Eyelid Lipoma

Purpose@#To report a rare case of eyelid lipoma. Case summary: A 41-year-old female presented with a palpable mass in her left upper eyelid. Diffuse hard mass was palpable at preaponeurotic fat layer of left upper eyelid, and there was no inflammatory sign. Under local anesthesia, a left upper eyelid mass partial excision was performed and a biopsy specimen was collected. The mass was yellower and harder than surrounding normal eyelid fat. A lipoma was diagnosed based on histopathological findings such as proliferation of mature adipocytes. @*Conclusions@#Lipoma is a benign tumor commonly found around trunk and limbs, but rarely occurs at eyelid. Eyelid lipoma should be considered as a differential diagnosis of diffuse mass at eyelid fat layer. Diagnosis and treatment can be achieved by partial excision and histopathological examination.

Eyelid Lipoma

Purpose@#To report a rare case of eyelid lipoma. Case summary: A 41-year-old female presented with a palpable mass in her left upper eyelid. Diffuse hard mass was palpable at preaponeurotic fat layer of left upper eyelid, and there was no inflammatory sign. Under local anesthesia, a left upper eyelid mass partial excision was performed and a biopsy specimen was collected. The mass was yellower and harder than surrounding normal eyelid fat. A lipoma was diagnosed based on histopathological findings such as proliferation of mature adipocytes. @*Conclusions@#Lipoma is a benign tumor commonly found around trunk and limbs, but rarely occurs at eyelid. Eyelid lipoma should be considered as a differential diagnosis of diffuse mass at eyelid fat layer. Diagnosis and treatment can be achieved by partial excision and histopathological examination.

Clinicopathological Characteristics of Caruncular Tumors in Koreans

PURPOSE: To investigate the clinical characteristics and histological features of tumors in caruncles. METHODS: We conducted a retrospective chart review of 126 eyes of 126 patients who underwent incisional or excisional biopsy of conjunctival masses between March 2008 and December 2016. RESULTS: Twenty-four patients (19.0%) including 10 males and 14 females had a mass located on the caruncle. The mean age at diagnosis was 41.8 ± 13.4 years (range, 15–67 years). Most patients (75%) visited us for a cosmetically visible mass without other symptoms. The mean duration of symptoms was 73.8 ± 113.0 months (range, 1–240 months). The most common histological diagnosis was a melanocytic tumor (50%) followed by a sebaceous gland tumor (12.5%), an epidermoid cyst (12.5%), and papilloma (12.5%). The symptom duration of the melanocytic tumor was significantly longer than other types of tumors (153.6 ± 139.8 months, p = 0.025). CONCLUSIONS: Caruncular tumors accounted for 19% of all conjunctival tumors. The most common pathological diagnosis of a caruncular tumor was a melanocytic tumor, which had a characteristically long symptom duration.

Effects on Periocular Tissues after Proton Beam Radiation Therapy for Intraocular Tumors

BACKGROUND: To present our experience on orbital and periorbital tissue changes after proton beam radiation therapy (PBRT) in patients with intraocular tumors, apart from treatment outcomes and disease control. METHODS: Medical records of 6 patients with intraocular tumors who had been treated with PBRT and referred to oculoplasty clinics of two medical centers (Seoul National University Hospital and Seoul Metropolitan Government-Seoul National University Boramae Medical Center) from October 2007 to September 2014 were retrospectively reviewed. The types of adverse effects associated with PBRT, their management, and progression were analyzed. In anophthalmic patients who eventually underwent enucleation after PBRT due to disease progression, orbital volume (OV) was assessed from magnetic resonance (MR) images using the Pinnacle3 program. RESULTS: Among the six patients with PBRT history, three had uveal melanoma, and three children had retinoblastoma. Two eyes were treated with PBRT only, while the other four eyes ultimately underwent enucleation. Two eyes with PBRT only suffered from radiation dermatitis and intractable epiphora due to canaliculitis or punctal obstruction. All four anophthalmic patients showed severe enophthalmic features with periorbital hollowness. OV analysis showed that the difference between both orbits was less than 0.1 cm before enucleation, but increased to more than 2 cm3 after enucleation. CONCLUSION: PBRT for intraocular tumors can induce various orbital and periorbital tissue changes. More specifically, when enucleation is performed after PBRT due to disease progression, significant enophthalmos and OV decrease can develop and can cause poor facial cosmesis as treatment sequelae.

A High-fat Diet Induces a Loss of Midbrain Dopaminergic Neuronal Function That Underlies Motor Abnormalities

Movement defects in obesity are associated with peripheral muscle defects, arthritis, and dysfunction of motor control by the brain. Although movement functionality is negatively correlated with obesity, the brain regions and downstream signaling pathways associated with movement defects in obesity are unclear. A dopaminergic neuronal pathway from the substantia nigra (SN) to the striatum is responsible for regulating grip strength and motor initiation through tyrosine hydroxylase (TH) activity-dependent dopamine release. We found that mice fed a high-fat diet exhibited decreased movement in open-field tests and an increase in missteps in a vertical grid test compared with normally fed mice. This motor abnormality was associated with a significant reduction of TH in the SN and striatum. We further found that phosphorylation of c-Jun N-terminal kinase (JNK), which modulates TH expression in the SN and striatum, was decreased under excess-energy conditions. Our findings suggest that high calorie intake impairs motor function through JNK-dependent dysregulation of TH in the SN and striatum.

Intraoperatively Observed Lacrimal Obstructive Features and Surgical Outcomes in External Dacryocystorhinostomy

PURPOSE: To analyze the features of lacrimal drainage system obstruction confirmed during external dacryocystorhinostomy surgeries and report the surgical outcomes. METHODS: We reviewed the medical records of a total of 769 cases who underwent external dacryocystorhinostomy for primary lacrimal drainage obstruction between 2005 and 2014. Data about detailed location and extent of obstruction were collected intraoperatively. The sites of obstruction were classified into nasolacrimal duct obstruction (NLDO), common canalicular obstruction (CCO), and canalicular obstruction. Lacrimal sac mucosa and lumen were grossly inspected, and the frequency of lacrimal sac changes, such as significant inflammation or fibrosis, was analyzed in cases of CCO or canalicular obstruction. The surgical success rate was also evaluated including effect of lacrimal sac status in the CCO and canalicular obstruction groups. RESULTS: Of 769 cases, primary NLDO with patent canaliculi was diagnosed intraoperatively in 432 cases (56.2%), CCO in 253 (32.9%), and canalicular obstruction in 84 (10.9%). Of 253 cases with CCO, 122 (48.2%) showed clear lacrimal sac lumen, and the other 131 (51.8%) showed significant inflammation or fibrosis of the lacrimal sac. In cases with canalicular obstruction, 35 of 84 (41.7%) showed a clear lacrimal sac, and the other 49 cases (58.3%) cases revealed mucosal changes of the lacrimal sac. The functional success rate was 87.5% for primary NLDO, 75.5% for CCO, and 72.6% for canalicular obstruction. In the CCO group, the functional success rate was lower in cases with significant lacrimal sac change (p = 0.044). CONCLUSIONS: Even in patients with CCO or canalicular obstruction, a large number of cases have lacrimal sac changes, and those changes were associated with lower functional success rate.

A Case of Delayed Orbital Cellulitis after Orbital Wall Fracture Repair Using Absorbable Implant

PURPOSE: To report a case of delayed orbital cellulitis with subperiosteal abscess after orbital floor fracture repair using an absorbable sheet implant (Macropore®, Medtronic Inc., Minneapolis, MN, USA). CASE SUMMARY: A 16-year-old male visited the oculoplastic clinic for left eye pain, lower eyelid swelling and vertical diplopia for 1 day. The patient had a history of inferior orbital wall fracture repair surgery using Macropore® 20 months prior. The orbital computed tomography scan showed a subperiosteal cystic mass with surrounding infiltration at the left orbital floor, and ethmoidal and maxillary sinusitis; however, sheet implant was not clearly observed. Despite systemic antibiotic treatment for 3 days, his clinical findings did not improve, thus we decided to drain the subperiosteal abscess through a transconjunctival approach. Intraoperatively, the Macropore® sheet was almost dissolved, but small pieces remained. The culture of drained contents showed no microorganisms. Systemic antibiotics were continued for 18 days after surgery, and clinical symptoms completely improved. CONCLUSIONS: Delayed orbital cellulitis should be considered in patients with extraocular muscle movement limitation and painful orbital swelling if the patient has a history of orbital wall fracture repair, even if a bioresorbable implant was used. Prompt imaging evaluation should be emphasized for early diagnosis and proper treatment.

A Case of Eyelid Sebaceoma Mimicking Chalazion

PURPOSE: To report a rare case of sebaceoma misdiagnosed as chalazion. CASE SUMMARY: A 42-year-old female presented with a visible mass in her right lower eyelid. An elevated, hard mass was located at the margin of the right lower eyelid, and she had a history of incision and curettage under the clinical impression of chalazion. On eversion of the lower eyelid, the tarsal portion of the mass was visible as a white-yellowish lesion. The mass was excised under local anesthesia. A sebaceoma was diagnosed based on histopathological examinations. Immunohistochemical studies showed positive staining results for mutator L homologue 1 (MLH1), mutator S homologue 2 (MSH2), and mutator S homologue 6 (MSH6), and she had no past medical history or family history of internal malignancy, suggesting a low possibility of Muir-Torre syndrome. CONCLUSIONS: Eyelid sebaceoma should be considered as a differential diagnosis for refractory chalazion.

Three Cases of Periorbital Nodular Fasciitis

PURPOSE: Herein, we report 3 cases of nodular fasciitis presenting with periorbital mass. CASE SUMMARY: An 18-year-old male presented with a mass in his left lateral temple area 3 months in duration. On physical examination, a subcutaneous mass approximately 20 mm in size was palpable with upper eyelid swelling. Orbital magnetic resonance imaging (MRI) showed T1 isointensity and T2 hyper intensity and a well-circumscribed enhancing lesion. A 36-year-old male presented with a 6-month history of a bump under his right upper eyelid. External examination revealed a 15 mm-sized subcutaneous mass in the right central sub-brow area. Orbital computed tomography showed a homogenous, well-circumscribed mass with moderate enhancement. A 3-year-old boy presented with a mass in his right upper eyelid 4 months in duration. A subcutaneous mass approximately 10 mm in size was palpated at the medial superior orbital rim. Orbital MRI revealed an enhanced mass of irregular shape. Surgical excision was performed for all cases. Histopathological examination showed pathognomonic proliferation of spindle cells and immunohistochemical stains showed the spindle cells were positive for smooth muscle actin, negative for S-100 and negative for CD34, consistent with nodular fasciitis. Recurrence of the tumors after excision in the 3 cases was not observed after 4 months, 3 months and 48 months, respectively. CONCLUSIONS: Nodular fasciitis is rare but can occur at the periorbital region. In particular, nodular fasciitis should be considered as a differential diagnosis of a subcutaneous mass short in duration in children or young adults.

Clinicopathologic Study of Chromosomal Aberrations in Ocular Adnexal Lymphomas of Korean Patients

PURPOSE: The incidence and clinical correlation of MALT1 translocation and chromosomal numerical aberrations in Korean patients with ocular adnexal mucosa associated lymphoid tissue (MALT) lymphoma have not yet been reported. We investigated the incidence and clinicopathologic relationship of these chromosomal aberrations in ocular adnexal MALT lymphomas in a Korean population. METHODS: Thirty ocular adnexal MALT lymphomas were investigated for the t(11;18) API2-MALT1, t(14;18) IgH-MALT1 translocations and chromosomes 3 and 18 aneuploidies using fluorescence in situ hybridization. Patient medical records were reviewed retrospectively for information on demographics and clinical characteristics, including treatment response. RESULTS: The MALT1 gene rearrangement was found in one out of 30 cases. The t(14;18) IgH-MALT1 translocation was demonstrated in only one case (3.3%), and the t(11;18) API2-MALT1 translocation was not found in any of the cases. Trisomy 3 was observed in three ocular adnexal MALT lymphomas (10.0%), and five cases showed trisomy 18 (16.7%). Translocation positive cases also showed trisomy 18. One case of tumor relapse showed trisomy 18 only in the recurrent biopsies. There were no statistically significant correlations between chromosomal aberrations and clinical characteristics and treatment responses. CONCLUSIONS: Translocations involving the MALT1 gene are not common in Korean ocular adnexal MALT lymphomas. The t(14;18) translocation was detected in only one out of 30 cases, and the t(11;18) translocation was not found at all. Furthermore, the chromosomal aberrations found in this study had no prognostic implications.

A Case of Intratarsal Keratinous Cyst of the Meibomian Gland

PURPOSE: To report a patient presenting with an intratarsal keratinous cyst of the Meibomian gland in the upper eyelid and a review of the relevant literature. CASE SUMMARY: A 65-year-old male presented with a right upper eyelid mass which started 5 months prior. The patient reported that the mass recurred several weeks prior even after incision and curettage procedure. The mass was 9 x 5 mm in size and located in the center of the right upper eyelid at the level of lid crease, fixed to the tarsus and a whitish elevated focus was observed at the palpebral conjunctival surface. The mass was excised under local anesthesia and originated from the tarsus. The histopathological examinations revealed an intratarsal keratinous cyst composed of stratified squamous epithelium without keratohyalin granules and filled with keratin. The immunohistochemical studies showed positive staining results for cytokeratin 5/6, epithelial membrane antigen, and carcinoembryonic antigen. CONCLUSIONS: Intratarsal keratinous cyst of the Meibomian gland should be considered as a differential diagnosis of a recurrent tarsal mass.

Results of Silicone Tube Intubation in Patients with Common Canalicular Obstruction in Dacryocystography

PURPOSE: To evaluate the effects of silicone tube intubation in patients showing common canalicular obstruction in dacryocystography. METHODS: We conducted a retrospective chart review of 136 eyes of 93 patients who underwent silicone tube intubation and who were followed for more than 6 months. The patients were divided into 2 groups: the normal canaliculus group (112 eyes of 72 patients) and the common canalicular obstruction group (24 eyes of 21 patients). The demographic characteristics, degree of nasolacrimal duct obstruction on probing, and functional and anatomical success rates of silicone tube intubation were compared between the two groups. Surgery success was noted when the patient was satisfied with the 'improved' tearing symptom and the tear meniscus height decreased. RESULTS: On probing, 17 (70.8%) of 27 eyes revealed definite obstructive feeling at nasolacrimal duct in the common canalicular obstruction group, and there was no significant difference compared to the normal canaliculus group (p = 0.639). The anatomical success rate of silicone tube intubation was 91.1% in the normal canaliculus group and 83.3% in the common canalicular obstruction group, and the functional success rate was 85.7% in the normal canaliculus group and 75.0% in the common canalicular obstruction group. There were no significant differences in success rates between the two groups (p = 0.271, p = 0.161, respectively). CONCLUSIONS: Silicone tube intubation can be considered as a primary treatment option for management of common canalicular obstruction.

A Case of Conjunctival Inclusion Cyst Managed with Marsupialization

PURPOSE: We present a case with conjunctival inclusion cyst at inferior fornix treated by marsupialization. CASE SUMMARY: A 23-year-old woman visited our clinic complaining of left lower eyelid swelling. Ophthalmologic examination and CT scan showed a cystic mass from inferior conjunctival fornix to anterior orbit with shallow fornix and focal symblepharon. The cyst was effectively removed with marsupializaion. Postoperatively, there was no recurrence of cyst and the fornix was deepened. CONCLUSIONS: Marsupialization can be a considerable treatment option in conjunctival inclusion cyst, especially when accompanied by shallow fornix and symblepharon.

A Case of Canaliculocele Treated with Punctoplasty and Marsupialization

PURPOSE: Canaliculocele is a rare cause of eyelid mass which is formed by dilation of the canaliculus. We introduce a case of canaliculocele treated with punctoplasty and marsupialization. CASE SUMMARY: A 35-year-old woman visited our clinic complaining of a right medial upper eyelid mass. It started 3 months ago and had the wax and wane feature. On slit lamp examination, cystic lesion was visible in the medial area of the right upper eyelid, and the punctum was obscure. Right upper canaliculus was not shown in dacryocystography. One-snip punctoplasty was performed for the diagnosis, and turbid contents were drained leading to collapse of the cyst. After diagnosis of canaliculocele, marsupialization was added by excision of the posterior wall of the mass. On histopathologic examination, the cystic wall was composed of nonkeratinized squamous epithelium with an attenuated superficial cell layer. The patient healed without recurrence of a cyst after 6 months of follow up.

A Case of Orbital Apex Syndrome Induced by Penetrating Orbital Injury with Long-Term Results

PURPOSE: To report a case of orbital apex syndrome induced by penetrating orbital injury by a wire with the recovery process and clinical outcomes. CASE SUMMARY: A 40-year-old female visited our clinic after a penetrating orbital injury through the left inferomedial conjunctiva by a wire. The best corrected visual acuity of the left eye was 0.6, and ptosis and total ophthalmoplegia were observed. The patient showed a dilated pupil, swelling of the optic disc on fundus exam, and an inferior field defect on the automated perimetry. The computed tomography image revealed mild retrobulbar hemorrhage, but there was no orbital bony fracture. Enhancement of the optic nerve sheath was observed on the magnetic resonance image. The patient was admitted and received systemic antibiotics and steroid treatment. After 1 month, visual acuity, ptosis, and limitation in adduction were partly improved. After 3 months, depression and adduction were improved and the pupil size was normalized. However, further improvement was not observed after the one-year follow-up. CONCLUSIONS: The recovery from orbital apex syndrome was achieved until 3 months after injury. The final outcomes may depend on the mechanism and pathophysiology of the injury. Emergent diagnosis and proper management are essential to achieve optimal clinical results.

A Case of Orbital Organizing Hematoma Presenting as a Chalazion

PURPOSE: Organizing hematomas (hematic pseudocysts) of the orbit are usually the consequence of direct blunt trauma and are important in the differential diagnosis of orbital cystic lesion. Herein, we report a case of orbital organizing hematoma masquerading as a chalazion. CASE SUMMARY: A 12-year-old female visited our clinic complaining of left lower eyelid swelling. CT scan and MR imaging showed a mass detected in the inferomedial space of her left orbit, which did not invade the adjacent tissue. Excisional biopsy of the orbital mass was performed. Histological examination showed the accumulation of blood-breakdown products within a thick fibrous capsule without epithelial or endothelial lining. The mass was diagnosed as an organizing hematoma. CONCLUSIONS: An orbital organizing hematoma can present, although rare, as a chalazion-like eyelid mass. Careful clinical and radiological examinations can help in making a differential diagnosis.

Correction of Lower Lid Retraction Using Autologous Ear Cartilage Graft

PURPOSE: To evaluate the surgical results of lower eyelid retraction using autologous ear cartilage graft. METHODS: Fifty patients (54 eyes) who received surgical correction of lower eyelid retraction by lower eyelid retractors and conjunctiva recession from the tarsal plate with autologous ear cartilage grafts from March 2002 to July 2010 were evaluated. Medical records were reviewed and clinical characteristics, surgical outcomes, and postoperative complications were analyzed retrospectively. RESULTS: The use of prosthesis due to anophthalmos or microphthalmos (22 eyes) was the most common cause of lower eyelid retraction. The mean postoperative follow-up period was 16.6 months (1-98 months). Lower eyelid retraction was successfully corrected in 52 of 54 eyes. Postoperatively, 2 cases of corneal erosions, 1 case of conjunctival erosion, and 2 pyogenic granulomas developed. Corneal and conjunctival erosions resolved with conservative management and granulation tissues were removed by excision. CONCLUSIONS: Correction of lower eyelid retraction using autologous ear cartilage graft is an excellent surgical procedure with low complication rates for eyelid retraction of various etiologies.

A Case of Medulloepithelioma Originating from the Retina

PURPOSE: To report a rare case of medulloepithelioma originating from the retina. CASE SUMMARY: A nine-year-old boy visited our clinic with conjunctival injection and decreased visual acuity in the left eye, which had developed two month previously. Slit lamp examination revealed a distorted pupil and an anteriorly protruding ciliary body displacing the peripheral iris toward the cornea on the inferonasal side. Funduscopic examination showed total retinal detachment accompanied by an inferior hypervascular mass. The examination of the right eye was unremarkable. On computer tomography imaging, a calcified mass was identified behind the iris of the left globe in the inferomedial aspect, and ultrasound biomicroscopy revealed a medium to high echogenic tumor with an uneven oval cystic cavity in the ciliary body. At the follow-up examination, the size of the mass was increased, so we performed enucleation of the left eye. Pathology demonstrated that the retrolental mass abutting the lens had arisen from the retina. Histological examination revealed that the tumor had originated from the retina and extended into the ciliary body, and most of the tumor was composed of hyaline cartilage with calicification. Tumor cells were identified in the periphery, forming elongated tubules and cord-like structures that were immunohistochemically positive for vimentin, neuron-specific enolase, and CD56 compatible with a teratoid medulloepithelioma. The patient was followed up for eight months without any metastasis in the orbit or elsewhere. CONCLUSIONS: Medulloepithelioma should be considered in the differential diagnosis of pediatric orbital mass accompanied by calcification.

Surgical Treatment of Extensive Conjunctival Melanocytic Nevus Mimicking Conjunctival Melanoma

PURPOSE: To report a case of diffuse conjunctival melanocytic lesion mimicking conjunctival melanoma and treated by surgical excision and amniotic membrane transplantation. CASE SUMMARY: A 29-year-old man presented with diffuse pigmented lesion on the bulbar conjunctiva in the right eye, which had been present since birth. Circumferential pigmentation was observed in the perilimbal conjunctiva from 4 to 11 o'clock, and slightly elevated, dark brown-colored lesions with multiple small cysts were noted on the superior, inferior, and temporal bulbar conjunctiva. Incisional biopsy was performed from multiple sites to rule out conjunctival melanoma. Histopathologic examination showed small nevus cells and multiple cysts. Under local anesthesia, temporal conjunctival excision and amniotic membrane transplantation were performed. The surgical pathologist confirmed compound nevus. Four weeks after the surgery, full epithelialization was observed over the amniotic membrane. Several lesions were intentionally left during the surgery, and unnoticeable from the frontal view. The patient was satisfied with the surgical result. CONCLUSIONS: In extensive conjunctival pigmented lesion, biopsy should always be performed to rule out melanoma. Temporal conjunctival excision rather than whole lesion excision can be a cosmetically good surgical option for a diffuse conjuntival lesion proven as a benign conjunctival nevus.

Three Cases of Hyper-IgG4 Syndrome Involving Ocular Adnexa

PURPOSE: To report 3 cases of hyper-IgG4 syndrome involving ocular adnexa. CASE SUMMARY: A 66-year-old woman presented with swelling of the bilateral upper eyelids with ocular pain that began 1 year before. Nodular episcleral injection of the left eye and other generalized symptoms, such as cough, decreased hearing ability, multiple nodular lesions of the bilateral lungs and right kidney, together suggested rheumatic disease. Orbital computed tomographic images revealed diffuse swelling of the bilateral lacrimal glands. After immunostaining a surgically-biopsied specimen from the lacrimal gland for IgG4 expression, 15% of infiltrated lymphoplasmacytic cells were IgG4-positive. Similar findings were shown with biopsied specimens from the lung and kidney; therefore, the patient was diagnosed with Hyper-IgG4 syndrome. A 49-year-old woman complained of a mass in the left upper eyelid that began 4 years earlier. Orbital computed tomographic images showed a 5-mm-sized mass in the left upper eyelid. Ocular adnexal Hyper-IgG4 syndrome was confirmed by the immunostained biopsy from the left upper eyelid, showing infiltration of IgG4-positive lymphoplasmacytic cells. A 51-year-old woman presented with swelling of the bilateral lacrimal glands. Enlargement of the bilateral lacrimal glands were apparent in orbital computed tomographic images. After anti-IgG4 antibody staining of a biopsied specimen from the right lacrimal gland, dense infiltration of IgG4-positive lymphoplasmacytic cells was observed. The patient was also diagnosed with Hyper-IgG4 syndrome.