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Cerebrospinal Fluid in the Upper Eyelid: An “Abscess” of a Different Kind Distinguishing between a cerebrospinal fluid (CSF) collection of the upper eyelid and an abscess can be challenging, as the following case demonstrates. Each may be preceded by surgical intervention and both could present with pyrexia. Good clinical skills will assist in differentiation, but laboratory tests are required to provide the final diagnoses. Report of a Case | A 24-year-old man with a Glasgow Coma Scale score of 3 was admitted to an intensive care unit following a motor vehicle crash with right orbital fractures as seen on computed tomography. He was ventilated on admission and extubated on day 12, when he developed right proptosis and entropion. Although forced duction testing was not performed, he had no extraocular movements of his right eye as seen with the vestibulo-ocular reflex. No disc swelling was present. Magnetic resonance imaging was performed to exclude any soft-tissue or pathological intracranial lesions that Figure 1. Magnetic Resonance Image Demonstrating Fistula Extending Between Intracranial Space and Orbital Collection

could have been overlooked on initial computed tomography. A T2-weighted magnetic resonance image revealed a localized superior hyperintense extraconal collection reminiscent of CSF that depressed the globe. Figure 1 shows a possible fistula connecting the collection with the intracranial space. The junction between the optic nerve and globe did not appear tented; thus, it was assumed that the optic nerve was not stretched due to downward pressure from the collection. It was therefore decided not to drain the collection. Although his corneas were lubricated, the patient developed a right epithelial defect due to corneal exposure. Because the defect increased in size, a temporary lateral tarsorrhaphy was performed. On day 16, the patient developed pyrexia and swelling of the right upper eyelid, which was pulsatile and warm. With palpation, a thrill was felt but no bruit was audible. The differential diagnosis included abscess formation, hematoma, or a CSF cyst. No bruit was audible to confirm a carotid cavernous fistula. Guided by the neurosurgeons, 20 mL of clear fluid was aspirated from the point of maximal swelling in the upper eyelid (Figure 2). Twelve hours later, the swelling reappeared and another 20 mL of clear fluid was drained. The fluid tested positive for β-2 transferrin, confirming CSF. No growth was reported during culture and sensitivity. On day 17, the swelling of the upper eyelid subsided and no temperature spikes were noticed. The epithelial defect and entropion resolved and eye movements reverted to normal. Discussion | Two cases were found in the literature describing CSF in the upper eyelid following trauma.1,2 Our patient deFigure 2. Aspiration of Cerebrospinal Fluid From the Upper Eyelid

Right

Sagittal T2-weighted short tau inversion recovery magnetic resonance imaging shows a white collection of cerebrospinal fluid in the superior aspect of the right orbit as well as a suspected breach in the roof of the orbit and communication in the cerebrospinal fluid space by means of a fistula (arrowhead) between the intracranial space and the orbital collection.

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Twenty milliliters of clear cerebrospinal fluid was aspirated from the right upper eyelid at the area of maximal fluctuation with a 21-gauge needle and syringe. Twelve hours later, the swelling reappeared and another 20 mL of clear fluid was drained.

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Letters

veloped proptosis 12 days after trauma, with the accumulation of CSF in the upper eyelid thus being of delayed onset. This corresponds with cases reported by Rha et al3 and Sibony et al.4 No signs of increased intracranial pressure were documented by the neurosurgical team. The case reported by Sibony and colleagues had associated orbital roof fractures and developed temperature spikes and pulsatile proptosis without a bruit but with limited eye movements. Rha and colleagues stated that the most common cause of CSF leakage is a meningeal fistula, which is the postulated mechanism in our case. We decided to aspirate fluid in the upper eyelid primarily to exclude abscess formation and to perform incision and drainage if indicated. Because no more fluid collected after the second drainage procedure, no surgery was performed. Rha and colleagues postulated that the drainage of a CSF collection is sufficient to prevent further CSF leakage. Wu et al5 confirmed this, stating that small CSF leaks may often self-seal because of the tamponade effect of orbital fat. Although the patient was pyrexial, a pulsatile swelling and the absence of a bruit favored CSF instead of pus. Twaij et al6 stated that β-2 transferrin is specific for CSF. Aspiration of CSF and a conservative approach in our patient led to the spontaneous closure of his fistula. To our knowledge, this is the first case in the literature demonstrating a large volume of clear CSF being aspirated through the upper eyelid. Leonard Goussard Heydenrych, FCOphth (SA), FRCOphth Colleen Michelle Aldous, PhD Roy Giles, FCRad (SA) Grant Andre du Plessis, MMED Neurosurg (Stell) Burnet Meyer, MMED Ophth (Stell), FCS (SA) Author Affiliations: Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa (Heydenrych); Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa (Aldous); Panorama Mediclinic, Cape Town, South Africa (Giles, du Plessis); Cape Eye Hospital, Cape Town, South Africa (Meyer). Corresponding Author: Colleen Michelle Aldous, PhD, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Rd, Durban, South Africa ([email protected]). Published Online: August 21, 2014. doi:10.1001/jamaophthalmol.2014.2866. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Bagolini B. Leakage of spinal fluid into upper lid following trauma. AMA Arch Ophthalmol. 1957;57(3):454-456. 2. Ide T, Yano C. A case of spinal fluid accumulation under the right upper lid following a traffic accident [in Japanese]. Nihon Ganka Kiyo. 1967;18(2):180-182. 3. Rha EY, Kim JH, Byeon JH. Posttraumatic delayed cranio-orbital cerebrospinal fluid leakage: case report. J Plast Reconstr Aesthet Surg. 2013;66 (4):563-565. 4. Sibony PA, Anand AK, Keuskamp PA, Zippen AG. Posttraumatic cerebrospinal fluid cyst of the orbit: case report. J Neurosurg. 1985;62(6):922924. 5. Wu W, Cannon PS, Selva D, Tu Y, Wu Q. Endoscopic transorbital approach for repair of cerebrospinal fluid leakage following removal of an orbito-cranial foreign body. Clin Experiment Ophthalmol. 2011;39(4):375-377. 6. Twaij S, Viswanathan P, Page AB. Acute traumatic orbital cerebrospinal fluid cystocele mimicking orbital abscess. J AAPOS. 2009;13(5):491-493. 1486

Eye-Preserving Treatment for Invasive Conjunctival Melanoma Although orbital exenteration has been recommended for extensive malignant conjunctival neoplasms, including those invading the palpebral margin, fornices, or caruncle, it has not been demonstrated to improve survival of patients with melanomas greater than 2.0 mm thick.1 We describe a patient with extensive conjunctival melanoma (CM) managed by eyepreserving therapies. Report of a Case | A woman in her early 70s reported foreignbody sensation in the left eye for 6 months. Corrected visual acuity was 20/20 OD and 20/30 OS. Ophthalmic examination revealed a dark brown superonasal forniceal tumor measuring 5.5 × 5 × 3 mm in the left eye (Figure 1A). Superior fornix fullness precluded eversion of the eyelid. Our diagnosis was nodular CM. Surgical excision was advised. Intraoperative eversion of the left upper eyelid revealed a ridge-like superonasal forniceal mass extending to the superotemporal palpebral and bulbar conjunctiva (Figure 1B). Subtotal incisional biopsy yielded a specimen measuring 27 × 11 × 5 mm. Histopathological analysis confirmed invasive CM without primary acquired melanosis. Tumor cells extended to the epithelial but not deep margins (Figure 1C and D). The patient refused exenteration after acknowledging her diagnosis, prognosis for tumor control, survival, and potential benefits and risks of wider tumor excision vs exenteration. One week later, wider excision 4 mm around the clinical margins but sparing the eyelid margin and tarsal plate was performed. Double freeze-thaw cryotherapy was applied over the resected area and margins. A 30 × 25-mm amniotic membrane graft sutured with running 7-0 Vicryl covered the conjunctival defect. Three full-thickness sutures were passed through the eyelid to reconstruct the fornix. Simultaneous lymph node biopsy was performed.2 Map biopsy was deferred because the tumor was confluent without primary acquired melanosis. Specimen margins and lymph nodes were tumor free. A symblepharon ring was fitted postoperatively (Figure 2A). Subsequently, an amelanotic forniceal nodule inferotemporally in the left eye was excised and found to be CM (Figure 2B). Such occurrence was attributed to surgical tumor seeding or multifocal melanoma. The patient was given two 14-day cycles of topical mitomycin C, 0.02%, 4 times daily with a 2-week pause between the cycles. Ten days into the second cycle, the patient experienced severe dermatitis (Figure 2C) and treatment was interrupted. Treatment shifted to topical interferon alfa-2b (1 000 000 IU/mL) 4 times daily continuous for 4 months. Fifteen months after wide excision, visual acuity remains 20/30 OS. The patient has full ocular motility with minimal fornix and conjunctival scarring (Figure 2D). She is being monitored periodically. Discussion | Because patients with extensive invasive CM managed by exenteration have shown no survival benefit, we agreed to preserve our patient’s eye.1,3 Current standard for CM includes “no-touch” wide excision followed by cryotherapy of exposed edges and primary surface repair. However, the size of

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Cerebrospinal fluid in the upper eyelid: an "abscess" of a different kind.

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