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These tumors are usually asymptomatic, and they do not become painful unless inflamed or irritated. Pedunculated lesions may become twisted, infarcted, and fall off spontaneously.[5] Only on rare occasions, histological examination of a clinically diagnosed FEP reveals a basal or squamous cell carcinoma.[6]

Figure 9: Postoperative photograph overview of scar and appearance of face

Discussion Fibromas are benign tumors that are composed of fibrous or connective tissue. The term fibrosarcoma is reserved for malignant tumors. There are two common fibroma types seen on the skin. They are the hard fibromas (dermatofibroma) and the soft fibroma (skin tag). The hard fibroma (fibroma durum) consists of many fibers and few cells. If seen on the skin it is known as a dermatofibroma, a special form of which is the keloid. A dermatofibroma is a round, brownish to purple growth commonly found on the legs and arms. Dermatofibromas contain scar tissue and feel like hard lumps in the skin. Soft fibromas also called “FEP,” “acrochordons,” or “cutaneous tags” occur as three types:  (a) Multiple small, furrowed papules, especially on the neck and in the axillae, generally only 1–2  mm long;  (b) single or multiple filiform, smooth growths in varying locations, about 2 mm wide and 5 mm long; and (c) solitary bag‑like, pedunculated growths, usually about 1 cm in diameter but occasionally much larger, seen most commonly on the lower trunk.[3] The soft fibroma consists of many loosely connected cells and less fibroid tissue then the hard dermatofibroma. Most FEP vary in size from 2 to 5 mm in diameter, although larger FEP up to 5 cm in diameter are sometimes evident. The most frequent localizations are the neck and the axilla, but any skin fold, including the groin, may be affected.[4]

Ascher’s syndrome: A rare case report Shivcharan Lal Chandravanshi, Vinay Mishra

Various methods of removal include cryotherapy for smaller lesions and ligation with a suture or a copper wire have been described; however, freezing of the surrounding skin during liquid nitrogen cryotherapy may result in dyschromic lesions. Taking hold of the acrochordon with forceps and applying cryotherapy to the forceps may provide superior results when the lesions are multiple and smaller in size.[7,8] In our case, simple excision gave excellent cosmesis leaving virtually no scar [Figs. 7‑9]. An online search using Medline Plus/PubMed and other medical search engines revealed this to be the only published case with photographs in detail. These lesions can easily be treated at any center using simple techniques.

References 1. Paul S, Vo DT, Silkiss RZ. Malignant and benign eyelid lesions in San Francisco: Study of a diverse urban population. Am J Clin Med 2011;8:40‑2. 2. Eads TJ, Chuang TY, Fabré VC, Farmer ER, Hood AF. The utility of submitting fibroepithelial polyps for histological examination. Arch Dermatol 1996;132:1459‑62. 3. Heenan  PJ.  Chapter 32 Tumors of Fibrous Tissue Involving The Skin. In: Elder  DE, editor. Lever’s Histopathology of the Skin. 9th ed.  Philadelphia, USA:Lipincott Williams and Wilkins; 2005. p. 996‑7. 4. Brodell RT, Pokorney DR. Fibroepithelial polyps and pathologic evaluation. Arch Dermatol 1997;133:915‑6. 5. Menn JJ, Boberg J. Fibroepithelial polyps. An unusual case report. J Am Podiatr Med Assoc 1990;80:496‑8. 6. Chiritescu  E, Maloney  ME. Acrochordons as a presenting sign of nevoid basal cell carcinoma syndrome. J Am Acad Dermatol 2001;44:789‑94. 7. Monfrecola G, Riccio G, Viola L, Procaccini EM. A simple cryo‑technique for the treatment of cutaneous soft fibromas. J Dermatol Surg Oncol 1994;20:151‑2. 8. Toro  JR, Glenn  G, Duray  P, Darling  T, Weirich  G, Zbar  B, et al. Birt‑Hogg‑Dubé syndrome: a novel marker of kidney neoplasia. Arch Dermatol 1999;135:1195‑202. Cite this article as: John M, Chirayath S, Paulson S. Multiple soft fibromas of the lid. Indian J Ophthalmol 2015;63:262-4. Source of Support: Nil. Conflict of Interest: None declared.

An 18‑year‑old Indian girl with upper lip deformity presented with on and off painless swelling of her both upper eyelids for 3 years. Clinical evaluation revealed bilateral blepharochalasis, Access this article online

Department of Ophthalmology, Shyam Shah Medical College, Rewa, Madhya Pradesh, India Correspondence to: Dr. Shivcharan Lal Chandravanshi, Department of Ophthalmology, Shyam Shah Medical College and Associated Gandhi Memorial Hospital, Rewa 486  001, Madhya Pradesh, India. E‑mail: [email protected] Manuscript received: 27.04.14; Revision accepted: 04.03.15

Quick Response Code:

Website: www.ijo.in DOI: 10.4103/0301-4738.156933 PMID: ***

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narrowing of horizontal palpebral fissure, decreased outer intercanthal distance, iris coloboma, cleft soft palate, bifid uvula, sensorineural deafness and double upper lip. Clinical examination of the thyroid, thyroid hormone assay and ultrasonography revealed normal thyroid gland structure and function. Ascher’s syndrome was diagnosed. To our knowledge, this is the first reported case of Ascher’s syndrome associated with iris coloboma, heterochromia iridum, and narrowing of horizontal palpebral fissure and decreased outer intercanthal distance secondary to lengthening of lateral canthal ligament. Key words: Ascher’s syndrome, blepharochalasis, double upper lip, Laffer‑Ascher’s syndrome, nontoxic goiter

Ascher’s (or Laffer‑Ascher’s) syndrome is a rare clinical entity which is characterized by blepharochalasis, double upper lip appearance with or without nontoxic goiter.[1] Nontoxic goiter is an inconsistent finding which was seen only in 10–50% cases.[2] Sometimes, it may appear few years after the onset of blepharochalasis, hence, it is not considered essential for diagnosis of Ascher’s syndrome.[3] This syndrome was first described by Ascher, an ophthalmologist from Prague, in 1920.[1] Till date, just over 100 cases have been reported in the literature.[3] We report an 18‑year‑old Indian girl with double upper lip deformity who presented with on and off painless swelling of her both upper eyelids for 3 years.

Figure 1: Face photograph showed bilateral upper eyelid edema, wrinkling and thinning of the upper eyelid skin and blepharoptosis

Case Report An 18‑year‑old Indian girl presented to oculoplasty clinic complaining of on and off painless swelling of her both upper eyelids for 3 years. She also had upper lip deformity since infancy. Family history was insignificant. Ophthalmic examination revealed visual acuity 20/40 in both the eyes which improved to 20/20 with ‑ 1 D cylinder at 90° in both the eyes. The eyelids showed bilateral upper eyelid edema, wrinkling and thinning of upper eyelid skin and marked blepharoptosis which was suggestive of blepharochalasis [Fig. 1]. Ocular anthropometric measurement showed outer intercanthal distance 66 mm; inner intercanthal distance 18 mm; interpupillary distance 52 mm; vertical palpebral aperture 6 mm in both eyes; distance from angle of lateral canthus to mid‑pupillary area 7 mm in both the eyes; and distance from angle of the medial canthus to mid‑pupillary area 11 mm [Fig. 2]. There was no lid lag or lagophthalmos. Extraocular movements were normal. However, lateral movements gave a false impression of the overaction of the lateral rectus due to medial displacement of the lateral canthus [Fig. 3]. Slit lamp examination revealed heterochromia iridum (left eye iris is lighter in color), iris coloboma in the right eye, incomplete pupillary frill in both the eyes and partial persistent pupillary membrane which was attached to anterior lens capsule in the left eye [Figs. 4, 5a and b]. Pupillary reaction, lacrimal apparatus, intraocular pressure, gonioscopy, rest ocular and adnexal examination was unremarkable in both the eyes. Dilated fundus examination showed normal findings. No thyroid enlargement was detected on clinical examination. Otorhinolaryngological examination revealed sensorineural deafness. Oral examination revealed hypertrophy of upper lip mucosa giving an appearance of double upper lip, slightly enlarged lower lip, cleft soft palate, and bifid uvula [Fig. 6a‑c]. She had hypernasal voice resonance and speech articulation errors. Ultrasonography of thyroid revealed normal size and architecture of the gland. Thyroid function test revealed

Figure 2: Ocular anthropometric measurements. Note bilateral narrowing of horizontal palpebral fissure and reduced outer intercanthal distance

Figure 3: Abduction in both the eyes. Note false impression of the overaction of the lateral rectus due to medial displacement of lateral canthi

normal free T3, free T4, and thyroid stimulating hormone level. A clinical diagnosis of Ascher’s syndrome was made. Patient received a course of oral prednisolone 1 mg/kg body weight

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which was failed to resolved blepharochalasis. Options of for surgical correction of deformity of the lip and palate were offered to the patient, but she refused for the same. Because as her blepharochalasis was in the active stage, hence surgical intervention was deferred, and she was kept under periodic follow‑up for the appropriate time for surgical intervention.

Discussion

Figure 4: Heterochromia iridum (the left iris color is slightly lighter than left)

b

a

Figure 5: (a) Slit-lamp photograph showing iris coloboma and incomplete pupillary frill in the right eye. (b) Incomplete pupillary frill and partial persistent pupillary membrane attached to anterior lens capsule in the left eye. Note bilateral rounding of angle of the lateral canthus

a

b

c Figure 6: (a) Double upper lip and slightly enlargement of lower lip. (b) Double upper lip became more prominent on smile. (c) Intraoral photograph showing cleft soft palate and bifid uvula

Ascher’s syndrome is rare, benign entity of unknown etiology.[3,4] It has no racial, gender or geographical predilection. It is characterized by bilateral blepharochalasis, double upper lip, and sometimes nontoxic goiter.[2] Diagnosis of Ascher’s syndrome is purely clinical.[2‑5] Onset of blepharochalasis occurs at puberty and is recurrent in nature. Recurrent attacks of painless edema of upper eyelids lead to laxity of the upper eyelid skin, weakness/dehiscence of the orbital septum and aponeurotic ptosis.[4] These anatomical changes in the orbital septum may lead to herniation of orbital fat pads and lacrimal gland prolapse. The upper eyelid skin becomes thin, wrinkled, elastic, atrophic, and gives an appearance of pseudo epicanthal fold in medial canthal area.[4] Other occasionally reported ocular manifestations of Ascher’s syndromes are the ectropion, and entropion which may lead to trichiasis and superficial corneal erosions.[4] In our case, few newer findings were observed; horizontal narrowing of the palpebral aperture, iris coloboma, incomplete pupillary frill, and partially persistent pupillary membrane which was attached to anterior lens capsule. In our case, horizontal palpebral fissure length and outer intercanthal distance were less than age‑ and sex‑matched Indian population standards. However, inner intercanthal distance and interpupillary distance were normal. [5] We assume this happened due to dehiscence of lateral canthal tendon from orbital tubercle secondary to recurrent attacks of blepharochalasis. In our case, elongation/dehiscence of lateral canthal tendon is well‑appreciated by rounding of lateral canthal angle, reduced distance from the angle of the lateral canthus to mid‑pupillary area, and pseudoappearance of the overaction of the lateral rectus. Vertical narrowing of palpebral apertures in Ascher’s syndrome may occur due to lid edema in active stage or weakness or dehiscence of aponeurosis of levator palpebrae superioris in long standing or inactive stage. Double upper lip is not a true duplication of lip rather it is an overgrowth of lip mucosa.[2] Nontoxic goiter was observed in only 10–50% cases.[2] In our case, no features of thyroid enlargement or dysfunction were observed. Differential diagnosis of Ascher’s syndrome includes hereditary angioedema, early dermatochalasis, acquired cutis laxa, inflammatory fibrous hyperplasia, and granulomatous cheilitis.[6] To the best of our knowledge, horizontal narrowing of palpebral aperture, decreased outer intercanthal distance, heterochromia iridum, iris coloboma, incomplete pupillary frill, partial persistent pupillary membrane were never reported in patient with Ascher’s syndrome. An ophthalmologist should consider it in the differential diagnosis of acquired blepharophimosis. These patients may be benefited with lateral canthoplasty.

References 1. Ascher KW. Blepharochalasis mit Struma und Doppellippe. Klin Monbl Augenheilkd 1920;65:86‑97. 2. Ali K. Ascher syndrome: A case report and review of the literature.

Brief Communications

March 2015

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e26‑8. 3. Ruiz‑Villaverde R, Anguita‑Carazo JL, Sánchez‑Cano D. Laffer‑Ascher’s syndrome mimicking hereditary angio‑edema. Int J Dermatol 2009;48:914‑5. 4. Mathew  MS, Srinivasan  R, Goyal  JL, Ratnakar  C, Garg  BR, Reddy BS. Ascher’s syndrome: An unusual case with entropion. Int J Dermatol 1992;31:710‑2. 5. Gupta  VP, Sodhi  PK, Pandey  RM. Normal values for inner intercanthal, interpupillary, and outer intercanthal distances in the Indian population. Int J Clin Pract 2003;57:25‑9.

Reliability of “Google” for obtaining medical information Mihir Kothari, Samita Moolani1 Internet is used by many patients to obtain relevant medical information. We assessed the impact of “Google” search on the knowledge of the parents whose ward suffered from squint. In 21 consecutive patients, the “Google” search improved the mean score of the correct answers from 47% to 62%. We found that “Google” search was useful and reliable source of information for the patients with regards to the disease etiopathogenesis and the problems caused by the disease. The internet‑based information, however, was incomplete and not reliable with regards to the disease treatment. Key words: Evaluation of Google, information on internet, medical information, patient counseling, patient information, web content

The World‑Wide‑Web or internet has become an important source of information including medical information globally. Many patients or their relatives, especially in an urban area have an easy access to the internet and routinely make use of it to obtain medical information. Various investigators have critically evaluated the websites and the patient‑oriented medical information on internet in the past and found Access this article online Quick Response Code:

Website: www.ijo.in DOI: 10.4103/0301-4738.156934 PMID: ***

Department of Ocular Motility, Jyotirmay Eye Clinic and Ocular Motility Laboratory, Thane, 1Department of Pediatric Ophthalmology and Adult Strabismus, Aditya Jyot Eye Hospital, Mumbai, Maharashtra, India Correspondence to: Dr. Mihir Kothari, Jyotirmay Eye Clinic for Children and Adult Squint, Ocular Motility Lab and Pediatric Low Vision Center, 205 Ganatra Estate, Khopat, Thane West, Thane ‑ 400 601, Maharashtra, India. E-mail: [email protected] Manuscript received: 28.07.14; Revision accepted: 13.03.15

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6. Dalmau  J, Puig  L, Roé E, Peramiquel  L, Pimentel  CL, Alomar A. Blepharochalasia and double lip: Diagnosis and treatment of Ascher’s syndrome. J Eur Acad Dermatol Venereol 2006;20:1390‑1.

Cite this article as: Chandravanshi SL, Mishra V. Ascher's syndrome: A rare case report. Indian J Ophthalmol 2015;63:264-7. Source of Support: Nil. Conflict of Interest: None declared.

them scientifically inaccurate, incomplete and biased.[1‑5] Nevertheless, patients as well as professionals around the world continue to rely on the internet for deriving important information regarding their health conditions and its management. Despite such a popular trend, there is no study that has evaluated the impact of the internet on the patient’s knowledge so far. In this study, we have found a few advantages and limitations of using internet for obtaining the medical information by the patient. The data presented in this study would would help the clinicians inform their patients on what to rely and how much to rely on the internet for their health needs.

Methods The study was performed between 31st March, 2012 and 30th  Jun, 2012. The parents of children with a squint and amblyopia, having an access to internet at home and/or office and who would access the internet on daily basis were given a questionnaire [Table 1]. Only those parents who had not visited an ophthalmologist prior to this visit and who had not done an internet search relevant to the study were included. The parents were first informed that the child had a significant strabismus and required further evaluation three days later. The child was prescribed atropine eye ointment for 3 days for cycloplegic refraction as was the routine protocol of the clinic. The parents were given a questionnaire and explained the purpose of this study. After an oral consent, the parents were recruited in the study. Completely filled questionnaire was returned on the follow‑up visit that was scheduled within a week. Each answer was scored (0 for no/wrong answer and +1 for the correct answer), and cumulative scores were analyzed. Paired t‑test was performed to compare the total score before and after the Google Search. P < 0.05 was considered as statistically significant. Sample size calculation For 80% power, 5% level of significance, 3.0 standard deviation and 20% effect size we needed n = (Z1−α/2 − Z1−β)2 Sd2/d2 that is, 18 patients.[6]

Results Twenty‑one consecutive parents were recruited in the study. About 48% were graduates and 52% were postgraduates. About 52% respondents were mothers, rest 48% were fathers. Mean total score before Google Search was 3.8 out of a maximum

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Ascher's syndrome: A rare case report.

An 18-year-old Indian girl with upper lip deformity presented with on and off painless swelling of her both upper eyelids for 3 years. Clinical evalua...
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