Mainly for locally advanced disease. The most obvious indication is a patient who would otherwise need orbital exenteration; by AJCC this may be T4 disease, greater than 30 millimeters and invading the orbit. For eyelid melanoma with nodal metastasis, the field is moving toward upfront immune checkpoint inhibitors. Surgically curable cancers should not get drug therapy.

Describe the lesion and have a differential in mind, take photos, and remove enough tissue to be diagnostic. Avoid crushing the specimen and don't biopsy with cautery. For suspected melanoma, excise deeper rather than shave to measure thickness. Biopsy the lesion margin, not a necrotic center, and go to the tarsus for suspected sebaceous carcinoma.

Yes. The panel says to err on the side of sending anything removed. Chalazia have come back as sebaceous carcinomas, and a basal cell next to a meibomian gland can cause a chalazion. Previous pathology showing lipogranulomatous inflammation changes management, while no prior pathology pushes toward biopsying faster.

Previously, squamous carcinoma with perineural spread got high-dose radiation, 66 grays, to the skull base, which almost guaranteed blindness about two years later and often recurred. PD-1 inhibitors now spare radiation and exenteration. In Michigan, with one year of treatment, survival was around 85% at two years and 75% at three years.

Dr. Kaufman says the median time to response is about 1.9 months, so after two doses you usually know the direction. His group's paper in press found almost all benefit came within the first two doses, suggesting treatment duration may be reduced to avoid side effects and resistance.

Ocular complications such as visual loss or uveitis are estimated at about 1% or less, and fatal reactions are also about 1%. Other immune-related 'itis' effects, most commonly diarrhea and dermatitis, are quoted at around 25 to 30% for a single PD-1 agent, and up to 50% or more with combination therapy.

Surgically manageable tumors get wide excision with sentinel lymph node biopsy, supported by NCCN guidelines, replacing empiric nodal radiation. Adjuvant immunotherapy or radiation depends on results. Nodal or metastatic disease should start with immunotherapy. Survival has doubled over the last decade, largely due to immunotherapy.

Flaps come first. The Hughes tarsoconjunctival flap is a workhorse for the lower eyelid. For large deep upper eyelid defects, one panelist still uses Cutler Beard flaps with an Alloderm sandwich graft. Others favor periosteal flaps, tarsal grafts, or oral mucosal grafts, and avoid hard palate in the upper eyelid.

When the canaliculi are gone, the surgeon should focus on lower eyelid position and attach it at the posterior lacrimal crest. Placing a Jones tube in patients who lost medial canthal tissue and were radiated sucks up any remaining tears and leads to horrible dry eyes, which the panelist calls misguided.

A nuanced ocular or medical oncologist. Both cancers metastasize during follow-up 50% of the time, and many medical oncologists misunderstand them, for example treating conjunctival melanoma as mucosal melanoma despite its brain metastasis risk. Panelists order their own systemic workup at least once a year.