Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
prior to excision were (a) lesions were not freely movable from the overlying skin, because most pilomatrixomas are located in the dermis, (b) irregular shaped rock hard lesions with the presence of nodular and chalky white nodules due to the calcifications, which could be seen through the skin, (c) reddish to blue discoloration of the lesions. Considering the clinical features, the short history and rapid increase in size, this is the first case being clinically diagnosed as pilomatrix carcinoma without the biopsy from periocular area. Though histologic confirmation of the diagnosis is mandatory, a strong clinical suspicion is very important to plan further management. The first 3 reported cases were men, and the diagnosis was made following biopsy,4–6 whereas in the instant case, the patient is a 68-year-old woman with a short history of 4 weeks with all surface characteristics like chalky white nodules, telangiectasia, and reddish-blue tinge. The differential diagnosis includes trichoblastic carcinoma that is a malignant tumor of hair follicle, made up of large cells with abundant cytoplasm and lack the typical shadow cells. There is no peripheral palisading of neoplastic cells and no cleft between the tumor lobule and the surrounding stroma.7 Another differential diagnosis is basal cell carcinoma with matriceal differentiation, in which retraction spaces are seen between neoplastic cells and stroma. The other clinical differential diagnoses are dermoid cyst, cavernous vascular tumors, and benign hair follicle tumors like trichoepithelioma and trichoblastoma. The histological examination can be challenging, especially because there are no clear histologic criteria distinguishing pilomatrix carcinoma from other matriceal tumors. Moreover, immunohistochemical investigations have failed to delineate a specific marker for this tumor. The main stay of treatment consists of wide excision with clear margins.3 Since these are locally aggressive tumors, the tendency for recurrence is as high as 59% if incompletely excised.8 Adequate wide excision with tumor-free margin on histopathological examination is very important to prevent local recurrence that is the predominant mode of relapse. Poor local control can lead to recurrence and distant metastasis to the lungs, bone, and viscera with a subsequent poor outcome.7 Adjuvant radiation can be given in recurrent disease or in residual macroscopic disease,9 but the role of radiotherapy and chemotherapy in the treatment of disseminated disease is unclear. As this is a rare disease, an appropriate discussion with head and neck oncologist should also be considered. Long-term follow up is necessary to detect early recurrence. Eyelid lesions with unusual signs should be thoroughly examined to avoid serious consequences, and the diagnosis of pilomatrix carcinoma should be explored. Thorough examination is mandatory in all eyelid tumors to detect any evidence of malignancy.
REFERENCES 1. Lopansri S, Mihm MC, Jr. Pilomatrix carcinoma or calcifying epitheliocarcinoma of Malherbe: a case report and review of literature. Cancer 1980;45:2368–73. 2. Hohberger GG, Bartley GB. Pilomatrixoma of the eyelids and eyebrows in children and adolescents. Ophthal Plast Reconstr Surg 1999;15:185–9. 3. Levy J, Ilsar M, Deckel Y, et al. Eyelid pilomatrixoma: a description of 16 cases and a review of the literature. Surv Ophthalmol 2008;53:526–35. 4. Vico P, Rahier I, Ghanem G, et al. Pilomatrix carcinoma. Eur J Surg Oncol 1997;23:370–1. 5. Cahill MT, Moriarty PM, Mooney DJ, et al. Pilomatrix carcinoma of the eyelid. Am J Ophthalmol 1999;127:463–4. 6. Wang X, Ma JM, Wang N. Malignant pilomatricoma in the upper eyelid. BMJ Case Rep 2009;2009
Case Reports
7. O’Donovan DG, Freemont AJ, Adams JE, et al. Malignant pilomatrixoma with bone metastasis. Histopathology 1993;23:385–6. 8. Sau P, Lupton GP, Graham JH. Pilomatrix carcinoma. Cancer 1993;71:2491–8. 9. Aherne NJ, Fitzpatrick DA, Gibbons D, et al. Recurrent malignant pilomatrixoma invading the cranial cavity: Improved local control with adjuvant radiation. J Med Imaging Radiat Oncol 2009;53:139–41.
An Unusual Complication of Crawford Tube Insertion Jennifer C. Fan Gaskin, M.B.Ch.B., and Brent J. Gaskin, M.B.Ch.B., F.R.A.N.Z.C.O Abstract: The authors describe an unusual and challenging complication of bicanalicular (Crawford) stent insertion that has previously never been reported. A 27-year-old man sustained multiple lacerations to the left (L) periocular and facial areas with a glass bottle. He was admitted under the care of the Plastic Surgical team at another institution and underwent repair of the facial, eyelid, and canalicular lacerations in the operating room. During the surgery, a Crawford stylet was guided in the L inferior canaliculus but was not retrieved nasally. Neuroimaging revealed that the metallic stylet of the Crawford tube was within the orbit, extending via the superior orbital fissure into the middle cranial fossa. The patient was then transferred under the care of the neurosurgical team and underwent a combined orbital/neurosurgical procedure to retrieve the stylet.
C
rawford stent insertion can be challenging in the setting of traumatic eyelid lacerations. An understanding of the potential complications and increased surgical experience reduces the likelihood of adverse outcomes. Canalicular lacerations are a common occurrence with periocular trauma. They can result from indirect blunt injury or by direct shearing or avulsing forces.1 The primary aim of surgical management is to restore functional anatomy, namely a patent canalicular system. The surgical technique involves intubation of the canalicular system with a temporary stent, either monocanalicular or bicanalicular, and suture repair of the pericanalicular tissues. A Crawford stent is a popular form of bicanalicular intubation that requires intranasal fixation.1,2 An unusual complication of Crawford stent insertion for the repair of a canalicular laceration is described. A 27-year-old man sustained multiple lacerations to the left periocular and facial areas with a glass bottle. He was admitted under the Plastic Surgical team at another institution and underwent repair of the facial, eyelid, and presumed bicanalicular lacerations in the operating room. An oculoplastic surgeon was not involved in this primary repair. During the surgery, a Crawford stylet was guided in the inferior canaliculus, but the stylet was unable to be retrieved nasally, even after
Accepted for publication August 21, 2013. Department of Ophthalmology, Auckland District Health Board, Greenlane Clinical Centre, Greenlane, Auckland City, Auckland. The authors have no financial or conflicts of interest to disclose. Presented at the 44th Annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists, Melbourne, Australia, November 2012. Address correspondence and reprint requests to Brent Gaskin, M.B.Ch.B., Department of Ophthalmology, Greenlane Clinical Centre, Auckland District Health Board, Private Bag 92189, Auckland Mail Centre, Auckland 1142, New Zealand. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
FIG. 1. Sagittal and axial CT imaging tracking the path of the Crawford stylet; A, sagittal view; B–E, Axial images demonstrating anterior most extent, proximity to carotid artery, proximity to cavernous sinus, and posterior most extent.
insertion of the entire stylet. When the stent was then withdrawn from the inferior canaliculus, the stylet was no longer attached to the silicone tubing. Urgent neuroimaging revealed that the stylet of the Crawford tube had been introduced into the orbit, extending via the superior orbital fissure into the middle cranial fossa (Fig. 1). The patient was transferred to the care of the neurosurgical team at this institution, and an oculoplastic opinion was sought. Retrieval of the stylet was planned as a combined neurosurgical/oculoplastic procedure with an orbital approach under general anesthesia. Surgical technique involved a transconjunctival postseptal lower eyelid approach to the inferior orbit. Malleable retractors were used to expose the stylet end, which was located at the level of the posterior globe. The stylet was successfully removed without complication. Postoperative
e12
FIG. 2. Coronal CT images tracking the course of the stylet. Images A–D tracking from anterior to posterior, the stylet passing through the superior orbital fissure (A), adjacent to the carotid artery (B), adjacent to the cavernous sinus (C), and resting underneath the tentorium (D).
imaging of the brain excluded any acute intracranial haemorrhage. Postoperative ophthalmic review the following day confirmed a left lower canalicular laceration but no other ophthalmic injuries.
COMMENT Lacrimal system intubation has proven to be a successful technique of repairing canalicular lacerations and maintaining lacrimal drainage function in patients following canalicular trauma.3 To the authors’ knowledge, this is the first report of intracranial penetration of a
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
bicanalicular stylet. Other reported complications of bicanalicular intubation include punctal or canalicular slitting, granuloma formation, superior loop dislocation, and chronic nasal irritation.1,4–6 In this case, the stylet of the stent was inadvertently implanted in the middle cranial fossa via the superior orbital fissure, narrowly missing critical structures such as the cavernous sinus and carotid artery (Fig. 2). With retrospective consideration, the authors have identified the following points that may prevent such an incident from recurring. First, preoperatively identify which canaliculi are involved. Monocanalicular stents are technically easier to insert and have a reduced risk profile, so may better suit cases with only a single involved canaliculus. Second, intraoperatively identify both ends of the lacerated canaliculus. This may require an operating microscope or loupes. Finally, recognize that the stylet length is significantly longer than the nasolacrimal duct. If the stylet end is not retrieved after introduction of the appropriate length, reassess, and consider endoscopic visualization. In addition to these practical steps, surgeons with less experience with canalicular intubation should have a low threshold for involving an oculoplastic surgeon in such cases. In conclusion, this case demonstrates an unusual but potentially life-threatening complication of bicanalicular stent insertion. Canalicular lacerations are common in the setting of periocular trauma, and successful repair involving canalicular intubation is desired to restore lacrimal anatomy and function. With thorough preoperative assessment, surgical experience, and meticulous repair, such complications may be prevented.
REFERENCES 1. Reifler DM. Management of canalicular laceration. Surv Ophthalmol 1991;36:113–32. 2. Walter WL. The use of the pigtail probe for silicone intubation of the injured canaliculus. Ophthalmic Surg 1982;13:488–92. 3. Neuhaus RW. Silicone intubation of traumatic canalicular lacerations. Ophthal Plast Reconstr Surg 1989;5:256–60. 4. Dresner SC, Codère F, Brownstein S, et al. Lacrimal drainage system inflammatory masses from retained silicone tubing. Am J Ophthalmol 1984;98:609–13. 5. Anderson RL, Edwards JJ. Indications, complications and results with silicone stents. Ophthalmology 1979;86:1474–87. 6. Lauring L. Silicone intubation of the lacrimal system: pitfalls, problems and complications. Ann Ophthalmol 1976;8:489–98.
Case Reports
CASE REPORT A 56-year-old Caucasian woman was referred to for a 1-month history of an enlarging nodule beneath her right upper eyelid. She denied any visual changes. She admitted to feeling pressure and a “twitching” feeling around the nodule. She has no significant past ocular history. Her medical history was significant for removal of a brain aneurysm several years prior and hand reconstructive surgery. Examination showed that her best-corrected visual acuity (BCVA) was 20/20 in OU. Pupils were equal, round, and reactive to light. There was no relative afferent pupillary defect. Hertel measurements at a base of 90 were 16.5 and 15.0 in the OD and OS, respectively. The intraocular pressure (IOP) was 20 mm Hg OU. Slit lamp biomicroscopy showed mild nuclear sclerotic cataracts in OU. There was a palpable mass in the lacrimal fossa along the right upper eyelid with overlying periocular inflammation. A CT scan of the orbits and sella demonstrated an asymmetric prominence of the right lacrimal gland without bony changes (Fig. 1). The patient underwent a right orbitotomy and incisional biopsy without complication. Gross examination of the biopsy specimen revealed a piece of tan tissue measuring 7 × 2 × 2 mm. Microscopic examination showed a mass composed of numerous histiocytes with ground glass cytoplasm (Fig. 2). There were occasional giant cells present, and some of the histiocytes contained vacuolated cytoplasm. Rare lymphocytes were present. Immunohistochemical stains were positive for CD68 and vimentin and negative for CD1a and S100 in the histiocytes. The lymphocytes immunostained for CD3. Based on the histologic appearance and immunohistochemical stains, the diagnosis was reticulohistiocytoma (RH). This study was Health Insurance Portability and Accountability Act compliant at this institution.
Reticulohistiocytoma of the Orbit Heather M. Weissman, M.D.*, Brent R. Hayek, M.D.*, and Hans E. Grossniklaus, M.D.*† Abstract: Reticulohistiocytoma is a rare, benign histiocytic proliferation of the skin or soft tissue. While ocular involvement has been documented in the past, there have been no previously reported cases of reticulohistiocytoma of the orbit. In this report, the authors describe a reticulohistiocytoma of the orbit in a middle-aged woman. Accepted for publication August 21, 2013. From the Departments of *Ophthalmology and †Pathology, Emory University School of Medicine, Atlanta, Georgia, U.S.A. Supported, in part, by NIH P30EY06360 and an unrestricted grant from Research to Prevent Blindness, Inc. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Hans E. Grossniklaus M.D., L. F. Montgomery Ophthalmic Pathology Laboratory, Emory Eye Center. BT 428, 1365 Clifton Rd., NE, Atlanta GA 30322. E-mail: [email protected]
FIG. 1. CT of orbits shows a mass in the lacrimal gland area (arrow) demonstrated by the transverse (top) and coronal (bottom) views.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e13
prior to excision were (a) lesions were not freely movable from the overlying skin, because most pilomatrixomas are located in the dermis, (b) irregular shaped rock hard lesions with the presence of nodular and chalky white nodules due to the calcifications, which could be seen through the skin, (c) reddish to blue discoloration of the lesions. Considering the clinical features, the short history and rapid increase in size, this is the first case being clinically diagnosed as pilomatrix carcinoma without the biopsy from periocular area. Though histologic confirmation of the diagnosis is mandatory, a strong clinical suspicion is very important to plan further management. The first 3 reported cases were men, and the diagnosis was made following biopsy,4–6 whereas in the instant case, the patient is a 68-year-old woman with a short history of 4 weeks with all surface characteristics like chalky white nodules, telangiectasia, and reddish-blue tinge. The differential diagnosis includes trichoblastic carcinoma that is a malignant tumor of hair follicle, made up of large cells with abundant cytoplasm and lack the typical shadow cells. There is no peripheral palisading of neoplastic cells and no cleft between the tumor lobule and the surrounding stroma.7 Another differential diagnosis is basal cell carcinoma with matriceal differentiation, in which retraction spaces are seen between neoplastic cells and stroma. The other clinical differential diagnoses are dermoid cyst, cavernous vascular tumors, and benign hair follicle tumors like trichoepithelioma and trichoblastoma. The histological examination can be challenging, especially because there are no clear histologic criteria distinguishing pilomatrix carcinoma from other matriceal tumors. Moreover, immunohistochemical investigations have failed to delineate a specific marker for this tumor. The main stay of treatment consists of wide excision with clear margins.3 Since these are locally aggressive tumors, the tendency for recurrence is as high as 59% if incompletely excised.8 Adequate wide excision with tumor-free margin on histopathological examination is very important to prevent local recurrence that is the predominant mode of relapse. Poor local control can lead to recurrence and distant metastasis to the lungs, bone, and viscera with a subsequent poor outcome.7 Adjuvant radiation can be given in recurrent disease or in residual macroscopic disease,9 but the role of radiotherapy and chemotherapy in the treatment of disseminated disease is unclear. As this is a rare disease, an appropriate discussion with head and neck oncologist should also be considered. Long-term follow up is necessary to detect early recurrence. Eyelid lesions with unusual signs should be thoroughly examined to avoid serious consequences, and the diagnosis of pilomatrix carcinoma should be explored. Thorough examination is mandatory in all eyelid tumors to detect any evidence of malignancy.
REFERENCES 1. Lopansri S, Mihm MC, Jr. Pilomatrix carcinoma or calcifying epitheliocarcinoma of Malherbe: a case report and review of literature. Cancer 1980;45:2368–73. 2. Hohberger GG, Bartley GB. Pilomatrixoma of the eyelids and eyebrows in children and adolescents. Ophthal Plast Reconstr Surg 1999;15:185–9. 3. Levy J, Ilsar M, Deckel Y, et al. Eyelid pilomatrixoma: a description of 16 cases and a review of the literature. Surv Ophthalmol 2008;53:526–35. 4. Vico P, Rahier I, Ghanem G, et al. Pilomatrix carcinoma. Eur J Surg Oncol 1997;23:370–1. 5. Cahill MT, Moriarty PM, Mooney DJ, et al. Pilomatrix carcinoma of the eyelid. Am J Ophthalmol 1999;127:463–4. 6. Wang X, Ma JM, Wang N. Malignant pilomatricoma in the upper eyelid. BMJ Case Rep 2009;2009
Case Reports
7. O’Donovan DG, Freemont AJ, Adams JE, et al. Malignant pilomatrixoma with bone metastasis. Histopathology 1993;23:385–6. 8. Sau P, Lupton GP, Graham JH. Pilomatrix carcinoma. Cancer 1993;71:2491–8. 9. Aherne NJ, Fitzpatrick DA, Gibbons D, et al. Recurrent malignant pilomatrixoma invading the cranial cavity: Improved local control with adjuvant radiation. J Med Imaging Radiat Oncol 2009;53:139–41.
An Unusual Complication of Crawford Tube Insertion Jennifer C. Fan Gaskin, M.B.Ch.B., and Brent J. Gaskin, M.B.Ch.B., F.R.A.N.Z.C.O Abstract: The authors describe an unusual and challenging complication of bicanalicular (Crawford) stent insertion that has previously never been reported. A 27-year-old man sustained multiple lacerations to the left (L) periocular and facial areas with a glass bottle. He was admitted under the care of the Plastic Surgical team at another institution and underwent repair of the facial, eyelid, and canalicular lacerations in the operating room. During the surgery, a Crawford stylet was guided in the L inferior canaliculus but was not retrieved nasally. Neuroimaging revealed that the metallic stylet of the Crawford tube was within the orbit, extending via the superior orbital fissure into the middle cranial fossa. The patient was then transferred under the care of the neurosurgical team and underwent a combined orbital/neurosurgical procedure to retrieve the stylet.
C
rawford stent insertion can be challenging in the setting of traumatic eyelid lacerations. An understanding of the potential complications and increased surgical experience reduces the likelihood of adverse outcomes. Canalicular lacerations are a common occurrence with periocular trauma. They can result from indirect blunt injury or by direct shearing or avulsing forces.1 The primary aim of surgical management is to restore functional anatomy, namely a patent canalicular system. The surgical technique involves intubation of the canalicular system with a temporary stent, either monocanalicular or bicanalicular, and suture repair of the pericanalicular tissues. A Crawford stent is a popular form of bicanalicular intubation that requires intranasal fixation.1,2 An unusual complication of Crawford stent insertion for the repair of a canalicular laceration is described. A 27-year-old man sustained multiple lacerations to the left periocular and facial areas with a glass bottle. He was admitted under the Plastic Surgical team at another institution and underwent repair of the facial, eyelid, and presumed bicanalicular lacerations in the operating room. An oculoplastic surgeon was not involved in this primary repair. During the surgery, a Crawford stylet was guided in the inferior canaliculus, but the stylet was unable to be retrieved nasally, even after
Accepted for publication August 21, 2013. Department of Ophthalmology, Auckland District Health Board, Greenlane Clinical Centre, Greenlane, Auckland City, Auckland. The authors have no financial or conflicts of interest to disclose. Presented at the 44th Annual Scientific Congress of the Royal Australian and New Zealand College of Ophthalmologists, Melbourne, Australia, November 2012. Address correspondence and reprint requests to Brent Gaskin, M.B.Ch.B., Department of Ophthalmology, Greenlane Clinical Centre, Auckland District Health Board, Private Bag 92189, Auckland Mail Centre, Auckland 1142, New Zealand. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e11
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
FIG. 1. Sagittal and axial CT imaging tracking the path of the Crawford stylet; A, sagittal view; B–E, Axial images demonstrating anterior most extent, proximity to carotid artery, proximity to cavernous sinus, and posterior most extent.
insertion of the entire stylet. When the stent was then withdrawn from the inferior canaliculus, the stylet was no longer attached to the silicone tubing. Urgent neuroimaging revealed that the stylet of the Crawford tube had been introduced into the orbit, extending via the superior orbital fissure into the middle cranial fossa (Fig. 1). The patient was transferred to the care of the neurosurgical team at this institution, and an oculoplastic opinion was sought. Retrieval of the stylet was planned as a combined neurosurgical/oculoplastic procedure with an orbital approach under general anesthesia. Surgical technique involved a transconjunctival postseptal lower eyelid approach to the inferior orbit. Malleable retractors were used to expose the stylet end, which was located at the level of the posterior globe. The stylet was successfully removed without complication. Postoperative
e12
FIG. 2. Coronal CT images tracking the course of the stylet. Images A–D tracking from anterior to posterior, the stylet passing through the superior orbital fissure (A), adjacent to the carotid artery (B), adjacent to the cavernous sinus (C), and resting underneath the tentorium (D).
imaging of the brain excluded any acute intracranial haemorrhage. Postoperative ophthalmic review the following day confirmed a left lower canalicular laceration but no other ophthalmic injuries.
COMMENT Lacrimal system intubation has proven to be a successful technique of repairing canalicular lacerations and maintaining lacrimal drainage function in patients following canalicular trauma.3 To the authors’ knowledge, this is the first report of intracranial penetration of a
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
bicanalicular stylet. Other reported complications of bicanalicular intubation include punctal or canalicular slitting, granuloma formation, superior loop dislocation, and chronic nasal irritation.1,4–6 In this case, the stylet of the stent was inadvertently implanted in the middle cranial fossa via the superior orbital fissure, narrowly missing critical structures such as the cavernous sinus and carotid artery (Fig. 2). With retrospective consideration, the authors have identified the following points that may prevent such an incident from recurring. First, preoperatively identify which canaliculi are involved. Monocanalicular stents are technically easier to insert and have a reduced risk profile, so may better suit cases with only a single involved canaliculus. Second, intraoperatively identify both ends of the lacerated canaliculus. This may require an operating microscope or loupes. Finally, recognize that the stylet length is significantly longer than the nasolacrimal duct. If the stylet end is not retrieved after introduction of the appropriate length, reassess, and consider endoscopic visualization. In addition to these practical steps, surgeons with less experience with canalicular intubation should have a low threshold for involving an oculoplastic surgeon in such cases. In conclusion, this case demonstrates an unusual but potentially life-threatening complication of bicanalicular stent insertion. Canalicular lacerations are common in the setting of periocular trauma, and successful repair involving canalicular intubation is desired to restore lacrimal anatomy and function. With thorough preoperative assessment, surgical experience, and meticulous repair, such complications may be prevented.
REFERENCES 1. Reifler DM. Management of canalicular laceration. Surv Ophthalmol 1991;36:113–32. 2. Walter WL. The use of the pigtail probe for silicone intubation of the injured canaliculus. Ophthalmic Surg 1982;13:488–92. 3. Neuhaus RW. Silicone intubation of traumatic canalicular lacerations. Ophthal Plast Reconstr Surg 1989;5:256–60. 4. Dresner SC, Codère F, Brownstein S, et al. Lacrimal drainage system inflammatory masses from retained silicone tubing. Am J Ophthalmol 1984;98:609–13. 5. Anderson RL, Edwards JJ. Indications, complications and results with silicone stents. Ophthalmology 1979;86:1474–87. 6. Lauring L. Silicone intubation of the lacrimal system: pitfalls, problems and complications. Ann Ophthalmol 1976;8:489–98.
Case Reports
CASE REPORT A 56-year-old Caucasian woman was referred to for a 1-month history of an enlarging nodule beneath her right upper eyelid. She denied any visual changes. She admitted to feeling pressure and a “twitching” feeling around the nodule. She has no significant past ocular history. Her medical history was significant for removal of a brain aneurysm several years prior and hand reconstructive surgery. Examination showed that her best-corrected visual acuity (BCVA) was 20/20 in OU. Pupils were equal, round, and reactive to light. There was no relative afferent pupillary defect. Hertel measurements at a base of 90 were 16.5 and 15.0 in the OD and OS, respectively. The intraocular pressure (IOP) was 20 mm Hg OU. Slit lamp biomicroscopy showed mild nuclear sclerotic cataracts in OU. There was a palpable mass in the lacrimal fossa along the right upper eyelid with overlying periocular inflammation. A CT scan of the orbits and sella demonstrated an asymmetric prominence of the right lacrimal gland without bony changes (Fig. 1). The patient underwent a right orbitotomy and incisional biopsy without complication. Gross examination of the biopsy specimen revealed a piece of tan tissue measuring 7 × 2 × 2 mm. Microscopic examination showed a mass composed of numerous histiocytes with ground glass cytoplasm (Fig. 2). There were occasional giant cells present, and some of the histiocytes contained vacuolated cytoplasm. Rare lymphocytes were present. Immunohistochemical stains were positive for CD68 and vimentin and negative for CD1a and S100 in the histiocytes. The lymphocytes immunostained for CD3. Based on the histologic appearance and immunohistochemical stains, the diagnosis was reticulohistiocytoma (RH). This study was Health Insurance Portability and Accountability Act compliant at this institution.
Reticulohistiocytoma of the Orbit Heather M. Weissman, M.D.*, Brent R. Hayek, M.D.*, and Hans E. Grossniklaus, M.D.*† Abstract: Reticulohistiocytoma is a rare, benign histiocytic proliferation of the skin or soft tissue. While ocular involvement has been documented in the past, there have been no previously reported cases of reticulohistiocytoma of the orbit. In this report, the authors describe a reticulohistiocytoma of the orbit in a middle-aged woman. Accepted for publication August 21, 2013. From the Departments of *Ophthalmology and †Pathology, Emory University School of Medicine, Atlanta, Georgia, U.S.A. Supported, in part, by NIH P30EY06360 and an unrestricted grant from Research to Prevent Blindness, Inc. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Hans E. Grossniklaus M.D., L. F. Montgomery Ophthalmic Pathology Laboratory, Emory Eye Center. BT 428, 1365 Clifton Rd., NE, Atlanta GA 30322. E-mail: [email protected]
FIG. 1. CT of orbits shows a mass in the lacrimal gland area (arrow) demonstrated by the transverse (top) and coronal (bottom) views.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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