Photodynamic Therapy for Tumors on the Eyelid Margins

The eyelids are prone to basal cell carcinomas (BCCs) and papillomas.¹ Cryotherapy, surgical excision, and radiotherapy have limitations related to their complexity and to the resulting functional deficiencies (eg, lagophthalmos or epiphora) and unsatisfying cosmesis.² New treatment techniques for eyelid tumors are therefore desirable.

Photodynamic therapy (PDT) with topical methyl aminolevulinate (Metvix cream, 16%; Photocure ASA, Oslo, Norway) is a safe and effective noninvasive treatment of BCCs that causes minimal damage to surrounding tissue and results in excellent cosmetic outcomes.³ However, PDT is not normally used to treat eyelid lesions owing to the risk of phototoxic eye damage. We describe how PDT can be performed safely in the treatment of eyelid BCC and papilloma in unselected cases.

Conjunctival anesthetic is administered (oxybuprocaine, 0.4%), and an ocular shield is inserted. Infiltration anesthetic (carbocaine, 20%, with adrenalin, 5%) is injected before debulking tumor tissue using a curet. A chalazion clamp may be used to hold the eyelid in a fixed position (Figure, A). Hemostasis is obtained by slight compression, and Metvix is applied to the lesion, including to a 5-mm margin of uninvolved skin (Figure, B).

Conjunctival tumors are treated by Metvix application on the ocular shield. The eye is covered with adhesive film and a light-impermeable eye patch. The patient rests for 3 hours in a calm environment, avoiding eyeball movements to minimize irritation. Then the tumor area is illuminated with a light-emitting diode lamp (37 J/cm², 632-nm wavelength) (Aktilite 128; Photocure ASA) (Figure, C).

The ocular shield is removed after illumination and replaced with a protective eye patch for 24 hours to protect from ambient light. Eye drops (chloramphenicol, 5%, and dexamethasone, 1%) are used daily for 3 days to prevent infection and irritation of the eye. After 1 week, crusts are removed, and the procedure is repeated (Figure, D).

We used PDT to treat 12 patients with histologically verified eyelid BCC and papillomas (Table). Median complete response time was 8 months for 9 of the patients (range, 5-21 months), yielding a response rate of 75%. In 3 patients, however, the tumor recurred after a median of 4 months (range, 0-21 months). In all cases, functional and cosmetic outcomes were highly satisfying, and treatment-related pain was acceptable thanks to the anesthesia.

Our patients' tumors were located primarily on the eyelid margin or rima palpebrarum, locations that make tumor debulking a challenge because of the soft base and tumor tissue involving the eyelashes. This might explain the poorer response rate for BCCs at this location, and more than 2 PDT sessions might be required for some of these tumors. However, our rate was more favorable than that found in a previous study,⁴ which treated eyelid and periocular BCCs with laser-mediated PDT and 5-aminolevulinate, achieving complete response in only 42% of cases.⁴ Six of our patients had already undergone surgery prior to referral to us but experienced recurrence, clearly less favorable outcomes than those achieved by PDT.

To our knowledge, the use of conventional PDT techniques solely for treatment of tumors on the eyelid margins has not previously been described. Our cases may expand the use of PDT for these difficult-to-treat tumors.

Correspondence: Dr Togsverd-Bo, Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark (katrinetogsverd@hotmail.com).

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hædersdal and Wulf. Acquisition of data: Togsverd-Bo, Hædersdal, and Wulf. Analysis and interpretation of data: Togsverd-Bo, Hædersdal, and Wulf. Drafting of the manuscript: Togsverd-Bo. Critical revision of the manuscript for important intellectual content: Hædersdal and Wulf. Administrative, technical, and material support: Hædersdal and Wulf. Study supervision: Hædersdal and Wulf.

Financial Disclosure: Dr Hædersdal has received a fee from Photocure ASA for organizing education seminars; Dr Wulf has received a fee from Photocure ASA for organizing education seminars and speaking engagements.

Additional Contributions: Clinical photographer Nis Kentorp took the photographs.