 of stuff. All right, and we have to leave time for my travel slot. So we're going back to Copenhagen again, where the best way to see Copenhagen is on these tourist boats that go underneath all the bridges in around the whole city because it's all full of canals. But like any other European city, there's museums and there's palaces and there's places all over the place that are there. Doctor, good of you to join us. So this was when we were looking for the National Museum and as we were wandering through this complex where there were museums everywhere, we stumbled upon this one door and came in and it's the National Museum of War and Armaments for Copenhagen, for Denmark. And so it's the strangest thing I've ever seen. This building is like 200 yards long and as far as you can see they've got every cannon from, you know, 1500 along this side and all the way to World War II along this side. And then they've got this interesting story about, you know, Denmark and World War II and that the Nazis did invade Denmark and the war lasted about six hours. And so seriously, so, you know, the Nazis came in and bombed the hell out of them and put a bunch of tanks across and then the Danes said, okay, okay, we're done. Good, good, good. We're okay. Come on in. And so that's what this exhibit was about. But I had no idea. You go up to the top floor and they basically talk about, you know, the warfare history for, you know, for 400 years and in the northern Baltic there was a war like every eight years for 400 years. And again, I had no idea, you know, Denmark and Sweden and Russia and Britain and, you know, they were just, there was wars about every eight to 10 years. And so as you go through, you'll see that there's carvings of ships. And again, you can see how far it goes. It's literally 200 yards long. And so we were there and there were four of us in there. It was interesting. We had the whole place to ourselves. Just kind of stumbled on it and said, oh, this is a cool museum. Look, cannons, you know, ships. All right, so we're going to talk about lids today. And, you know, lids like anything else in the eye have layers. Exactly. So layers. Oh, God, this is a good intern. Sorry, I have intern questions. So what are the layers of the lid? Okay, the skin. Tarsis, the auricularis. Okay, we've got to go in order from front to back. So skin, what's underneath skin? Auricularis. Vicularis. Okay, auricularis. And underneath that? Tarsis. Tarsis. And then the inside? Conjective. Exactly. So we always forget that the conjective aligns the inside of the eyelid, but it does the people conge lines that so then as we look at a little bit closer power, how is this picture different than the previous one? Okay, staying. That's one difference. Another one. See if you guys are awake. It's upside down. You're paying attention. Alright, so let's see. Did you pay attention last week? What kind of state is this? Actually, this is what's called a trichroma. And the way you can tell it is trichroma stains stain epithelial tissue. They stain muscle and tissue red. They stain connective tissue blue. And so that's why I purposely showing this. So when we look at this, as we're looking right here at low power here, you can see the layer of skin. Auricularis. Tarsis. Note all the connective tissue. Tarsis. Cognitivin and underlined man is corny. Alright, so Lee, we're looking kind of at the first couple layers here. Tell me about the skin of the eyelid. So it's stratified, squamous, keratinized, epithelium with this connective tissue. And there's muscular tissue underneath that. Okay, now in terms of the skin, how is the skin of the eyelid different from skin elsewhere in the body? It's thinner. It's thinner? They're not a lot of reedy ridges. Exactly. So when you have skin elsewhere in the body, you see these reedy ridges and pegs going through, but you look at the skin of the eyelid, it's relatively smooth. What's another difference between skin of the eyelid and skin elsewhere in the body? Eyelid skin does not have dermis. There is. That's right. So elsewhere in the body, there's dermis underneath the skin and there's fat. And you know, eyelid skin doesn't have dermis. It's just got this loose connective tissue. So it's very, very loose. It's not tightly adherent to the tissue underneath it. Like skin elsewhere in the body. Alright, Tara, so what is this right here? Obicularis. And what are the three different parts of the obicularis muscle when we divide it, you know, grossly? There's the, there's the tarsal portion, pre-tarsal. Okay, pre-tarsal. Preceptile. Preceptile, good. And the last one's just like an orbital part. And also if you think about it, the obicularis muscle, it's almost like Chicago Bears C, you know, that comes immediately like this. And then you've got the part of it in front of the tarsus, the pre-tarsal, the front part of it that's in front of the orbital septum. And then finally a third one that's furthest out, you know, almost underneath the, you know, the eyebrows there. And so it's got three layers in. The thing about the obicularis muscle is it runs this way as opposed to the levator muscle, which runs, you know, this way. So it's different. It runs that way. So when you look at the cross-section of the eyelid, you actually see, you know, several sections of the lid, you actually see the obicularis in cross-section. When you're saying those three layers you're saying from superficial to deep, right? No, no. Actually, zones I may be safe from the margin of the eyelid to the, you know, orbit. Okay. So like, like this, not deep, but layers where they're, you know, zones. Maybe you can think of it that way. Alright, so Jason, what are we looking at here now? It's like the tarsal pleat. Okay. Tell me about the tarsal pleat in primates. What is it made of? A lot of dense connective tissue. Exactly. How is the tarsal pleat in primates different from the tarsal pleat in lower animals? Cartilage. And it's interesting in that you look at bunnies, you look at rats and all that. They have cartilage in their tarsal pleat. It's extremely strong. Humans don't, nor primates. And so it's just it's dense irregular connect, or dense regular connective tissue. It's a very dense connective tissue. And then what are these right here? It's like sebaceous glands. Sebacious glands. And what do we call them? Mybomene glands. The mybomene glands. Alright, you can see how the pattern you want to think about, it's almost like grapes that are growing. And so what you'll see is you'll see clusters of these mybomene glands on a central trunk, which is a mybomene duct. And so these ducts come down and they dump out right at the end. And so there'll be a series of these mybomene glands. The reason that these are important is when they get plugged up. Wow, this isn't even good evening. This is good night. So you can see. So again, lecture starts at 7 unless you are in the ER putting an eyeball back into the head. Be here at 7. If you have traffic, get up 10 minutes earlier. Okay. So again, I get, you want to piss off an attendee. Make him get up at 5.30 and then don't show up. So that's it. So if I'm up, you guys are a little better to be up. Alright, so they've dumped into a central duct here and they empty out right on the posterior aspect of the lid margin. Let me look right there. Alright, what are we looking at right here on these glands? Okay, what kind of glands? These are mybomene things. Alright, look more closely. Echorin. Exactly. These are echorin glands. So the lids are the one place in the body where all three types of glands are present. And you guys are going to hear these until you're sick of them. Ah, glands again. Ah. So these are echorin glands. And so what are examples of echorin glands? Sweat glands, but also in the eye itself. Around the eye. The lacrimal glands. Exactly. So these are echorin glands. When you look at them, they have this round assender pattern meaning that the glands line up in a circle here and then they go into this little central lumen and eventually those all gather into ducts. So echorin glands are sweat glands. Believe it or not, there are sweat glands in the eyelid. I know we forget about that, but there really are some echorin glands or the sweat glands and they're the lacrimal glands. Now the reason I like the lid margin is because the lid margin is a very, very busy area. It's got examples of all kinds of glands. And so if you look, it's the anterior surface. It's got this keratinized genomics glumus epithelium and look at the keratin goes only back to the posterior edge of the lid. The reason that that's important is if you get entropion the eyelid rolling in, first of all the lashes can scratch on the cornea but even beyond the lashes, this keratinized epithelium can scratch on the cornea. So this shows you where the lionine glands are down here. These are where the hair follicles are and they come out right here. So we're going to go a little bit higher power. Now, here we have an idol actually, a hair follicle and then we've got a couple of different glands sitting here on the eye lice follicle. So we'll go ahead and Dr. Bernheisel, what kind of glands are we looking at here? Here's a hard one. It's an apocrine gland. How do you tell apocrine glands? Because they have snouts. Exactly. So apocrine glands have snouts. Here's the snout sticking out. Those little apical projections that are sticking out. And how do we remember the name of the apocrine glands in the eyelid? Because they have the pullals, snouts of moles. Like moles. So you mispronounce that the glands of moles, because moles have snouts. So that's how you remember them. So these apocrine glands they literally chop off their snouts and then their snouts fall into the lumen here. And so these are interesting glands. They're thought to be ascending glands in other animals. And you know, animals like you know deer have got these all over. You look at deer, not only do they like urinate on things but they rub their inner eye on twigs and branches and this stuff from the apocrine glands since. And so humans have evolved and we don't have many left. But for some reason these glands sit in the eyelash follicles so we can still kind of set ourselves with the eyelids there. So these are the apocrine glands of moles. And then so the acryl glands are the Zeiss? Nope. Which ones are Zeiss? That was my next question to Dr. Conrad. What are the glands of Zeiss made out of? They're holocrine glands. Exactly. And so if you look at a holocrine gland, what denotes the holocrine glands is they've got this central liqueur and you've got this bony looking cytoplasm. The reason why it looks fomious is because it's filled with lipid. I mean sebum is lipid. So sebaceous type glands look like this and we already said that the mybomene glands are one and the Zeiss are the other. And so the Zeiss glands also dump into the eyelash follicles. And so in the lids you've got all three. You've got acryl glands. You've got apocrine glands and you've got holocrine glands. Now when the apocrine glands secrete they cut off their snouts and it goes into aluminum. These guys are interesting because when you look at the reason they call these holocrine glands is they give their hole to the secretion. So when these guys secrete they literally gurgitate all of their contents into the lumen and then reform again. And so these guys literally it's like when you've had too much two carbon chains and if you ever notice that when you have too many two carbon chains and you suddenly get religious and you're sitting there holding onto the porcelain and you're saying oh god make me do this and I'll never drink again. And what happens in that setting is you are pretty much gurgitating all of your contents. I mean there's like intestines coming out and everything else. That's how these guys secrete. They just gurgitate all of their stuff into the lumen. So that's why they call them holocrine. They give their hole. Can you go back a couple slides so she's wondering if that one is not a Zeiss. This is the gland of Zeiss dumping into the hair follicle. And then these are the glands of the whole also dumping into that hair follicle. So exactly. So they're all there and what kind of stain is this, Chris? Closed. I mean oil red. And what do we have to do in order to get this stain? It has to be fresh. It has to be fresh. So this is a fresh section. We're looking for a sebaceous carcinoma by moving that carcinoma and you can see it's easy to remember that this stains the oil. These little red O's. Oil red O stain is a fresh stain for the Alright, let's start looking at some various lid lesions. Niko, what do we see in here? So it's an external photograph of the right eye. My attention is drawn to the lower eyelid margin. There seems to be like a raised lesion there. This could be sty, basal cell, carcinoma, external boreal loom. Yeah, so the key is you've got to think of a pretty broad differential diagnosis when you see kind of a bump on the middle of the eyelid. And so you want to look for several features. You want to say eye lashes falling out. I mean is there lots of lashes here in the hospital? Now what else can you tell me about this patient? The upper eyelid seems to be kind of swollen as well. It's kind of a contractatic vessels. This was Dr. Conrad's last surgery. I hope you can hear your chain grow well. Alright, here's a different one. How is this one a little bit different than that one? So there seems to be like multiple lesions in the left eye tube that I can count. There's more loss of lashes immediately. How old is this patient? Younger than the last patient. Yeah, it's a pretty young patient if you look at it. Young patient, multiple lesions right here. When you ask them, you say, how long has this been here? Well, been here a few weeks. It kind of comes up. It kind of goes down. So it doesn't go away. And this is what you see on the pathology. There's a giant cell. Exactly, there's a giant cell. And look at all these little white foamy spaces here. Those aren't artifacts. Those had stuff in them. Those had what dissolves normally when we process our lipid. Yeah, so that had lipid. So this lesion has got with lipid droplets all over. It's got giant cells here. And at the thelioid cells, and a few of them besides. So what is this lesion? It's a chelazion. Exactly. So chelazion is a lipogranulomarous inflammation. So what happens is the chelazion ducts get plugged. The lipid backs up as it starts to go into the tissue. Lipid is very irritating. And will induce this granulomarous inflammation. So this is what we see normally in a chelazion. And here's a close-up. This is really a giant cell. I mean, it looks like an amoeba right here. This is a huge giant cell. And look at the lipid droplets all over. So this is a chelazion, lipogranulomarous inflammation. Probably one of the most common lesions that we see. Alright, now what do we see right here? We'll start back to you. What do we see right here? Alright, well, it's a little simple thing we can do sitting right there in the chair to tell us about the qualities of this lesion. Well, if you look at it, it almost looks kind of tight as if there's like something inside of there pushing it out. As if this were a cyst instead of solid. So what's a quick way we can tell if something's solid or cystic? Exactly. Put the light with the fat on our hand on it. You just try it on and you'll see the light will illuminate through if it's a cyst. So some of the hints that it's a cyst are, you see, again, it's like, again, like a balloon. Somebody is just, you know, plating it and pushing it out. And sure enough, oh man, that must have been the picture that Jason took, you know, telling us sometimes to think of as important. This is his last picture. So when we look at a cyst, the most important thing we want to look at is we want to... We have to see you guys. So we need to look at the cyst lining and see what the lining of the cyst is. So we're going to give this a low power, kind of a lining on the cyst. Now, rather than think of a cyst, just think if you were looking at an epithelium and you're looking at that, what kind of epithelium is that? Actually, this is a stratified squamous. And so it looks just like, let's get, basically, in fact, if you look on the inside, this eosinophil explaining stuff here is an epithelial carotid. And so another common thing that we see in the eye is what we call epithelial inclusion cysts. And for some reason, either for trauma or surgery or whatever, some surface epithelium gets implanted underneath them. When it does, it tends to round up and then the epithelium keeps growing and it keeps making material like carotid. And so it will keep growing. So this is an epithelial inclusion cyst. And here's a close-up. The epithelial inclusion cyst is very common in this. All right, Lee, what do we see in here? So this is an external photo of the right eye. Should I copy this out of some of this? I should get one from Willow but I don't have any. There appears to be that's non-earthemis. It looks like it may be cystic in nature. Exactly. So that kind of looks cystic also. Now we look at the lining. What's the lining of this cyst? So it's cuboidal, bilayer, cuboidal. It's a bilayer cuboidal. What kind of cysts are bilayer cuboidal? Ekran cyst. Ekran and what are we called? Ekran hydrosystem, exactly. From what language? Greek. From the Greek. Hydro means water. Cyst. Water hydrosystem. So very common. These are benign cysts. Some people call these ekran duckles cysts. It might be derived from one of the ekran gland ducks, but it's a bilayer cuboidal. You don't have to feel the lining. So ekran and hydrosystem. And so if we have an ekran hydrosystem, we can also have, what's the difference between this one and that one? So there's no keratin, so this would be even more. Well actually, look at the surface here. That's moldy. So it's got snouts. So you can not only have an ekran hydrosystem, you can even have an ekran hydrosystem. Now, ekran glands are much more common than ekran hydrosystems are more common. Ekran hydrosystems are very rare, but again you can still get even ekran hydrosystem. And the difference is the snouts. So do you see all the snouts that are there? Alright, Tara. So on the upper eyelid margin it looks like more immediately there's a raised nodule or lesion near the tarsal border and there's disruption of the lashes. But if you look though the whole cluster of these guys you're going to see more on these guys right here. What do you make of the configuration of these little lesions? Jeff Tabin's favorite lesion they're actually probably haven't rotated with them. They're kind of, they're flatter and not acistic. If you look at them they've almost got this little milcated center. So we've got these kind of raised pearly edges and then the center of milcates a little bit and there's a cluster of them. So whenever you see a cluster you think of something maybe infectious. And they've got this pearly raised edge and they've got this little indented center. If you look at the pathology it looks like this. So what is this lesion? It's a smallescombe. Exactly, this is a smallescombe. So not from the Greek, from what? From the Latin. Contagiosum literally means contagious. And so this is thought to be viral in Houston. When you look at these you'll see they tend to have the raised pearly edges, the umbilicated center. The epithelium is more going to be thickened but look at all these eosinophilic inclusions. If you look at it close up basically what happens is the virus starts taking over the cell and it'll start making viruses, making viruses, and by the time it comes to the surface it literally pushes the nucleus out of the cell. And you're left with just a bag of viruses and then they dump out on the surface which is why you have a cluster of them. And so it'll start with one and then it'll end up with a whole cluster. These are kind of fun to take out because you can literally just kind of quorum out. You numb it up and just quarter the things out. But you've got to be careful because you could spread this. You know if you're trying to take this out and you're grabbing it with a forcep and then grab somewhere out you can actually spread this yourself. So be really careful when you're moving these because these are indeed viral induced. So nothing looks like this. When you see this it's like, okay, a moluscum contagiosa. So just to warn you guys who haven't taken O-caps yet and boards eventually, they ask two-part questions. So let's show a picture of this and you'll say, ah, moluscum, I knew that, I studied hard. And then they'll say, okay, a person with this lesion would have an infection with what? And then they'll list you like four different viruses and you'll say, oh, shit, what virus is it? So they ask two-part questions, which is no fun. So you have to not only know what mythology is here, but you have to know what the common viruses are that cause this. Alright? So we're looking around here, Jason. Both eyes. One though, right upper medial lid. It used to be kind of a whitish-raised circular lesion. It doesn't really appear cystic, just based on what you can see here. And it's definitely far away from the lip margin. So this looks almost sebaceous to me, just externally. It kind of looks almost yellow white. I mean, it looks kind of lippity, if that's a word, you know? And then we look at the pathology, and you see all these macrophages looking settled. Obviously, it's like sebaceous hyperplasia. Actually, no, because the sebaceous glands actually form a specific glandular pattern. This is just like the macrophages came in and are gobbling up a bunch of lipid that's deposited there. So this is called xanthalasma. And you see these very commonly in old people. It's kind of a flat, plaque-like, yellowish-looking thing. And what it's characterised by is these lipid-feel macrophages. Now, the reason you don't see any of these in the path lab so far in the last six months is because we don't usually remove these in centered paths. But this is called xanthalasma. So now they're just kind of a common benign lesion of the days. Alright, Reese? So, lower eyelid is kind of an elevated lesion of just a little bit of lip and margin. Maybe it looks kind of papillomidous. Exactly. So it looks kind of bumpy, it looks kind of papillomidous, and we look at the path, and indeed it's papillomidous. Exactly. So you see the finger sticking out. So the papilloma is the loved hand. So it's thickened epithelium like a glove, with little fibrovascular cores in the middle but sticking out. And so you can see these areas of thickened epithelium, little fibrovascular core in the center sticking out. Lots of keratin. So they've got hyperkeratin on them. They've got keratin-filled cysts, keratin-filled crypts. And so this is a papilloma. They can be infectious or they can be non-infectious if they're wrong. And here's a little closer up. Again, look at the little center here. A little fibrovascular core or thickened agent. So while we're here, some skin path terms that you guys have to know. So the thickened keratin layer is hyperkeratosis. If you have keratin deeper where it shouldn't be down here in the bottom of your thing, what do we call that? Diskeratosis with the D-Y-S. Actually what we call it when we have a few of the layer itself is thickened. Acanthosis. Okay, so acanthosis, thickening of the especially the prickly cell layer. Hyperkeratosis, diskeratosis. What is parakeratosis? Actually that's where you have the nuclei all the way to the surface. And so normally you don't have them. Now here's a close up of what this would look like in cross-section. So this is if you took the left hand and you chopped all your fingers off and you look at it. So here's the chopped fingers and this is what these look like in cross-section. Little fibrovascular core, thickened agent surrounding. Alright, so this is sorry I shouldn't ask you to, but actually that didn't count in the first one. So what do we see in here? So this is a skin lesion that's elevated, bumpy, kind of greasy appearing. It's like it's maybe stuck on. So what would this be like? Every vet has these, by the way. As soon as the spotlight hits I know it's like... So you're going to be an aural board, you're going to be saying now, if you can, okay, Harry Spider, good man, Harry Spider. This is a seborrheic keratosis. So it's greasy, it's keratinized. Now a couple of differences. It kind of looks like a well-made set. The fingers go down instead of in. So it's like the Harry Spider as opposed to the gloved hand. They go down and the other thing is look at the pigment in the basilar layer. Oftentimes these will have a little bit of pigment in the basilar layer so they will look tan or brown instead of, you know, flesh. And so they'll often have a little bit of a brownish keratinization. They'll get really hyper keratotic and these old vets will tell you, oh yeah, I had this thing but then it fell off and then it grew back. And so literally you'll get a big keratin plaque and the plaque will fall off. And then the keratin will build up again over time. And so these are really hyper keratotic and you can see that there's this increased pigmentation on the basilar layer. It gives these kind of a brownish tan appearance. When you see these, it'll often be brownish tan. Alright, Nico, what are we looking at right here? This is an external photograph and in the lower eyelid you see kind of this small yellowish irregularly shaped grey. The path on this one, kind of looking like almost like a seborrheic keratosis. Lots of keratin here but look at the epithelium. What's different with this epithelium here? You can come closer if you need to. So first, in the opium, it's like a kind of e-canthotic stick-in. Elevated as well. There seems to be the kind of central kind of glumen that's extending upwards. So there's the little fingers going out for the rest of the tissue. What is this thing right here? Those like nuclei. Well, nuclei in nuclei. So if you look at this, these little nuclei are more active than usual. They've got little nucleoli in them. So this epithelium starting to get active. Look right there. What is that thing right there? It's even a little mitotic figure here. So the epithelium starting to get active is going on down here. I think we have a solar endosynthesis. Exactly. So this is what we call basophilic degeneration. It's a solar induced degeneration. So these are on sun exposed skin. So this is what we call an actinic keratosis. And so this is kind of pre-malignant. It's a pre-cancer. It's not quite cancerous yet, but you're starting to see a lot of sun induced damage, basophilic degeneration collagen. You see a lot of keratosis, like you had a seborrheic keratosis, but now you're starting to see some activity in the nucleus here. So this is now called actinic keratosis. This is now moving along the scale towards something malignant that you worry about. The picture, like it's usually rough, correct? It's usually rough and have keratom, but it almost looks like kind of a seborrheic keratosis when you look at it. And here's a close-up to another one that, you know, Joe probably took this. This is not a picture to defend himself, but pretty, you know, and I got to get a better picture. So next time we get one I need you to remind me we'll take a picture of the places. But hyperkeratosis, dyskeratosis, and just some increased activity within the cell that's a bad picture. But here's a closer one and you can see, again, a little bit more active. And here's dyskeratosis, a little keratoprol down here. So these are ones you start to worry about being kind of a pre-malignant lesion at this point. Now, back to you again. What are you seeing here? All right, so lots of lashes, thickens, kind of ulcerated in the center. What would your concern be here? So if you see what you think is a tumor of the eyelid, by far the most common tumor is the basal cells. So if you take a hundred lid tumors, 90 of them will be basal cells. And so if you're going to make a guess and you're not sure, just guess basal cell. Because you'll be right 90% of the time. Now the second thing I've got to train you guys for oral boards and for answering in grand rounds, project. I know you're taught people, I don't talk loud, but I can't hear you up here. So project. And so you could get the right answer and not get credit for it if you talk quietly. Project. Project. The second thing is say things with confidence. And I got to kill Julia about this all the time. Don't go up when you say an answer. Because it sounds like you're guessing and you will not get credit even if you get it right. So even if you're wrong you say basal cell. Sit with conviction. And then if you got it right, great and get credit. If not, well, you were wrong anyway. Say it conviction. Alright so this is very concerning for a basal cell. You see the ulcerated center, the raised early edges, but how thick that lid is. And so this lesion goes right into this patient's bottom of the patellar specialty. Now I mean they're going to be not only taken off the lid, but swinging tissue around from over here and flaps by. And so this is a pretty, pretty advanced tissue. Now sometimes they can look not quite that advanced and so this would be something I look at and say maybe that's a little cyst. I don't know but if you look, there's a notch in here. So there's cell syndrome. Look at that notch in here. That little nodule there. You're starting to lose lashes. You've got this notch in here. So that little dizzle, believe it or not, turned out to be a basal cell. What's the most common pattern we see with the basal cell here? How do we know this is a basal cell? Exactly. This is a nuclei that line up around the edge, the so-called palisading of these. And they look pretty benign when you look at it. There's no mitotic figures. There's no nuclei. And they really look benign. And indeed this behaves benign in that basal cells don't metastasize. Now if you leave them alone and don't remove them, they can really, you know, keep growing and dig in and cause lots of damage given enough time. But you don't really metastasize or go anywhere else. So the classic little nodules or figures of the basal cell with the palisading around the edges is what we're going to see. There's a close-up. You see kind of a nine-hooking large nuclei, scat cytoplasm around them, and palisading that little picket fence that it forms around the edge. So when we look at basal cells, we can look at them in a couple of different ways. You can look at them grossly and say, okay, what kind of pattern do these have? And Lee, what's the most common pattern over all the basal cells we see? Nodular. Nodular. Even people will sometimes throw in cystic. Nodular with conviction. Nodular cystic. Okay. See, I don't have to worry about this Greeks. Nobody ever accuses the Greeks of talking quietly and being like this. They're always like, bye. With conviction. Nodular. But sometimes people throw cystic in that too. So nodular and nodular cystic. These are the most common forms you see. You see these large nodules. Sometimes they'll be a little cyst in the middle. But looking at the low power, there's the palisading around the edge of the nucleus. So nodular and nodular cystic. Tara, what's different about this pattern? All right, so you see these little, weird looking little fingers of cells. And then what kind of tissue is this in between? It's connective tissue. So what pattern is this? You need to worry about basal cells. Even you guys hint at me. You're Winston Churchill, how there's an iron curtain descending across Europe. Well, when the spotlight's not on you, everybody knows the answer. As soon as the spotlight hits you, that iron curtain goes right across the front wall. And it's like, what's your name? Oh, I don't know your name. The targeting spotlight hits you. Tara, also, we got two hours of sleep last night. Okay, well, you're a the urgent person from Idaho. This is called a morphia form. Basal cell. Or the other little people might say scurus. Scurus means with connective tissue and phylogelized tissue in between them. So the reason why these are difficult to treat is there are multiple little of these tumor cells that extend out so it's not a big nodule. So if basal cells aren't going to recur, they're going to, you know, invade, this is the type that does it because you can't see these. And so when you go to cut out the tumor, you can't see where these little fingers go. Sometimes they'll even spread under the epithelium. They'll call this a patchatory scrap. And so the morphia form is the scurus type of the worst because you can't get all the edges. They don't have any metastatic potential. They can locally invade. Sometimes you can get different types of cell growth with the basal cell. Because basal cells come from a little pluripotential cell that lives along the basal layer of the epithelium. So not only can you get a basal cell, if you look right here, look, here's a basal cell. Alright, Jason, what does this look like down here? They're bigger, they're pinker, there's lots of keratin in them. Yeah, that's more squamous. More squamous. And so you can get a basal squane. So you can even get a basal cell with more squamous differentiation. Because remember the little pluripotential cells at the base of the epithelium can give rise to different types of cells. Let's comment that a basal squane, you can get. Yeah, what happens if you don't treat a basal cell? This is actually one of Rick Anderson's original patients. Stubborn little old lady from the ranch in Nevada. She came in 10 years ago with a morphia form basal cell. And Rick basically said, okay, we got to do some surgery, we got to get this all off here. She said, leave me alone, I'm an old lady, you're not touching me, I'm going to go home and die. So 10 years later she's now 94 and so they're 84. She comes in and the reason why the family brought her here is because it smelled. And she had a piece of Kleenex stuck up here covering this. She said, oh, what's the matter? What have you got here? Oh, I've got this little thing. And so if you look right here, it actually went all the way back through the sinuses. Believe it or not, there was CSF dripping down here. And so once you let it get to this point over 10 years, that's going to be a heavy headectomy. You can't really do that to get that off. So you say, well, basal cell is benign, it doesn't metastasize. But if you let it grow for 10 years, it can cause this. So, and this was a morphine. So that's, you know, don't let it go that far. What do we see in here, Reese? So it's just a large leach on the upper eyelid on lots of the lashes. Just. That surface is kind of ulcerated a little bit. See, almost this parchment paper looked to it. Instead of, you know, the ulcerated look that we have with the basal cell, what would you be concerned about here? Maybe a squamous cell. Exactly. So that's a squamous cell. And if you look right here, there's another way they could look. And so people call this a rodent ulcer. Now, again, in my simplistic way of thinking, I thought rodent, it meant like it looks like a rodent took a bite out of it. So that's not what it means. But that's our memory. These are rodent ulcer. Because they're rodent chewed on it, you know. So, sometimes you get these little focal areas of ulceration. Look at this person with their skin. This is all sun damaged skin. But this is a so-called rodent ulcer. And sometimes they can look like that. So, when you think about the lid tumors though, you know, the most common place you're going to see the tumors is on the lower lid medially. Because that's where you get most of the sun exposure. And you sometimes get them up a little bit. You think of basal cells, lower lid, medial, medial canthus. Because the brow tends to shade us. Now, some of us I'm looking, you don't have many chromagons here. So, some people have this chromagon brow that really shades them. So, they're safe. You know, they're not going to get basal cells. But, squaring the cells can also occur on the upper lid. And so, you'll see them. They'll have that little parchment paper look to it. They may even have an orange-ish look to them. And when you look at them, they're different. The basal cells were blue with a lot of big nuclei and not much cytoplasm. How are these different? They're pink. They're eosinophilic steaming. And you see there's the central nucleus. And there's this eosinophilic steaming cytoplasm. And when you look at them, what is this stuff? So, you get these keratin pearls, keratin murals, which you see, this is now under the epithelium. This is made beyond the base you're going to bring. Look at the nucleoline. Look how active these cells are. Big, keratin pearls, keratin murals. Alright, Ashley, what are we seeing here? This is an external photograph of the right eye. I see the upper lip that looks thickened. The blood everywhere. If that's just discoloration of the photo. What would your worry here be? I mean, I always worry about a sebaceous person. Exactly. So don't ever forget a sebaceous gland carcinoma, because it's called the Great Mimicur. So this was called blepharoconjunctivitis. And so you go to the doc at the box. You know, what do the doc at the box give you? They all give you topodex, you know. So, first of all, non-ophthalmonia should never be using a steroid ever, but everybody gets topodex. And so they get topodex, it doesn't get better. They go see the optometrist who gives them Neosporin, it doesn't get better. Finally, they come and see you four weeks later and look at the thickening of that lid. See how thick it is? Those yellow splotches look at the loss of lashes. This is not blepharoconjunctivitis, but the problem with sebaceous gland carcinomas is they can sometimes mimic blepharoconjunctivitis. They can mimic recurrent chelacy. So you're always going to keep behind bits of suspicion. And this one is not why this is, you know, blatant. Look at that if you stick it in the upper lip. This is again mybomium gland sebaceous gland carcinoma. Alright? And now sometimes they can be fairly well differentiated if you look. This almost looks like a lobular mybomium gland. And if you look carefully at them, you can see that there's activity, there's chromatin, there's nucleolid, it's got all the little lipid droplets, but this is fairly well differentiated. And so if you get a sebaceous gland carcinoma and it's fairly well differentiated and lobular, the prognosis is better. If it's diffuse, then the prognosis is really poor. For that bloody one, would you have sampled a sentinel node too? You may want to. And so when you're thinking about nodes, you know, because these do spread, they can spread by nodes, so can squamous cells. The way you want to look at what nodes you want to do is take a finger, go across the eye with a 45 degree angle, and upper outer goes to pre-irricular nodes, lower inner goes to subhandful nodes. So you can look for nodes, but these can spread and so these can metastasize. So you want to watch these. In fact these can be very aggressive. They can be pretty nasty looking. If you look at this, you can look at the basal cell, look benign. You look at a sebaceous gland, it looks malignant. I mean it just looks aggressive. Look at the clear line. You can see the little mitotic figures starting up here. I mean this just really looks aggressive and indeed it is. Here's a close up. Look at those nice mitotic figures there. And then all the little dissolve and all those. A sebaceous gland carcinoma is very aggressive. The great mimicry. Don't miss those. And what scene is this? Oil Red-O. Oil Red-O. You can see it stains the oil with the little Red-O's. Nico, what do we see in here? So there's lower eyelid margin. There is a pigmented Loss of Lashes. It looks like a, I guess, Nevis. Okay, so you want to look just like the other things. You look for Loss of Lashes. You look for thickening. You say how long has it been there. So chances are this is probably a Nevis. But you know you take a picture of it. You tell the person, come back. Let's check it again. Let's measure it. See what it looks like. Indeed, we see this picture. What do we see in here? So I see nests of maybe pigmented or like brownish cells in the junction between the epidermis and the dermis as long as there's also a couple in the dermis as well. So what do we call this? Compound Nevis. Compound Nevis. So if the benign melanocytes are just at the junction between the epithelium and subepithelial tissue, we call it a junction Nevis. If you have them both at the junction and on your Nevis, we call it a compound Nevis. If it's just underneath, we call it a dermal Nevis. Even though there's no dermis in the eye there, we still call it a dermal Nevis just because it's in the literature. It should be a subepithelial Nevis. But the key thing is once the melanocytes lose the connection to the junction, they lose their malignant potential. So is a natural history for them to come down? Yeah, exactly. They'll drop off and then lose their junction of the corner. For some reason, once they do, they don't become malignant. And can you still see the pigment when it's that low? Or people just have it? Sometimes they lose pigment as it goes down so they don't necessarily look pigmented. In fact, here we see just that case. Here's the epithelium. Here's a clear space of some connective tissue. Here are the nest of the melanocytes, some of them pigment and some of them not. So this is what we call now a dermal Nevis or subepithelial Nevis. So these guys have lost their malignant potential. Alright, let's go back. See, you thought you'd be safe. You thought you were all done. What do we see in here? Of course they look brownish or redish even. What would your concern be? Exactly. Look, it's very effusive. It is kind of fucking beautiful. It's probably beyond the simple nevis. This is worried about in melanoma. Sure enough, we should start looking at these cells. You start to see nuclea here. You start to see pleomorphism. Pleomorphism means many sizes, literally, beyond morphism, many sizes, many shapes. So pleomorphism, so this is indeed a malignant melanoma. And just like sebaceous, of course, we should really gotta worry about these because these can't spread. And these are getting more common now. The baby boom generation, my generation loved the golden glow, the healthy glow of sun tan. And so my generation all had sun tans. And so we're seeing an explosion of melanomas because of all the sun worshiping. So hopefully you guys are smarter than that where your sunscreens are. So this is a melanoma. And you can see that it's definitely more aggressive than the nevus was. Alright, believe me. What are we seeing here? It's not the two dudes. You're running into the two dudes. So it looks like a very left upper eyelid. It's very swollen erythema. Yeah, it's kind of doughy. The eye underneath it's okay. It's a very doughy, you know, elevated lesion right here. And so you see, I don't know what the heck this is. A little biopsy. And you see this. What kind of cells are these? It looks lymphocytes. You could get lymphoma of the lid. Now it's not common. You get lymphoma of the orbit. You get lymphoma of the conch. More commonly, lymphoma of the lid. Uncommon. But you can also get lymphoma of the eyelid. Usually it's due to an extension of an organ lymphoma. But you get lymphoma. So these are all lymphocytes. Big lymphocytes. Let's go back one more. And I'd like to show just some weird stuff here. So I don't expect anybody to know this one. But if you look at it, it's kind of a bluish-looking nodular thing coming out. Now this guy's been letting it go. So we get all the crustiness around here. But it's kind of a red nodular looking thing. You know, we looked at it. It was very weird because it had these big nuclei that almost looked benign. In the middle of it, it had all these mitotic figures all over the place. This was a myrtle cell carcinoma. And so there could be weird tumors of the eyelid because they could be not just the common ones. I hope that we'll put this on words. But I just want to show you that there is some weird stuff that can appear on the eyelids too. This was a myrtle cell carcinoma. Otherwise, you can get other carcinomas too. You can also get mucin producing abnormal carcinomas. And these are really cool looking. These are often, you know, believe it or not, there are some little abnormal glands in the eyelids. Not real common. But if you look at them, you see an iron tumor cell swimming in a sea of mucin. This is all mucin in here. This is called a mucicarmine. It's a mucin stain. Sure enough, islands of these cells swimming in a sea of mucin. So don't worry about these. I just wanted to show you there's all kinds of weird tumors that can show up in the eyelids. So we say goodbye. Here's one of the, where they used to build the ships. And believe it or not, one of these buildings is left over. This is where the armament museum is. It's actually a 1600 building that was made into the Armament Museum. So this part of it here is the museum where we're standing. And here's a model of these to build the ships. Okay, so next week, conge. Please, set it. Okay, so we can get it all covered, alright? Okay, thanks.