Screen for skin cancer during complete eye exam, expert advises
NEW ORLEANS — Optometrists should examine and palpate the lids as part of a comprehensive eye exam, Richard Castillo, OD, DO, chief of surgical services at Northeastern State University College of Optometry, told attendees at SECO 2022.
“One in five Americans will develop skin cancer,” he said. “That’s more than the number of diabetics walking around, and we make sure we see those patients for their screenings.”
Of the 15,000 new cases of skin cancer diagnosed every day, 10% are in the eye.
“This is a big deal,” Castillo said. “We need to check for bumps the patient may not be aware of. Nobody is in a better position to screen for this than you are. Things have really improved, as far as the public health aspect of what a primary eye care practitioner can do for their community; that’s been a real service.”
He noted that optometrists are permitted to perform biopsies in some states.
“A simple bump on the eyelid is not necessarily a simple bump on the eyelid,” Castillo said. “Eighty percent of them that we see may be benign. But lid cancer, squamous cell cancer, are the main reasons people lose their eye.”
Castillo recommends checking the parotid chain for bumps, and if lymphadenopathy is found, the patient should be referred to an internal medicine specialist.
When a lesion is found, Castillo advises using the “ABCDE” screening system.
“Check for asymmetry,” he said. “Does the left look like the right? Does the top look like the bottom?
“‘B’ is for border,” he continued. “I look 360 degrees around. If I can discern clearly where the lesion ends and the skin starts, there is no red flag. If the margins get feathery, that’s a red flag.”
A lesion that is more than one color also is a red flag, he said, and according to literature, a diameter of more than 5 mm to 6 mm should also arouse suspicion.
“We go by the size of a standard No. 2 pencil eraser,” Castillo said. “If it’s larger, it’s a red flag.”
The last letter, “E,” is for evolution. This includes not only change in appearance, but also symptoms, like new-onset itching or swelling.
“In states where optometrists can perform biopsies, generally you have to have medical justification to do a procedure,” Castillo said. “How many red flags do you need? Just one. Documentation is important.”
Clinicians also must take into consideration a patient’s history of skin cancer, the amount of UV light absorbed over a lifetime, exposure to industrial chemicals, areas that have been radiated and physical exam findings.
Castillo emphasized the importance of looking for additional clinical signs.
“Madarosis is one,” he said. “Once cancer cells invade, they destroy normal anatomy, hair follicles included. If I look at a lesion and it’s in hair-bearing skin, and hair is growing out of it, I tend to feel better about it. If I see hair loss, that signifies that there’s been an invasion into deeper tissue.”
Other signs include lid notching, loss of meibomian gland orifices and surface telangiectasias.
“There are very few things that will totally wipe out the meibomian gland orifices, so that’s a big red flag,” he said, adding, “You’re not supposed to have blood vessels on the surface of the skin.”
Castillo advised attendees that one of the most important points to remember is that “you cannot tell simply by looking at something with 100% certainty what it is.”
He noted that actinic keratosis is the most typical precancerous eye lesion.
“Order a biopsy,” Castillo said. “This is easily managed. Once it’s an invasive squamous cell, it gets more complicated.”
Some patients may have a papilloma that has no concerning characteristics, and they say it “has been there forever, doesn’t bother me and hasn’t changed.”
In that case, “No worries,” Castillo said. “However, if the patient is high risk, if they have a genetic predisposition, a personal history of skin cancer or actinic keratosis or environmental or occupational risks, you screen that lesion along with your eye exam every year. Yes, that’s part of what you do as an eye doctor.”
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Castillo R. Screening for skin cancer. Presented at: SECO; New Orleans; March 9-13, 2022.
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