Eyelid Tumors — MCQs
Identify the diagnosis based on the clinical image shown.
Which of the following stages of lip carcinoma does not have nodal involvement?
A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
What is the most common malignant tumour of eyelid?
A patient with ptosis has the upper 4 mm of cornea covered by the upper eyelid. What is the grade of ptosis?
Internal hordeolum is due to inflammation of-
Senile ptosis is:
What is Euryblepharon?
Modified Wheeler's operation is done for which condition?
What is the treatment for congenital ptosis with poor elevation?
Eyelid Tumors Indian Medical PG Practice Questions and MCQs
Question 1: Identify the diagnosis based on the clinical image shown.
- A. Horner-Trantas spots
- B. Herbert's pits (Correct Answer)
- C. Pannus
- D. Corneal dystrophy
Explanation: ***Herbert's pits*** - The image displays characteristic **pits at the limbus**, which are a hallmark of healed follicular conjunctivitis, specifically **Herbert's pits**. - These pits are pathognomonic for **trachoma**, a chronic keratoconjunctivitis caused by *Chlamydia trachomatis*. *Horner-Trantas spots* - These are small, raised, gelatinous white dots found at the limbus, typically containing **eosinophils**. - They are characteristic of **vernal keratoconjunctivitis**, an allergic inflammatory condition, and not seen in the provided image. *Pannus* - **Pannus** refers to the growth of **vascularized connective tissue** onto the cornea. - While pannus is also a feature of trachoma, the image specifically shows distinct limbal pits, rather than diffuse vascularization. *Corneal dystrophy* - **Corneal dystrophies** are a group of inherited, bilateral, and progressive corneal disorders that manifest as opacities or structural changes in the cornea. - The findings in the image, such as pits, are inflammatory in origin and distinct from the typically stromal or epithelial changes seen in corneal dystrophies.
Question 2: Which of the following stages of lip carcinoma does not have nodal involvement?
- A. T2N1
- B. T3N0 (Correct Answer)
- C. T2N2
- D. T1N1
Explanation: ***T3N0*** - The **'N' classification** in the TNM staging system refers to **nodal involvement**. A stage with **'N0' indicates no regional lymph node metastasis**. - A **T3 lesion** signifies a large primary tumor, but if it's accompanied by **N0**, it means there's no evidence of spread to the lymph nodes. *T2N1* - The **'N1' classification** indicates the presence of **regional lymph node metastasis**, specifically in a **single ipsilateral lymph node** that is 3 cm or less in its greatest dimension. - This stage therefore **does have nodal involvement**, contradicting the premise of the question. *T2N2* - The **'N2' classification** signifies more advanced regional lymph node metastasis, such as a **single ipsilateral lymph node** greater than 3 cm but not more than 6 cm. - It could also refer to **multiple ipsilateral lymph nodes**, none greater than 6 cm, or bilateral/contralateral lymph nodes, none greater than 6 cm. In all these cases, **nodal involvement is present**. *T1N1* - Similar to T2N1, the **'N1' component** in T1N1 indicates the presence of **regional lymph node metastasis** in a single ipsilateral lymph node of 3 cm or less. - Therefore, this stage **does involve nodal spread**, despite having a smaller primary tumor (T1).
Question 3: A 10 cm tumor is found on the anterior surface of the thigh. What is the most appropriate procedure to obtain a diagnosis?
- A. Incision biopsy (Correct Answer)
- B. Excision biopsy
- C. FNAC
- D. USG
Explanation: ***Incision biopsy*** - An **incision biopsy** is most appropriate for a large tumor (10 cm) to obtain a tissue diagnosis without performing a potentially morbid or disfiguring complete excision upfront. - It involves removing a representative section of the tumor for histopathological analysis, providing adequate tissue for diagnosis, grading, and subtyping. - This allows definitive treatment planning based on confirmed histopathology. *Excision biopsy* - **Excision biopsy** is generally reserved for smaller tumors (typically <3-5 cm) that can be completely resected with acceptable cosmetic and functional outcomes. - Excision of a 10 cm tumor on the thigh would be a significant surgical procedure, potentially causing substantial morbidity, without a prior definitive diagnosis. - Could compromise subsequent definitive surgery if margins are inadequate. *FNAC* - **FNAC (Fine Needle Aspiration Cytology)** provides only cytological diagnosis, which is insufficient for definitive diagnosis, grading, and subtyping of soft tissue tumors, especially sarcomas. - It misses crucial architectural features and tissue patterns needed for accurate classification. - May yield inadequate or non-diagnostic samples from large heterogeneous tumors. *USG* - **USG (Ultrasound)** is an imaging modality, not a tissue diagnosis procedure. - While useful for characterizing mass features (size, location, vascularity, solid vs cystic), it cannot provide histopathological diagnosis. - The question specifically asks for a procedure to "obtain a diagnosis," which requires tissue sampling for microscopic examination.
Question 4: What is the most common malignant tumour of eyelid?
- A. Sebaceous gland carcinoma
- B. Squamous cell carcinoma
- C. Melanoma
- D. Basal cell cancer (Correct Answer)
Explanation: ***Basal cell cancer*** - **Basal cell carcinoma (BCC)** is by far the most common malignant tumor of the eyelid, accounting for approximately **90% of all eyelid malignancies**. - It typically appears as a **slow-growing nodule** with rolled borders, central ulceration, and telangiectasias, most commonly affecting the **lower eyelid and medial canthus**. - BCC is strongly associated with **chronic UV radiation exposure** and rarely metastasizes, but can cause significant local tissue destruction if untreated. *Sebaceous gland carcinoma* - **Sebaceous gland carcinoma** (also known as meibomian gland carcinoma) is a rare but aggressive malignant tumor arising from the sebaceous glands of the eyelid. - It accounts for approximately **1-5% of eyelid malignancies** and has a higher risk of metastasis compared to BCC. - More common in **Asian populations** and often masquerades as chronic blepharoconjunctivitis, leading to delayed diagnosis. *Squamous cell carcinoma* - **Squamous cell carcinoma (SCC)** is the **second most common** malignant eyelid tumor, accounting for approximately **5-10% of cases**. - It presents as a firm, erythematous nodule or plaque and has a higher metastatic potential than BCC. - Associated with **UV exposure, HPV infection**, and immunosuppression. *Melanoma* - **Melanoma** is a rare malignant tumor of the eyelid, accounting for less than **1% of eyelid malignancies**. - It arises from melanocytes and carries a significant risk of metastasis and mortality. - Presents as a pigmented lesion with irregular borders, but amelanotic variants can also occur.
Question 5: A patient with ptosis has the upper 4 mm of cornea covered by the upper eyelid. What is the grade of ptosis?
- A. Moderate (Correct Answer)
- B. Profound
- C. Severe
- D. Mild
Explanation: ***Moderate*** - **Moderate ptosis** is defined as **3-4 mm of lid drooping** below the normal position - In this case, the upper eyelid covers **4 mm of the cornea**, which falls into the moderate category - The lid margin is typically **at or slightly below the superior limbus** in moderate ptosis - This degree of ptosis is **functionally significant** and may warrant surgical correction *Mild* - **Mild ptosis** is defined as **2 mm or less** of lid drooping - The upper lid margin is **above the superior limbus** but below the normal position - This patient has 4 mm coverage, which **exceeds the mild category** *Severe* - **Severe ptosis** is defined as **5 mm or more** of lid drooping below the normal position - The upper lid typically **covers the pupillary axis significantly** and causes marked visual obstruction - This patient's 4 mm coverage **does not reach severe criteria** *Profound* - **"Profound"** is not a standard term in ptosis grading systems - The standard classification uses **mild, moderate, and severe** as the three grades - If used, it would refer to extreme cases where the lid almost completely covers the pupil
Question 6: Internal hordeolum is due to inflammation of-
- A. Meibomian glands (Correct Answer)
- B. Moll's gland
- C. Lacrimal gland
- D. Zeis gland
Explanation: ***Meibomian glands (Correct)*** - An **internal hordeolum** results from acute **bacterial infection** (usually *Staphylococcus aureus*) and inflammation of a **Meibomian gland**, which are modified sebaceous glands located within the tarsal plate of the eyelid. - These glands produce the **lipid layer** of the tear film, and their blockage and infection lead to a painful, red lump on the **inner surface of the eyelid**. *Moll's gland (Incorrect)* - **Moll's glands** are modified apocrine sweat glands located near the base of the eyelashes. - Inflammation or infection of a Moll's gland would more commonly contribute to an **external hordeolum (stye)**, not an internal one. *Lacrimal gland (Incorrect)* - The **lacrimal gland** produces the watery component of tears and is located in the superotemporal orbit. - Inflammation of the lacrimal gland is called **dacryoadenitis**, which presents with swelling in the outer part of the upper eyelid and is distinct from a hordeolum. *Zeis gland (Incorrect)* - **Zeis glands** are sebaceous glands associated with the hair follicles of the eyelashes. - Similar to Moll's glands, infection of a Zeis gland is a common cause of an **external hordeolum (stye)**, which appears on the eyelid margin.
Question 7: Senile ptosis is:
- A. Neurogenic
- B. Myogenic
- C. Aponeurotic (Correct Answer)
- D. Mechanical
Explanation: **Explanation:** **Senile ptosis** (also known as Involutional ptosis) is the most common form of acquired ptosis in the elderly. **Why Aponeurotic is correct:** The primary pathology in senile ptosis is the **disinsertion, dehiscence, or stretching of the Levator Palpebrae Superioris (LPS) aponeurosis** from its attachment to the tarsal plate. This occurs due to age-related degenerative changes. Characteristically, these patients present with a **high or absent upper eyelid crease** and good levator function, as the muscle itself is healthy, but its "tendon" (aponeurosis) has slipped. **Why other options are incorrect:** * **Neurogenic:** Caused by nerve defects, such as 3rd Nerve Palsy or Horner’s Syndrome. Senile ptosis does not involve nerve dysfunction. * **Myogenic:** Caused by primary muscle disorders (e.g., Myasthenia Gravis or Myotonic Dystrophy). In senile ptosis, the LPS muscle fibers are typically normal. * **Mechanical:** Caused by the weight of a mass (tumor, edema, or chalazion) pulling the lid down. Senile ptosis is due to structural laxity, not added weight. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** A "high skin crease" is the hallmark of aponeurotic ptosis. * **Thinning of the lid:** The eyelid may appear thin, sometimes allowing the iris to be visible through the skin (due to LPS dehiscence). * **Surgical Management:** The treatment of choice is **LPS Aponeurosis advancement or repair**. * **Differential:** If ptosis is associated with miosis, think Horner’s; if associated with ocular motility issues, think 3rd Nerve Palsy.
Question 8: What is Euryblepharon?
- A. A full-thickness triangular gap in the tissue of the eyelids.
- B. Unilateral or bilateral horizontal widening of the palpebral fissure. (Correct Answer)
- C. Small eyelids.
- D. Failure of the eyelid to develop.
Explanation: **Explanation:** **Euryblepharon** is a rare congenital anomaly characterized by a **horizontal widening of the palpebral fissure**, typically associated with a vertical shortening of the eyelids. 1. **Why Option B is Correct:** The primary defect in euryblepharon is the lateral displacement of the lateral canthus and an enlargement of the eyelid opening. This results in a characteristic "drooping" of the outer half of the lower lid, leading to increased scleral show and potential lagophthalmos (inability to close the eyes completely). It can be unilateral but is more commonly bilateral and symmetrical. 2. **Why Other Options are Incorrect:** * **Option A (Coloboma):** A full-thickness triangular gap in the eyelid is known as an **Eyelid Coloboma**. It most commonly affects the medial third of the upper lid. * **Option C (Microblepharon):** Small eyelids are termed **Microblepharon**. This is a vertical deficiency where the lids are too short to cover the globe. * **Option D (Ablepharon):** The complete failure of the eyelid to develop is called **Ablepharon**. It is often seen in Ablepharon-Macrostomia Syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Patients often present with epiphora (tearing) and exposure keratopathy due to the malposition of the lids. * **Associations:** It is frequently associated with **lateral canthal dystopia** and **ectropion**. * **Management:** Mild cases require lubricants; severe cases require surgical correction via lateral canthoplasty or skin grafting to address the vertical skin deficiency.
Question 9: Modified Wheeler's operation is done for which condition?
- A. Entropion (Correct Answer)
- B. Ectropion
- C. Symblepharon
- D. Ankyloblepharon
Explanation: **Explanation:** **Modified Wheeler's Operation** is a surgical procedure specifically designed for the correction of **Spastic Senile Entropion**. 1. **Why Entropion is Correct:** In senile (involutional) entropion, the primary pathology involves horizontal lid laxity, disinsertion of the lower lid retractors, and **overriding of the preseptal orbicularis oculi** muscle over the pretarsal orbicularis. The Modified Wheeler’s operation involves a **double-breasting (imbrication) of the orbicularis oculi muscle**. By overlapping and suturing the muscle fibers, the surgeon creates a barrier that prevents the muscle from overriding the tarsal plate, thereby rotating the eyelid margin back to its normal outward position. 2. **Why Other Options are Incorrect:** * **Ectropion:** Common surgeries include the **Kuhnt-Szymanowski procedure** (for senile ectropion) or the **Lazy-T procedure** (for punctal ectropion). These focus on horizontal shortening rather than muscle imbrication. * **Symblepharon:** This refers to the adhesion of the palpebral conjunctiva to the bulbar conjunctiva. Treatment involves **symblepharectomy** with the use of amniotic membrane grafts or mucous membrane grafts. * **Ankyloblepharon:** This is the adhesion of the upper and lower eyelid margins. It requires **y-v plasty** or simple surgical division (separation) of the lids. **Clinical Pearls for NEET-PG:** * **Wheeler’s Operation (Original):** Originally described for entropion, but the "Modified" version is the standard reference in exams. * **Other Entropion Surgeries:** * **Bick’s Procedure:** For horizontal lid laxity. * **Jones Procedure:** For tightening lower lid retractors. * **Weis Procedure:** A transverse lid split with eversion sutures. * **High-Yield Tip:** If the question mentions "Double-breasting of orbicularis," always think of Wheeler’s and Entropion.
Question 10: What is the treatment for congenital ptosis with poor elevation?
- A. Levator resection
- B. Frontalis sling (Correct Answer)
- C. FS operation
- D. None of the above
Explanation: In congenital ptosis, the choice of surgical procedure is primarily determined by the **Levator Palpebrae Superioris (LPS) function** (measured as the amount of upper lid excursion). ### Why "Frontalis Sling" is Correct The **Frontalis Sling (Suspension) operation** is the treatment of choice when LPS function is **poor (less than 4 mm)**. Since the levator muscle is dysplastic and cannot effectively lift the eyelid, the surgery involves "coupling" the eyelid to the frontalis muscle using a sling material (such as autologous fascia lata or synthetic materials like Prolene or Silicone). This allows the patient to elevate the eyelid by using their eyebrow muscles (frontalis). ### Why Other Options are Incorrect * **Levator Resection:** This is the preferred procedure when LPS function is **fair (5–8 mm) or good (>8 mm)**. If performed on a patient with poor elevation, the results are unsatisfactory because the muscle lacks the contractile strength to lift the lid even after shortening. * **Fasanella-Servat (FS) Operation:** This is a "posterior approach" ptosis surgery involving the resection of the superior tarsus, conjunctiva, and Müller’s muscle. It is indicated only for **minimal ptosis (1.5–2 mm)** with good LPS function, such as in Horner’s syndrome. ### High-Yield Clinical Pearls for NEET-PG * **LPS Function Grading:** Good (>8 mm), Fair (5–8 mm), Poor (<4 mm). * **Marcus Gunn Jaw Winking Phenomenon:** The most common surgery is a bilateral levator excision followed by a bilateral frontalis sling to achieve symmetry. * **Gold Standard Material:** Autologous **Fascia Lata** (harvested from the thigh) is the best material for a frontalis sling in children over 3 years of age. * **Complication:** The most common complication of ptosis surgery is under-correction; however, lagophthalmos and exposure keratitis must be monitored post-operatively.
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