abdomen
Flabby , no scars
Hypoactive bowel sounds
No abnormal areas of
tympany and dullness
No organomegally
PHYSICAL EXAMINATION
Extremities
Equal palpable peripheral
Back pulses
No gross deformities CRT < 2 seconds
No CVA tenderness & No peripheral edema
negative kidney punch sign
No nail clubbing
on both sides.
Nail beds not pale
 PRIMARY IMPRESSION
T/C BASAL CELL CARCINOMA
LOWER LID, RIGHT
At the Emergency Room

• Patient admitted
• Secure consent for procedure
• Procedure: Excision biopsy of lower lid mass,
Right, under GA
• DAT
• Venoclysis started with PNSS 1L at 10 gtts/min
• CP cleared as out-patient
At the Emergency Room

• Materials:
▫ Vicryl 6-0 #1
▫ Blade 11 #1
▫ Blade 15 #1
▫ Prolus 5-0 #1
▫ Tobramycin + Dexamethasone Ointment #1
• I and O q shift
• VS q 4h
 RESULT NORMAL VALUES
Hemoglobin 13.3 11.7 – 14.5 g/dL
Hematocrit 39 34.10 – 44.3 %
RBC 4.38 4.35-5.90 x 106/uL
WBC 4.44 3.3 – 10 x 103/uL
Neutrophil 54.2 43.4 – 76.3
Lymphocyte 33.6 17.4 – 48.2
Monocyte 8.8 4.5 – 10.5
Eosinophil 3.1 2–3
Basophil 0.3 0-0.5
Platelet 300 174-390
 RESULT NORMAL VALUES
Color Light Yellow Transparency Hazy
pH 6.50 Epithelial cells Rare
Specific
1.010 Amorphous Urates Moderate
Gravity
Amorphous
Albumin (-) -
Phosphate
Sugar (-) Bacteria Few
WBC 1-3 Mucus Threads Rare
RBC 0-2
 RESULT NORMAL VALUES
FBS 97.7 68.0 – 116 mg/dL
Creatinine 0.7 0.51 – 1.17 mg/dL
Uric Acid 6.4 0.0 – 7.0 mg/dL
Sodium 142 135 – 148 mmol/L
Potassium 3.5 3.5-5.3 mmol/L
Chloride 105 99 – 114 mmol/L
• Heart is not enlarged
• Aorta tortuous and atherosclerotic
• Trachea mildly arches to the right due to tortousity of the aorta
• The costophrenic angles and hemidiaphrams are intact
• No other remarkable findings

• IMPRESSION:
BILATERAL PARACARDIAC FIBROSIS, NO CHANGE
TORTUOUS AND ATHEROSCLEROTIC AORTA
CASE DISCUSSION
ANATOMY OF THE EYELID
• SKIN
• SUBCUTANEOUS AREOLAR TISSUE
-very loose and contains no fat

• LAYER OF STRIATED MUSCLE

- Orbicularis muscle
- Levator palpebrae superioris

• SUBMUSCULAR AREOLAR TISSUE

- Nerves and vessels lie in this layer

• FIBROUS LAYER
- Tarsal Plate – give firmness and shape of the eyelid
- Septum Orbitale – thin membrane of connective tissue perforated
by nerves, vessels and LPS

• LAYER OF NON-STRIATED MUSCLE

- palpebral muscle of Muller

• PALPEBRAL CONJUNCTIVA
GLANDS OF THE EYELIDS
• marginal arterial arcades - lie in the submuscular plane in
front of the tarsal plate, 2 mm away from the lid margin
• superior arterial arcade - lies near the upper border of the
tarsal plate.

• Posttarsal plexus ->ophthalmic veins

• Pretarsal plexus -> subcutaneous veins.

• Lateral half of the eyelids -> preauricular lymph nodes

• Medial half of the eyelids -> submandibular lymph nodes.
BASAL CELL CARCINOMA
OF THE EYELID
 ETIOLOGY
• Ultraviolet light induced damage to the epidermis
• Defects of the PTCH gene located on chromosome 9q22.3
have been associated with the development of BCC.
 RISK FACTORS
• BCC tends to occur in lightly pigmented individuals (Skin
Type 1 and 2) at sites of sun exposure.
• Other risk factors include:
▫ Elderly
▫ Radiation
▫ Immunosuppression
▫ Previous scar
▫ Inherited syndromes, e.g., xeroderma pigmentosum
PATHOLOGY
• BCC derives from cells of the epithelial basal
cell layer
• Histologically the tumor has an appearance
similar to the normal epithelial basal cell layer
• BCC forms strands, cords, and islands of tumor
• Characteristic:
▫ Palisading of nuclei at the periphery of the
islands of tumor
▫ Dark-staining nuclei and scant cytoplasm

Morpheaform Type
• small islands of tumor within dense fibrous
tissue
• tend to invade the underlying tissue more
deeply
• presents a challenge in determining the
extent of the tumor; the variant carries a
higher rate of recurrence
 DIAGNOSIS
• The diagnosis of BCC can be suspected clinically and is confirmed
histologically.

DIFFERENTIAL DIAGNOSIS
• The differential diagnosis includes any benign or malignant condition of the eyelid
skin, including:
Benign Malignant
• Seborrheic keratosis • Squamous cell carcinoma
• Actinic keratosis
• Chalazion • Sebaceous gland carcinoma
• Cyst • Malignant melanoma
• Squamous papilloma • Lymphoma
• Blepharitis
• Xanthelasma • Merkel cell tumor
• Nevus • Metastasis
• Verruca
 MANAGEMENT
• BCC is nearly always a locally invasive disease. Treatment is
recommended to prevent damage to neighboring tissues.
Medical therapy
• topical imiquimod 5% cream
has been shown to be
effective
Surgery
• Complete surgical excision with
margin control.
• Assuring that the surgical
margins are without cancerous
cells may be accomplished by
frozen sectioning or Mohs surgery
 PREVENTION
• Minimize sun exposure by use of sun block products, as well
as hats and appropriate clothing.

PROGNOSIS
• Five-year recurrence rate of 5%
• Five-year cure rates of up to 98% have been reported for
BCC. There is a worse prognosis with:
 Lesions greater than 3 cm
 Long-standing lesions
 Deeply invasive tumors
 Inadequate treatment
FOLLOW-UP