Answer Sheet
GOAL
This special issue is the second in our series of home-study, continuing
education courses for optometrists. The lesson describes skin changes
of the eyelids and surrounding tissues that accompany middle- and
old-age, and it offers a number of suggestions on how to correct and/or
camouflage skin defects that affect persons entering these age groups.
At the conclusion of the course, optometrists should become familiar
with periocular skin imperfections so that they are immediately recognizable.
Early recognition and treatment of skin defects is especially important
in today's optometric world since some of these disorders may be amenable
to treatment by TPA O.D.s1. Optometrists also have the
tools to camouflage or "cover up" age-related skin imperfections
through astute frame selection and lens tinting. The text addresses
both subjects. Please note that direct quotes are referenced at the
end of the lesson, but unreferenced statements of fact are based upon
the list of selected readings that accompany the reference list.
Defects beyond the range of optometric practice should be referred
to dermatologists. However, to help prevent over- and under-referrals,
the text carefully distinguishes between benign skin disorders (which
do not necessarily require referrals), and pre-cancerous and malignant
cancers (which legally and morally do). On the other hand, if any
doubt exists as to diagnosis, O.D.s should take the risk of over-referral.
Although the course reviews medical and surgical procedures to correct
skin disorders, surgical therapy in itself is beyond the scope of
the text. For "how-to-do-it" operating techniques, the reader
is referred to textbooks and training courses on the subject.
Details on how to carry out the multiple-choice examination that
appears at the end of this material are spelled out below. Note that
by obtaining a passing grade on the test (70 percent), you will be
entitled to two hours of continuing education credits (CECs) toward
your annual State Board relicensing. However, even if you don't intend
to qualify for credits, why not check your new knowledge of the subject
by taking the examination for your own enlightenment and satisfaction?
If you would like to receive future lessons for State Board continuing
education credits, or simply for their interest and practical benefit,
we invite you to contact your Marchon sales representative or write
directly to Marchon for full information.
[Return to Table of Contents]
Instructions
- Read and study the text on the following pages.
- Analyze and study the multiple-choice questions.
- Circle the answers to the questions on the answer sheet.
- Clip the completed answer sheet and mail it to: Marchon, Department
of Education and Research, 35 Hub Drive, Melville, New York 11747-3500,
together with your check in the amount of $24.95 to cover processing
costs (applicants who fail the examination may re-take it at no
extra charge).
Credits
The 34-state Committee on Optometric Education (COPE) along with
several non-COPE-aligned optometry boards have approved this course
on skin changes for two hours of continuing education credits. There
are a few states, however, that do not recognize home-study courses,
so it's advisable to check with your board if you are unfamiliar with
its continuing-education regulations.
You must achieve a grade of 70% or higher on the test to earn the
two hours of CECs. Once you've successfully completed the examination
Marchon's Department of Education and Research will issue a CEC certificate
to you with the completion date stamped on the form. At that point
it will be your responsibility to submit the CEC form to your state
board for recognition.
About the Author
The author is director of Education and Research at Marchon Eyewear.
He had practiced optometry in New Jersey for almost 50 years and is
now a Life Member of AOA, a Fellow Emeritus of the American Academy
of Optometry and the American Association for the Advancement of Science,
and an active member of the American Medical Writers Association.
Dr. Weber has published more than 60 papers in all leading optometric
journals including those published by the American Academy of Optometry,
Review of Optometry, Optica International, and others. He has served
as chairman of the American Optometric Association's Committee on
Publications, president of the Optometric Editors Association, and
New Jersey Academy of Optometry Liaison to the New Jersey Academy
of Science.
Marchon is a registered trademark of Marchon Eyewear,
Inc.
©1997 by Marchon Eyewear, 35 Hub Drive, Melville, NY 11747.
[Return to Table of
Contents]
OPTOMETRIC MANAGEMENT OF
AGE-RELATED SKIN CHANGES OF THE EYELIDS AND SURROUNDING TISSUES
By Jack M. Weber, O.D., F.A.A.O.
INTRODUCTION
Skin changes around the eyes and surrounding tissues are among the
first signs of advancing age. The changes worry patients, not only
because the new growths are cosmetically unattractive, but also because
these persons fear the new growths may be precursors to skin cancers
or other serious skin diseases.
Unfortunately, as skin ages, certain adverse changes occur: These
include thinning of the epidermis, diminished production of collagen,
and degeneration of elastin fibers - all of which cause a marked loss
in the skin's resiliency. You can see this for yourself if you perform
a simple experiment: First, pinch up the skin in a young person and
notice how it snaps back instantly to its original contour. Next,
do the same with the skin of a baby boomer and notice that the skin
snaps back, but now it stays up for a second or two before returning
flat. Finally, pinch the skin of an elderly person and see how old
skin hangs up there for many seconds before becoming flat again. This
experiment proves that, over time, the skin loses its ability to function
at a top capacity.
Skin aging, of course, is inevitable. But with our current optometric
ability to treat some of these age-related disorders, together with
our expertise in ophthalmic-lens technology and modern frame-styling
techniques, overcoming skin blemishes during the golden years is now
possible. Moreover, a side benefit of optometric search for cutaneous
lesions on the lids and surrounding tissues opens up a new avenue
of practice for O.D.s.
We begin our study of age-related skin changes with Section I:
A Review of Normal Skin Anatomy and Physiology, as follows:
[Return to Table of
Contents]
SECTION I
A REVIEW OF NORMAL SKIN ANATOMY AND PHYSIOLOGY
PURPOSE: To review normal skin anatomy and physiology as
a basis for understanding normal vs. age-related skin changes that
are discussed on the following pages.
The skin is an organ, as is the heart, the lungs, and the kidneys.
In fact, it is the body's largest organ, measuring some 19-20 square
feet (if laid out flat), and weighing approximately seven to nine
pounds.
Skin is comprised of three layers, each distinct in form and function.
These are: 1. The epidermis, or top layer; 2. The dermis,
or middle layer; and 3. The subcutis, or bottom layer (Fig.
1).
 |
Fig. 1. Cross-section of normal
skin. HS = hair shaft; A = artery; V = vein; HF = hair follicle;
S = subcutaneous tissue; E = epidermis; and D = dermis.
|
1. The epidermis. Though paper thin,
the epidermis is comprised of 15-20 cell layers and three well-defined
sections of its own; namely, (A) The stratum corneum layer (more
commonly referred to as the "horny" layer due to its tough,
"animal horn-like" composition; (B) The stratum spinosum,
or prickle cell layer, so named for its prickly-looking projections
that connect its cells (particularly the scale-like squamous cells which
migrate to the top of the epidermis for eventual shedding at the top);
and, (C) The basal cell layer, in which new cells are continually germinated,
most important of which are melanocytes, producers of melanin, the determinant
of our skin coloration.
2. The dermis layer is the skin's middle
layer. It is 15 to 40 times thicker than the epidermis and is
best described as the "skin's nourishment center." Produced
here are collagen (fibrous protein that form the skin's major connective
tissue) and elastin (bundles of elastic fibers that bring the skin
back to its normal shape after smiling, gesturing, or making other
movements involving the skin). Also housed here are our sensory nerve
endings and tiny nutrient-supplying arteries and veins.
3. The subcutis. Completing the composition
of our skin is the third and bottommost layer, the subcutis, or fatty
layer. This layer helps protect our internal organs by both cushioning
the blows our bodies receive and by conserving body heat. Located
here are our hair and its follicles along with three kinds of sweat
glands.
Functioning in tandem, all of the skin's components serve to perform
an amazing array of services - far beyond merely "clothing"
the body. Thanks to our skin, toxins cannot penetrate into deeper
tissues, nor can essential fluids escape. Body waste is eliminated.
Harmful ultraviolet rays are absorbed and cleverly converted into
increasingly darker pigments. Body temperature is regulated. We are
able to feel a range of sensations, from the silky softness of a kitten's
fur to the unpleasant pangs of pain. At times, the skin can even reveal
a person's emotions: It turns red with anger or embarrassment, pale
with fright, and sweaty with nervousness.
As with every organ of the human body, the onslaught of age brings
with it a breakdown in function in which an already thin sheath becomes
even thinner, producing thinner cells, proteins and other sustaining
substances. Age-related skin can no longer "bounce back"
as efficiently when it is stretched, resulting in the wrinkles and
sags that plague the vanities of most people. Moreover, they tend
to develop precursors to cancers and other skin maladies that accompany
middle and old age.
In line with age-related defects that occur on and around the eyelids
that are amenable to treatment and/or camouflage, we open Section
II, Common, Benign Disorders of the Lids and Surrounding Tissues.
However, before we begin, let's review the following short glossary
of skin terminology:
D. The Glossary
bulla. A fluid-filled lesion more than 5 mm. in diameter.
crust (scab). Dried serum, blood or pus.
erosion. A wearing away or injury of superficial skin.
excoriation. A linear or hollowed-out crusted area, caused
by scratching, rubbing or picking.
intrinsic aging. Skin changes due to the passage of time
alone.
macule. A small, flat blemish less than 1.0 cm. in diameter.
nodule. A raised, solid lesion deeper than a papule.
patch. A flat lesion more than 3 cm. in diameter.
papule. A small, raised, firm lesion less than 10 mm. in
diameter.
photoaging. Skin changes due to the combination of aging
and chronic sun exposure.
plaque. A raised, solid, superficial lesion more than 10
mm. in diameter.
pustule. A fluid-filled lesion containing pus.
scales. Heaped-up particles of horny epithelium.
vesicle. A blister-like lesion containing fluid, less than
5 mm. in diameter.
[Return to Table of
Contents]
SECTION II
COMMON, BENIGN DISORDERS OF THE LIDS AND SURROUNDING TISSUES
PURPOSE: To discuss innocuous age-related skin defects on
and around the eyelids that are amenable to treatment and/or camouflage.
As mentioned earlier, step-by-step surgical procedures can be found
in any number of textbooks and/or in training courses on the subject.
A few of these sources are listed at the end of the course text.
Following are discussions on seven benign disorders of the lids
and surrounding tissues:
A. Furrows (wrinkles, "crow's-feet")
B. Ptosis and Pigmentary Hypertrophy (drooping eye lids,
excessive skin overhang [dermatochalasis] bags and circles under the
eyes)
C. Xanthelasma (yellow, fatty deposits)
D. Telangiectasias ("spider veins")
E. Herpes Zoster (shingles)
F. Ectropion (eyelid eversion)
G. Contact Dermatitis (allergic skin rash)
A. Furrows. Furrows, or wrinkles (often
referred to as "crow's-feet") are the tiny lines that form
at the outer canthi. They are caused by collagen that progressively
loses its solubility.
Cosmetically, very fine lines can be camouflaged by certain skin
products, such as Ocuderma (Medinich, Inc., (800-711-4303)
and/or by clear-bridge frames that darken as they reach the endpieces,
together with lightly tinted lenses that match the wearer's complexion.
Medically, laser skin resurfacing - the newest treatment
for crow's-feet removal - gently "irons" wrinkles away using
a state-of-the-art, high-energy, pulsed CO2 laser. Areas as small
as one crow's-foot or as large as an entire face can be treated. Deep
wrinkles are resurfaced more vigorously and finer wrinkles less, so
that the treatment successfully removes fine wrinkles and reduces
deeper ones2.
Each pulse of the laser feels like the snapping of a rubber band
against the skin, which proves to be difficult for most patients.
However, light sedation and local anesthesia make the patients more
comfortable during the procedure.
After-effects include skin reddening and slight swelling, which
soon disappear with time. However, the new, fresh skin needs to be
protected from sun and wind for several months.
As with any surgery, there are certain complications that may arise.
There is a chance that a patient may gain or lose pigment, thereby
causing the treated area to be a different color than the rest of
the skin. For this reason, a patch test is done prior to laser application
to note any adverse reactions.
(Note: Laser therapy for the correction of skin defects is rapidly
growing in professional acceptance. It's conceivable, therefore, that
some of the following skin disorders may also eventually be treated
with lasers.)
Another form of treatment for the elimination of skin wrinkles includes
the use of collagen injections. This technique uses a series of needles
to inject small amounts of collagen in a row underneath each wrinkle
line. There is some controversy surrounding this form of treatment
since a case was reported in which an accidental injection into a
blood vessel resulted in the loss of an eye. However, the Collagen
Corporation (manufacturer of collagen materials called "Zyderm"
for normal action and "Zyplast" for longer action) has since
alerted dermatologists to make doubly sure they are not injecting
into a blood vessel during the procedure.
Injectable collagens have a number of advantages. For one thing,
the treatments take only a few minutes to perform; they are usually
only minimally uncomfortable; and the patient can usually return to
work immediately. Unfortunately, the results are only temporary in
that they only last from six months to a few years after injection.
Subsequent touch-ups, however, generally require fewer treatments
than the initial therapy3.
Skin peeling is yet another form of cosmetic treatment for crow's-feet.
In this form of therapy, a potent chemical (usually phenol) is applied
to the skin. The acid stings for a few seconds, after which the acid
is neutralized with water or alcohol. The resultant scab falls off
in about a week or two. The cosmetic effect lasts for several years
before treatment has to be reinstituted. Results are usually favorable,
although the patient has to avoid the sun for a few months after peeling
because the therapy renders skin more sensitive to ultraviolet rays4.
Finally, dermabrasion - the superficial sanding off of the upper
two layers of the facial skin - is sometimes used to minimize skin
wrinkles at the outer canthi, although it is not as popular as skin
peeling. The technique is performed with brushes and serrated wheels
that plane, or sand down, the skin in order to smooth out the wrinkles
(Fig. 2). As in the case of skin peeling, patients must avoid the
sun's UV rays for about three months after treatment5.
B. Ptosis and Pigmentary Hypertrophy (drooping
eyelids, excessive skin overhang, and puffy bags under the eyes).
As a person ages, the connective tissue around the eyes loosens, allowing
gravity to pull the eyelids down and cause the normal fat around the
eyes to bulge. Dark circles under the eyes are caused by a network
of tiny blood vessels (see also telangiectasias, below) that
are very close to the skin's surface. Because dark circles could also
be indicators of anemia, any underlying problems should be ruled out
before making a definitive diagnosis.
 |
Fig. 2. Dermabrasion. Removal
of scars and other marks by sanding or wire brushing off some
of the outer skin layer while the skin is anesthetized.
|
A keen analysis of the blemishes should be made, and carefully designed
glasses should be fitted to suit the problem. For example, a smoke-colored
frame with its lenses tinted about 10 percent gray could be an effective
camouflage.
Medically, a 2 percent to 4 percent hydroquinone (Solaquine®)
in an alcoholic glycol or cream base may be helpful in bleaching out
some of the pigmentation. However, the preparation should be tested
for a week (preferably under one ear) to make sure it does not cause
dermatitis. In addition, the patient must be advised to avoid excessive
exposure to sunlight if the bleaching is to work. In cases where the
skin also "hangs down," plastic surgery is often the only
answer.
A relatively new technique called laser blepharoplasty removes
excess skin and fat by making small laser incisions that are hidden
in the folds of the upper eyelids. These hairline incisions usually
fade and become virtually invisible. Puffy bags under the eyes are
treated by making a laser incision on the inside of the lower lid
(no incisions are made on the outside skin where they can be seen).
Laser blepharoplasty is performed on an outpatient basis under local
anesthesia. Most patients are back to work in a few days6.
C. Xanthelasma (yellow, fatty
deposits). This condition is characterized by the presence of dull,
yellow, flat, or slightly elevated plaques containing fatty material
(Fig. 3). The word xanthelasma is derived from the Greek word
meaning "yellow plate," which is exactly what the lesion
looks like.
Xanthelasma appear most often on the bridge of the nose and the
eyelids. The deposits are benign and chronic, occurring primarily
in middle-agers and most frequently affecting females.
 |
Fig. 3. Xanthelasma. The formation
of yellowish, fatty deposits around the eyes. |
Xanthelasma sometimes develop in a "butterfly" distribution.
As mentioned earlier, they are non-cancerous and entirely innocuous,
but they do produce a noticeable blemish.
O.D.s can be of great help to patients exhibiting xanthelasma by
prescribing pinkish-yellow tinted lenses in the 15-to-20 percent range,
with the yellow predominating in direct proportion to the number and
size of the xanthelasma present.
Bichloroacetic acid is sometimes used to medically treat xanthelasma,
but a small test area should be initially treated and followed to
ensure a favorable result7.
Xanthelasma can be painlessly removed through surgery, although
the condition tends to be recurrent. Large defects may need skin grafting.
A word of caution: Since the yellowish blotches are sometimes indicative
of high cholesterol or diabetes, persons with this defect should be
advised to consult with their family physicians or internists for
differential diagnosis.
D. Telangiectasias ("spider
veins") are dilated, thin veins that merge together to form a
distracting reddish-blue, spidery pattern that produces a flushed
appearance on faces of middle- and older-aged patients. Sun damage,
excessive alcohol intake, and acne rosacea (an inflammatory, age-related
skin disease) are common causes of blood vessel dilation, which, in
turn, triggers facial flushing.
Although telangiectasias are difficult to conceal with frame and
lens selection, the use of lightly tinted lenses that match the discoloration
sometimes help to mask facial flushing in mild cases.
Telangiectasias are often treated by electrolysis in which a tiny
electric current is delivered through a fine needle to the blood vessels
to close them off so that they do not show through the skin. The coagulating
therapy is usually quite successful, with an estimated 80 percent
overall improvement expected.
Telangiectasias also lend themselves to laser treatment because
the visible components of the blood selectively absorb the laser's
energy. When this occurs, the vessels of the lesion coagulate, blanche,
and disappear8. Laser treatment for the correction of telangiectasias
was formerly looked upon with disfavor because it was believed the
risk of scarring could be cosmetically worse than the appearance of
the original spider-like veins. However, cosmetic surgeons claim the
problem of scarring is now under control.
E. Herpes zoster (shingles). Herpes
zoster is a disease caused by the same virus that causes chicken pox.
This childhood infection becomes latent; it can lay dormant for many
years and, because of diminishing immunity, becomes reactivated later
in life. Under the latter condition, the disease is called herpes
zoster, or, more commonly, shingles.
Shingles can erupt on any part of the skin, but they often develop
on the face (Fig. 4). They also occur mainly in middle-aged and older
persons, exceeding 10 persons per 1,000 annually at age 80 years.
When shingles appear on the face, they are characterized by the formation
of blisters over an area supplied by the frontal branch of the fifth
cranial nerve. The vesicles are usually preceded by tingling, burning
or painful sensations on the lids and surrounding tissues. Redness
and blisters then develop, following the path of the fifth-nerve's
branch. The rash develops into scabs, which fall off two or more weeks
later. Recovery then sets in.
 |
Fig. 4. Herpes zoster (shingles).
A disorder in the elderly due to reactivated chickenpox of childhood
that has remained latent since then. |
Initial medical management of herpes zoster centers around pain control,
the prevention of bacterial superinfection and resolving the cutaneous
lesions. Antiviral therapy with acyclovir, famciclovir ant others lead
to a more rapid resolution of the eruptions and pain.
After recovery, however, a problem sometimes arises in that the
shingles are accompanied by severe pain, which can persist in the
elderly even after the primary problem clears up. This pain, called
"post-herpetic neuralgia," can be severe and last indefinitely,
but it can be relieved somewhat by the administration of cortisone.
Early referral to a specialist is vital since post-herpetic neuralgia
could ultimately involve the eye's cornea (herpes zoster ophthalmicus).
It's a good working rule that, if the side of the tip of the nose
is involved, eye complications are likely9 (Hutchinson's
Sign).
F. Ectropion (lid laxity). Ectropion
is an eversion of the lower lid margin. It causes exposure of the
lid's conjunctival surface, which, in turn, leads to poor drainage
of tears through the nasolacrimal system. The constant flow of tears
over the lid, combined with wiping the eye with a handkerchief, causes
excoriation and subsequent retraction of the skin, which tend to aggravate
the eversion.
Ectropion is commonly caused by a lessening of muscle tone combined
with a decrease in orbital fat in older persons, which allows the
lower lid to fall away from the globe. There also may be some spastic
element present; for instance, the lower fibers of the orbicularis
muscle may contract more than the fibers near the lid margin, thus
tending to add to lid eversion. Notice in Figs. 5,a and 5,b that the
conjunctival surface of the lid is exposed and the punctum is well
away from the globe. The skin at the inner canthus is excoriated and
taut, pulling the lid downward. The exposed conjunctiva becomes chronically
inflamed and unsightly, while the cornea experiences extreme dryness.
Mild cases of ectropion (Fig. 5,a) respond well to artificial tears
and lubricating ointments. A plastic shield worn during sleep is also
helpful. More severe cases (Fig. 5,b) require surgical intervention
in order to bring the lid back to its normal position. The surgery
is done on an outpatient basis using a local anesthetic.
G. Contact dermatitis. Contact dermatitis
is a rash resulting from the contact of an irritating or allergic
substance against the skin. Although all age-groups are affected,
it's believed there is a slight predominance in older females. Contact
dermatitis is important to optometrists because of possible adverse
reactions to the various ingredients used in the manufacture of plastic
and metal frames; for example, plasticizers, stabilizers and coloring
agents found in plastic frames, and the nickel in metal frames.
 |
Fig. 5. Fig. 5,a. Mild ectropion.
Moderate eversion of the lower lid. Fig. 5,b. Severe eversion
of the lower lid. |
The symptoms of contact dermatitis range from transient redness to severe
swelling. Itching and the formation of vesicles are common. Any exposed
skin surface that contacts a sensitizing or irritating substance may
be involved. Contact dermatitis due to eyewear is easily detected once
the symptoms appear, since outlines of the offending parts reveal themselves
upon close inspection (Fig. 10). However, there's no way to anticipate
that this will happen unless you include the question, "Do you
have any skin allergies to plastic or metal?" when taking the patient's
history.
Allergic reaction to plastic parts in ophthalmic frames does not
necessarily require replacement of the offending frame. A coating
or two of polyurethane film, carefully applied, should do the trick.
In these cases, the offending parts should be buffed with steel wool
before applying one or more coatings to allow better adhesion of the
polyurethane. Allergic reaction to metal frames, on the other hand,
demands frame replacement with eyewear that has little or no nickel
content.
[Return to Table of
Contents]
SECTION III
MANAGEMENT OF EYELASH AND EYEBROW PROBLEMS
PURPOSE: The loss of eyelashes poses a problem for older
patients. This section offers: (A) a brief review of eyelash and eyebrow
anatomy and physiology; (B) an analysis of hypotrichosis - the name
for hair thinning and/or loss of hair on the lid margins and eyebrows;
and, (C) Rosacea, a chronic, age-related inflammatory disorder that
sometimes leads to a loss of eyelashes.
A. A review of lid and eyelash anatomy
and physiology. Each cilium of the eyelashes comprises a strong,
cylindrical hair growing from a typical hair follicle which, in turn,
is surrounded by a nerve network with a very low threshold. It is
because of this low threshold that touching a lash is sufficient to
excite it into producing a split-second reflex to closure.
The base of each lash is "fed" by sebaceous glands (the
glands of Zeis), which open into the hair follicles by short, wide
ducts. Excessive or altered secretion of the glands produces blepharitis
marginalis.
Eyelash color is often deeper than that of the scalp hair throughout
life. Occasionally, however, cilia pigment loses color with advancing
age, and the cilia may turn gray or white. In either case, the change
in color is called poliosis.
The normal, average life of an eyelash is from three to five months,
after which it falls out and a new one grows in to take its place,
reaching full size in about two months.
B. Hypotrichosis. Middle- and
old-aged patients are subject to hypotrichosis (sometimes called
madarosis) - a term used to describe thinning, or loss, of
eyelid and eyebrow hairs10.
Among the chief causes of age-related hypotrichosis are: alopecia
areata (segmented hair loss in individuals who have no other hair
disorders) and alopecia universalis (total loss of eyelash
and eyebrow hairs from unknown causes). Non-age-related causes of
hypotrichosis include: ulcerative blepharitis marginalis, physical
trauma, burns, x-ray therapy, overuse of glued-on false eyelashes,
and trichotillomania (a morbid impulse to pull out one's hairs, including
the eyelashes).
Hypotrichosis cannot be treated optometrically. However, to help
camouflage irreversible cases of lash and eyebrow hair thinning and
loss, an effective eyelash enhancement procedure is currently available
from ophthalmologists. Called blepharopigmentation, the technique
involves tattooing the lid margins and eyebrows to create a cosmetic
illusion that hairs are present11.
One device for performing the procedure is the Permark Tattooing
Unit invented by Michael Patipa, a Florida ophthalmologist. In
Dr. Patipa's technique for alopecia areata (where there is just some
thinning of the lashes), small dots of a special mixture of synthetic
ferrous oxide and titanium dioxide in a glycerine base are tattooed
between the hairs of the lower and upper lids to enhance the lid margins
and provide a thicker, fuller appearance of the eyelashes and eyebrows.
In alopecia universalis (where hair loss is complete), "artificial"
eyelashes and eyebrows are tattooed on the lid margins and brow lines
(Fig. 6).
Blepharopigmentation was originally looked down upon by some critics
because pigment, once applied, was extremely difficult to remove.
However, if for any reason the tattooing has to be removed, the use
of an alexandrite laser now makes it possible to remove tattoos without
scarring and is proving to be a safe and effective modality for black
and blue-black tattoo-pigment removal12.
 |
Fig. 6. Before and after photos
of a patient's eyelashes and eyebrows which were tattooed following
hypotrichosis of alopecia universalis. |
C. Rosacea. Rosacea is a chronic skin
disorder of unknown cause that is frequently seen in the elderly. Typical
symptoms include: easy flushing, telangiectasia, and papules and pustules,
especially on the facial areas below the eyes. Conjunctivitis is often
present. Other ocular findings include keratitis and ulcerative blepharitis
marginalis13, the latter resulting in substantial eyelash
loss (Fig. 7).
 |
Fig. 7. Ulcerative blepharitis.
Note marked loss of eyelashes. |
Rosacea patients should be encouraged to avoid alcohol and spicy foods
and to be careful of solar overexposure. Broad-spectrum oral antibiotics
such as tetracycline 500 to 1,000 mg/day are often useful to control
the inflammatory lesions. This treatment usually eliminates pustules
and papules within a few weeks. Abnormal redness of the skin and telangiectasias
do not respond as well to antibiotics but they usually are amenable
to treatment with argon or pulsed-dye lasers. The condition is usually
not serious unless the cornea is involved.
[Return to Table of
Contents]
SECTION IV
AGE-RELATED BENIGN SKIN TUMORS
PURPOSE:To discuss non-malignant tumors that are amenable
to cosmetic treatment.
Benign tumors (also called benign neoplasms) are abnormal
growths of new tissue that retain the characteristics of their original
cells and, therefore, do not metastasize.
Tumor types of the skin are named according to the cells from which
they develop. Thus, basal cell carcinoma and squamous cell carcinoma
are tumors that arise from the basal cell layer and the squamous
cell layer, respectively (see below). Sarcomas are tumors that
develop from bones, muscles, or other connective tissue. Where tumor
cells are identified as being of primitive or undeveloped form, blast
is inserted into the description; for example, retinoblastoma (hereditary
tumors of the retina); more mature, acquired tumors add cyto, as in
cytomegalovirus (reactivation of a previous infection)14.
Following are five of the more common age-related benign skin tumors:
A. Papillomas ("skin tags")
B. Sebaceous cysts ("keratin sacs")
C. Keratoacanthomas (elevated tumors)
D. Lipomas (fatty cells)
E. Seborrheic keratoses (age-related, liver, or stucco spots)
A. Papillomas are the most frequently
found benign eyelid tumors. Nicknamed "skin tags," they
develop mainly on the lid margins of older people as brownish-red,
pedunculated (stalk-like) lesions.
Papillomas are non-contagious and non-malignant, and they grow slowly.
But they are annoying nuisances of the skin because they constantly
catch on clothing, necklaces, and other objects of wear. They also
sometimes cause problems if they are large-sized with thin stalks.
When this occurs, bleeding and infection may result.
When the base or attachment to the skin is less than 1 mm in size,
a papilloma can be easily removed by holding it erect with a forceps
or tweezers and cutting it off at the base with fine, sharp scissors
(Fig. 8). The small bleed that subsequently occurs can be effortlessly
controlled with direct pressure and/or disposable cautery15.
Longer-stalked papillomas respond well to laser removal. Also, electrosurgery
and cryosurgery are successful methods for removing long-stalked papillomas
- with cryosurgery being the method of choice today. These procedures
are usually so rapid that papillomas can be removed in a single session
under local anesthesia.
 |
Fig. 8. Curved scissors. Used
for removal of stalk-like growths that protrude above the skin
surface. |
B. Sebaceous cysts (Fig. 9) are slow-growing,
benign tumors containing keratin (the protein that forms horny tissues),
cellular debris, and oil-gland secretions. They tend to be painless,
round, rubbery masses that occur most often in the elderly (due to aging
of the skin) and are seen most often on the eyebrows.
 |
Fig. 9. Sebaceous cyst. A
slow-growing benign tumor that tends to be painless, round, and
rubbery. |
On palpation, these cysts are firm, globular, movable and non-tender;
they seldom cause discomfort unless infected (when in such a state,
they resemble boils in appearance).
Small cysts (about 1-2 mm. in diameter) on the surface are called
superficial milia. (Cysts located deeper into the skin are
usually larger (over 10 mm.) and are known as subcutaneous cysts.)
Milia are whiteheads that are filled with hard, round, pearly, yellowish-white
keratin and fat (Fig. 10). Expression of the contents through a tiny
stab incision removes the unsightly milia. After the area of the cyst
is anesthetized, a linear incision is made parallel to the natural
folds of the overlying skin; care should be taken not to puncture
the cyst capsule. The skin is then spread apart, and the sebaceous
cyst is carefully excised out, capsule and all. If the capsule is
simply punctured and the contents expressed, the cyst usually recurs
once the wound heals16.
 |
Fig. 10. Milia (whiteheads).
Minute, white cysts caused by obstruction of hair follicles or
sweat glands. |
For larger (subcutaneous) cysts, the area is first anesthetized and
the contents evacuated through a small incision. Then, the cyst wall
is carefully removed through the incision with a curette or a hemostat.
Finally, any accompanying infection is incised and drained. The gauze
drain is gradually removed 7 to 10 days later. Appropriate oral antibiotics
may be required.
C. Keratoacanthomas. Often
abbreviated as KAs, keratoacanthomas are benign, self-healing epithelial
tumors that develop from hair follicles. Onset is rapid, and lesions
can obtain a large diameter within one or two months. These growths
can leave large scars and, because they generally occur on the face,
cause severe cosmetic effects. Some dermatologists believe kerato-acanthomas
are precursors to skin malignancy because of their resemblance to
squamous cell carcinomas; therefore these professionals treat the
disorder as they would a malignant precursor17.
KAs usually appear as single lesions on the lids and surrounding
tissues of elderly patients (Fig. 11). They are slightly elevated
and, as mentioned earlier, grow rapidly, often exhibiting a characteristic
crusted central crater. They sometimes resolve spontaneously, but
tend to leave a scar. More often, they have to be removed by cryosurgery
or excision.
 |
Fig. 11. Keratoacanthomas
(often abbreviated as "KAs"). KAs are self-healing epithelial
tumors that develop from hair follicles. Some authorities classify
keratoacanthomas as pre-cursors to a skin malignancy.
|
D. Lipomas. Lipomas are benign tumors
containing an overproduction of fat cells within the deep, fatty layer
of the skin. On examination, the overlying skin appears to be normal.
But when compressed, the lipomas have a characteristic spongy feel to
them, which may cause confusion with sebaceous cysts (see sebaceous
cysts, above). As a rule, lipomas are tumors that cause no adverse
problems, although they can sometimes be quite painful.
If the lipomas are asymptomatic, they can be ignored. On the other
hand, if they cause cosmetic embarrassment, excisional surgery is
the preferred means for removing them.
E. Seborrheic keratoses are benign
lesions that are common in middle and older age. They usually begin
as multiple, oval, reddish-brown to black, sharply demarcated papules
with a rough, wart-like surface. Seborrheic keratoses give the appearance
of being "glued on" to the skin (Fig. 12) and, as a matter
of fact, are often nicknamed stucco keratoses because of their stuck-on
appearance. They are sometimes also referred to as "age spots,"
because they are age-related, or "liver spots," but only
because they resemble the liver in color and shape (they have nothing
to do with the liver).The most important clinical aspect of seborrheic
keratoses is the differential diagnosis from malignant melanoma.
Seborrheic keratoses are simple to remove by liquid nitrogen cryosurgery.
An alternative method is curettage under local anesthesia. Scarring
is usually minimal18.
 |
Fig. 12. Seborrheic keratoses
are benign lesions that are common in middle and old age.
|
[Return to Table of
Contents]
SECTION V
PRECURSORS TO MALIGNANT SKIN DISORDERS
PURPOSE: Skin cancer is almost always preventable. In most
cases, it is also completely curable when treated in the earliest
stages. For this reason, O.D.s are legally and morally obligated not
only to recognize skin malignancy, but also to identify early signs
of developing cancers. The purpose of this section is to present five
of the most common precursors to malignant skin disorders, as follows:
A. Solar keratoses
B. Lentigo maligna
C. Basal cell carcinoma
D. Squamous cell carcinoma
E. Dysplastic nevi
A. Solar (actinic, sun-related) keratoses.
Chronic exposure to sunlight ages skin. A case in point concerns solar
keratoses - cancer precursors of horny-cell overgrowths caused by
accumulated exposure to the sun's UV rays. Solar keratoses first make
their appearance as smooth, flat areas that develop, with aging, into
slightly raised, scaly, reddish-brown rough spots resembling large
freckles (Fig. 13, a).
 |
Fig. 13,a. Solar (actinic)
keratoses. A skin cancer percursor to horny-cell overgrowth caused
by accumulated exposure to the sun's UV rays. The keratoses develop
into slightly raised, scaly, reddish-brown rough spots resembling
large freckles. 13, b. The Sensometer indicates the presense of
UV protection in eyewear. |
Patients of all ages should be advised to avoid overexposure to UV rays,
especially when the sun is at its peak. A good way to determine when
this peak time occurs is to observe one's shadow: when the shadow is
shorter than the person is tall, the sun is much more likely to burn
than at any other time of the day. Thus, the mnemonic "S.S.S.S."
for Short Shadow? Seek Shade19."
An effective warning device against overexposure to ultraviolet
rays is the Sensometer-a 2 1/2" x 3 1/4" plastic
card that can measure the presence and degree of UV rays. All one
has to do is expose the card's front surface to sunlight. After ten
seconds, a sensor strip at the bottom of the card should be matched
up with a violet, three-stage color chart at the top (Fig. 13,b).
The comparison reveals the degree of UV exposure, namely: Weak
(which suggests the need for a 15 SPF [sunscreen] value; Medium
for 20 SPF; and strong for 30 SPF.) The card functions
on both sunny and cloudy days.
The Sensometer has another benefit: it can check for the presence
or absence of UV protection in eyewear (especially sunglasses). If
the glasses have UV protection, the sensor strip remains white behind
the lenses, but turns violet in unprotected spots.
The product is available in quantities from Optiwear (800-451-2095)
at low cost, so it's a good idea to distribute complimentary cards
to patients to help protect their eyes and skin against overexposure
to the sun's rays.
Solar keratoses are the most common premalignant lesions. It is
estimated that 60 percent of predisposed persons older than 40 years
of age have at least one solar keratosis. Solar keratoses absolutely
must be treated. Chief among current therapeutic modalities to destroy
the keratoses are: curettage (scraping with a curette), cryosurgery
(freezing with liquid nitrogen or carbon dioxide) and chemical (applying
trichloroacetic acid). Topical 5-Fluorouracil (which seeks out and
destroys sun-damaged cells before they become malignant) is no longer
recommended since it is now known to be associated with extensive
dermal spread under a healed epidermis and should not be used for
local treatment of precancerous or cancerous lesions.
B. Lentigo maligna. Also called Hutchinson's
freckle (after its original describer), lentigo maligna is a premalignant
disorder of melanocytes limited to the epidermis. It appears on the
skin of the face in elderly patients as an asymptomatic, large (2
to 6 cms), flat, tan or brown, macule with darker brown spots scattered
irregularly on its surface (Fig. 14). The lesion's early appearance
is confined to the epidermis, but later the cells invade the dermis
and develop a malignant focus (called lentigo maligna melanoma).
For this reason, early removal of the lesion (before it grows very
large) is strongly recommended.
Treatment consists mainly of cryosurgery, in which the affected
skin is frozen with liquid nitrogen delivered by open spray, or by
surgical excision.
 |
Fig. 14. Lentigo maligna.
A precursor to melanoma. Often appearing on the face of elderly
patients, the lesion is a flat tan or brownish in color. It is
usually pain free. |
C. Basal cell carcinoma. This defect, which
has an affinity for developing on or near the eyelids, is the most common
form of cancer precursor that appears in the elderly (some authorities
classify basal cell carcinoma as being already cancerous). The growth
usually begins as a small, shiny papule; it then enlarges slowly and,
after a few months, shows a shiny, purple border. Next, the growth may
ulcerate, bleed (because of the tiny blood vessels that develop over
the surface) and crust (Fig. 15). Some basal cell carcinomas have a
"chewed out" appearance and are called "rodent ulcers,"
after their resemblance to the ragged, punched-out border of a rat bite20.
Finally, the sores alternately crust and heal so that patients mistakenly
think the carcinoma has healed when the scab goes away. (This gave rise
to the classic American Cancer Society admonition: "Beware of a
sore that doesn't heal!")
 |
Fig. 15. Basal cell carcinoma.
This is the most common form of cancer precursor (some authorities
classify basal cell carcinoma as being already cancerous). Note
its chewed-out appearance which resembles a "rodent ulcer"
|
Basal cell carcinomas rarely metastasize but they are highly destructive
because they tend to invade normal tissues. Biopsy and treatment should
be by a qualified dermatologist. The clinical appearance, size, site
and histology determine choice of treatment; namely, curettage and electrodesiccation,
surgical excision or, occasionally, x-ray therapy. Mohs' chemosurgery
is especially useful in treating recurrences with large diseased
areas. In this procedure, a detailed three-dimensional map is made of
all quadrants of the carcinoma. The growth is then repeatedly sliced
away, and each slice immediately examined microscopically. The procedure
is continued until all diseased tissue has been removed. Cure rates
with Mohs' surgery, for even the largest and most difficult skin growths,
are more than 95 percent.
D. Squamous cell carcinoma. This
type of tumor is the second most common form of premalignant skin
disease (as is the case with basal cell carcinoma, some experts classify
squamous cell carcinoma as a true cancer. The defect arises in the
epithelium, especially on sun-exposed areas. Squamous cell carcinomas
may develop in normal tissues or in preexisting keratoses.
The clinical appearance begins as a pink or red papule with wart-like,
scaly, or mushroom-like growths (Fig. 16). These later tend to ulcerate
and bleed. Unfortunately, about one-third of the lesions have metastasized
before they have been diagnosed. Differential diagnosis includes many
types of benign and malignant defects such as: basal cell carcinoma,
keratoacanthoma and actinic and seborrheic keratoses.
 |
Fig. 16. Squamous cell carcinoma.
The secind most common form of cancer presursor (some experts
classify squamous cell carcinoma as being already cancerous).
It tends to ulcerate and bleed. |
A biopsy for squamous cell carcinoma is essential, as it is for basal
cell carcinoma. In general, the prognosis is excellent for small squamous
cell carcinomas that have been removed early. As with cell carcinomas,
recurrences should be treated with Mohs' microsurgery.
|
| A COMPARISON OF BASAL AND SQUAMOUSCELL PRECURSORS
TO SKIN MALIGNANCY21 |
|
| |
BASAL |
SQUAMOUS |
|
Nodule |
Frequent |
Occasional |
| Telangiectasias |
Frequent |
Rare |
| Scaling |
Less common |
Frequent |
| Color |
Pale, pearly, rarely pigmented |
Red or brown |
| Sun caused |
Yes |
Yes |
| Prognosis |
Excellent |
Excellent |
| Preceded by solar keratoses |
No |
Yes (usually) |
| "Rodent ulcer" |
Often |
Rarely |
| Bleeding |
Yes |
Less frequently |
| Incidence |
400,000 cases a year |
100,000 cases a year |
|
E. Dysplastic nevi are atypical
moles (birthmarks) that have the potential to progress to malignant
tumors. This is especially so in patients who have close blood-relatives
with histories of malignant skin disease. As a matter of fact, the
disease was first recognized because of its increased frequency in
certain families. Thus, it is believed the affliction may be an autosomal
dominant trait (transmitted by an affected person to an average
of 50 percent of the offspring). Most authorities recommend full excision
of the affected nevi so that the condition will never have the opportunity
to turn into a malignancy.
Dysplastic nevi measure 5 to 12 mm. in diameter - much larger than
common moles. Their color variegations range from tan to dark brown
on a pink background. Although common moles usually appear before
adult life, dysplastic nevi continue to appear even after middle age.
A family history should be obtained with special reference to moles
and malignancies or other skin cancers. The entire facial skin should
be examined with a biopsy of one or more atypical-bearing lesions.
As mentioned earlier, excision of the disorder is strongly recommended.
Patients with dysplastic nevi should avoid excessive sun exposure
and use sunscreens with a sun protective factor (SPF) of 15 or higher.
They should also be advised of complete body self-examination to detect
changes in existing nevi22.
[Return to Table of
Contents]
SECTION VI
MALIGNANT MELANOMA - THE LIFE-THREATENING SKIN TUMOR
PURPOSE: Because melanoma frequently makes its appearance
on the skin of the eyelids and surrounding tissues, optometrists are
in an excellent position to detect this life-threatening disease.
In this section, we present clinical features of incipient and advanced
melanoma with special emphasis on guidelines to help uncover suspicious
cases.
Melanoma is a malignant neoplasm of the skin consisting of melanocytes.
Most develop from pigmented nevi (moles). Any change in color or shape
of a skin growth suggests melanoma.
Malignant melanoma is by far the least common of cancerous skin
lesions. On the other hand, it is the most serious: It can spread
so rapidly that it is fatal within months of recognition. Fortunately,
it's been established that early superficial melanomas have excellent
prognosis and that metastases will not develop in patients with melanomas
less than 0.76 mm. thick23. (Some authorities believe metastasis
will not occur in melanomas less than the thickness of a U.S. 25-cent
coin [about 2 mm])
Incipient melanomas are sometimes mistaken for simple lentigines
(common freckles or pigmented nevi). However, unlike these benign
blemishes, which have regular margins, early malignant melanomas are
usually asymmetrical with irregular borders (Fig. 17). The melanomas
are also variegated with regard to color, ranging from various hues
of tan and brown to black and sometimes intermingled with red and
white, whereas common lentigines are generally uniform in color.
Other clues in detecting suspicious cases of melanoma concern the
diameters; they are usually more than 6 mm. in diameter vs. less than
6 mm. for benign tumors. These characteristics can be easily remembered
by thinking of the mnemonic A-B-C-D24, as follows:
 |
Fig. 17. Malignant melanoma.
This classic illustration shows the melanoma as a disorganized
lesion with irregular, notched borders and mixed red-white-and
blue pigmentation that spills over one edge of the tumor.
|
A = Asymmetry
B = Border irregularity
C = Color variegation
D = Diameter
In addition, the diagnosis of melanoma is based not only on its
clinical appearance but also on its history and symptomatology. A
change in a preexisting mole or the development of a new, pigmented
neoplasm, particularly after the age of 40 years, is a warning signal
about the possibility of a malignancy. Other important warning signals
are changes in size, shape, color, and elevation.
Epidemiologic studies also suggest that melanomas may be related
to additional risk factors, including the following categories:
- Light-colored eyes (blue, green, gray), light complexions, and
light-colored hair.
- Xeroderma pigmentosa (pigmented areas of dry skin).
- Severe sunburn, especially in childhood through the early 20s.
- Increase in the number of melanocytic nevi.
Recognizing precursors
is key to prevention
Because early diagnosis of melanoma is the key to preventing its
metastasis, emphasis is highly placed on persons with a family history
of the disease and/or the presence of one or more precursors (please
review Section V, Precursors to Malignant Skin Disorders .
Treatment of malignant melanoma is by extensive surgical excision
when its depth is restricted to the upper levels of the skin. A check
with a pathologist is always made to determine if all diseased tissue
has been removed. As a rule, the deeper the invasion of the tumor
at the time it is discovered, the poorer the diagnosis. The services
of an oncologist are required if the melanoma has already metastasized.
Recently, an experimental vaccine was introduced by Dr. Malcolm
Mitchell, director of the Center for Biological Therapy and Melanoma
Research at the University of California. His promising therapy is
administered to afflicted persons as a way to stimulate the body's
own defense against melanoma cells. As our CEC went to press, there
were 60 patients taking the vaccine drug, which is currently awaiting
approval by the U.S. Food and Drug Administration. Even so, Dr. Mitchell
says, melanoma is usually curable if people recognize the early warning
signs. "Malignant melanoma writes its message with its own ink,"
he says, "so that's why it's crucial to watch for changes in
the size, color, shape, or texture of any mole."25
Prompt referral is a moral
and legal responsibility
Early detection of melanoma on the skin of the eyelids or surrounding
tissues is a moral and legal professional obligation.
Moral responsibility is self-evident, since early detection and
referral prevent metastasis and the patient's eventual death. Legally,
failure on the part of an O.D. to refer suspicious cases to a medical
specialist could result in serious litigation. Should such a referral
be overlooked, the degree of injury suffered by the patient - from
the time when referral should have been made to the time therapy was
initiated to arrest the disease - determines damages against the optometrist
for which the patient may claim compensation26.
Extra benefit
for O.D.s
The ability to recognize early melanoma provides an extra benefit
for O.D.s. inasmuch as the knowledge could help save their own lives
and the lives of their loved ones: Periodic examination - not only
of their own lids and surrounding tissues, but also of their entire
bodies - could uncover a suspicious lesion that is usually amenable
to successful treatment.
DANGER SIGNALS
OF MALIGNANT MELANOMA
Change in Color
Especially multiple shades of dark brown or
black; red, white, and blue spread of color from
the edge of the lesion to the surrounding skin.
Change in Size
Especially sudden or continuous enlargement.
Change in Shape
Especially development of irregular margins.
Change in Elevation
Especially sudden elevation of a previously small pigmented
lesion.
Change in Surface
Especially scaliness, erosion, oozing, crusting, and/or
bleeding.
Change in Surrounding Skin
Especially redness, swelling, and satellite pigmentations.
Change in Sensation
Especially itchiness, tenderness and/or pain.
Change in Consistency
Especially in softening or fragility.
|
[Return to Table of
Contents]
RAISED-NUMERAL REFERENCES
- Melore, CG, "Treating Eyelid and Conjunctival Conditions,"
Optometry Today, Sept. 1995, p.33.
- Wallace, IB, personal correspondence.
- Novick, NL, Super Skin, New York, Crown Pub., 1988, pp.174-175.
- Ibid. p. 105.
- Ibid.
- Wallace.
- Melore, p.33.
- Wallace.
- Perkins, ES, An Atlas of Diseases of the Eye, New York,
New York, Little Brown, 1961, p.9.
- Weber, JM, "Management of Eyelash Problems," OP-TOPICS,
Autumn, 1987, p.8.
- Ibid, p.9.
- Fitzpatrick, RE, "Tattoo Removal Using the Alexandrite Laser,"
Arch. Derma., Dec. 1994, p.130.
- Tassman, W. (Ed.), Duane's Clinical Dermatology, Lippincott-Raven,
Phila., PA., pp.32-33.
- Cockburn, DM., in Rosenbloom and Morgan's Vision and Aging,
Fairchild Pub., N.Y., 1986, pp.112-114.
- Catania, J., "Lumps and Bumps of the Eyelids," So.
Jrnl. Optom., May 17, 1979, p.17.
- Melore, p.34.
- Dermatology, Appleton and Lange, Norwalk, CT., 1991, p.505.
- Merck Manual, 16th ed., Rahway, N.J., Merck Research Labs.,
1995, p.2455.
- Holloway, L., "Shadow Method for Sun Protection," Lancet,
1990, p.484.
- Bark, JP., Skin Secrets, New York, McGraw Hill, 1987, p.254
- Ibid, p.238.
- Sauer, GC., Manual of Skin Diseases, JB Lippincott, Phila.,
PA., 1985, p.319.
- Dermatology, p.513.
- Friedman, RJ., "Detection of Malignant Melanoma," Cancer
Jrnl. for Clinicians, May 1985., p.130.
- Johnson, T., 20/20 with Hugh Downs, TV station WABC, New
York, April 26, 1996.
- Classe, JG., "Clinical Aspects of Practice," So.
Jrnl. Optom., May 1985, p.26.
GENERAL REFERENCES
Hbif, AB, Clinical Dermatology, 3rd ed., Mosby, St. Louis,
Mo., 1995.
Fitzpatrick, TB et al, Dermatology in General Medicine, 3rd
ed., McGraw Hill, New York, 1987
Reichel, AA, Care of the Elderly, 4th ed., Williams & Wilkins,
Balt., Md, 1995.
Fisher, AA, Contact Dermatitis, 3rd ed.,Lea & Febinger, Phila.,
Pa., 1986.
Sabiston, DC, Jr., Textbook of Surgery, W. B. Saunders Co.,
Phila., Pa., 1991
O Collin, JR and Rose, GF, Slide Atlas of Clinical Ophthalmology,
2nd ed., M. Wolfe, London, Eng., 1994.
Mannis, MJ, et al, Eye and Skin Disease, Lippincott-Raven,
Phila., Pa., 1996.
Yang-Williams, K and Bezan, D, How to Differentiate Pigmented
Skin Lesions, Review of Optometry. Aug. 15, 1996, p. 77-85.
[Return to Table of
Contents]
MULTIPLE-CHOICE EXAMINATION
Questions
1. Laser blepharoplasty is effective
in removing:
| a. |
birthmarks. |
| b. |
spider veins. |
| c. |
crow's-feet. |
| d. |
excess skin and fat. |
|
2. Telangiectasias can be caused
by:
| a. |
sun damage. |
| b. |
excessive alcohol intake. |
| c. |
acne rosacea. |
| d. |
all of the above. |
|
3. For bleaching excessive pigmentation,
a hydroquinone solution can be used at what strength?
| a. |
2-4% |
| b. |
5-7 % |
| c. |
8-10% |
| d. |
none of the above |
|
4. A papule is:
| a. |
a small, raised, firm lesion less than 10 mm. in diameter. |
| b. |
a raised, solid lesion deeper than a nodule. |
| c. |
a fluid-filled lesion more than 5 mm. in diameter. |
| d. |
a flat lesion more than 3 cm in diameter. |
|
5. If the _________________
is involved, eye complications are likely for postherpetic neuralgia:
| a. |
upper cheek |
| b. |
side of tip of nose |
| c. |
forehead |
| d. |
side of bridge of the nose |
|
6. Symptoms of rosacea can include:
| a. |
conjunctivitis. |
| b. |
keratitis. |
| c. |
ulcerative blepharitis marginalis. |
| d. |
all of the above. |
|
7. Which of the following can
cause hypotrichosis? (may be more than one):
| a. |
alopecia areata |
| b. |
poor diet |
| c. |
excessive UV exposure |
| d. |
alopecia universalis |
|
8. Though usually benign, ___________
are often treated as a malignant precursor:
| a. |
seborrheic keratoses |
| b. |
lipomas |
| c. |
keratoacanthomas |
| d. |
none of the above |
|
9. Metastases will not develop
in patients with melanomas less than ____ mm. thick:
| a. |
0.49 |
| b. |
0.76 |
| c. |
1.0 |
| d. |
1.2 |
|
10. True or False -Sebaceous
Cysts:
| a. |
are generally painful and tender to the touch T F |
| b. |
appear most often on the eyebrows T F |
| c. |
of the superficial milia variety can be permanently eliminated
by puncturing and draining the capsule, whereas subcutaneous
cysts require excision of the entire cyst wall T F |
| d. |
is another term for lipomas T F |
|
11. These cancer precursors
are sometimes referred to as "rodent ulcers" due to
their chewed-out appearance:
| a. |
squamous cell carcinoma |
| b. |
basal cell carcinoma |
| c. |
seborrheic keratoses |
| d. |
lentigo maligna |
|
12. True or False?
| The incidence of squamous cell carcinoma is more than
twice that of basal cell carcinoma. T F |
|
13. A flat, tan or brown macule
with darker brown spots irregularly scattered on its surface is
indicative of:
| a. |
lentigo maligna. |
| b. |
dysplastic nevi. |
| c. |
keratoacanthomas. |
| d. |
lipomas. |
|
14. If laid out flat, skin measures
an average of __________ square feet:
| a. |
10-11 |
| b. |
15-16 |
| c. |
19-20 |
| d. |
25-26 |
|
15. Most malignant melanomas
develop from:
| a. |
squamous cell carcinomas. |
| b. |
pigmented nevi. |
| c. |
solar keratoses. |
| d. |
basal cell carcinomas. |
|
16. The most common location
for xanthelasma is:
| a. |
under the eyes to outer corners. |
| b. |
forehead at hairline. |
| c. |
bridge of the nose and eyelids. |
| d. |
side of the nose at nostrils. |
|
17. The most frequently found
benign eyelid tumors are:
| a. |
lipomas. |
| b. |
keratoacanthomas. |
| c. |
papillomas. |
| d. |
seborrheic keratoses. |
|
18. _________ is the preferred
method for removal of long-stalked papilloma:
| a. |
cryosurgery. |
| b. |
electrosurgery. |
| c. |
laser. |
| d. |
none of the above. |
|
19. Which of the following is
not a common precursor to malignant skin tumors?:
| a. |
dysplastic nevi. |
| b. |
solar keratoses. |
| c. |
squamous cell carcinomas. |
| d. |
seborrheic keratoses. |
|
20. Mohs' chemosurgery is performed
to treat:
| a. |
basal cell carcinoma. |
| b. |
squamous cell carcinoma. |
| c. |
dysplastic nevi. |
| d. |
solar keratoses. |
|
[Return to Table of
Contents]
MARCHON ANSWER SHEET
| 1. |
a |
b |
c |
d |
| 2. |
a |
b |
c |
d |
| 3. |
a |
b |
c |
d |
| 4. |
a |
b |
c |
d |
| 5. |
a |
b |
c |
d |
| 6. |
a |
b |
c |
d |
| 7. |
a |
b |
c |
d |
| 8. |
a |
b |
c |
d |
| 10. |
a (T) (F) |
b (T) (F) |
c (T) (F) |
d (T) (F) |
| 11. |
a |
b |
c |
d |
| 12. |
T |
F |
| 13. |
a |
b |
c |
d |
| 14. |
a |
b |
c |
d |
| 15. |
a |
b |
c |
d |
| 16. |
a |
b |
c |
d |
| 17. |
a |
b |
c |
d |
| 18. |
a |
b |
c |
d |
| 19. |
a |
b |
c |
d |
| 20. |
a |
b |
c |
d |
| Name_________________________________________________ |
| Address______________________________________________ |
| City_________________________________________________ |
| State_________________________________________________ |
| Zip__________________________________________________ |
| Phone________________________________________________ |
Send To:
MARCHON TRAINING CENTER
35 Hub Drive
Melville, NY 11747-3500 |
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