Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
delving deeper into her emotional state. Recommending psychiatric evaluation to a patient is a very sensitive subject that must be approached carefully and tactfully. Goin and Goin12 propose taking a nonthreatening approach by saying something along the lines of: “Operations that change the shape of the body may have all sorts of psychological effects—many that are beneficial but some that can be quite disturbing. You and I need some help in figuring out how this operation is going to affect you. Making up your mind to have an elective surgical operation is a major decision, one we shouldn’t make lightly. I would like to refer you to a psychiatrist who is an expert in helping people understand their feelings about their bodies and how they may react to operations that change the body.” A patient’s refusal to accept referral to a psychiatrist for evaluation could be considered a contraindication for surgery, as it demonstrates a lack of insight on the part of the patient.10 The patients in Cases 2 and 3 were lost to follow up, and in retrospect, they should have been offered a psychiatric consultation. There are different opinions on the role of surgery in treating BDD patients with actual anatomical defects. Some believe that the diagnosis of BDD is an absolute contraindication to surgery, while others believe that the patients with BDD and anatomic or perceived defects may benefit from surgery.9,13 The authors’ experience with the patient in Case 2 lead them to agree with Jakubietz et al.9 and favor BDD as a contraindication to surgical intervention. Preoperatively, the possibility that the patient in Case 2 may remain unemployed despite undergoing surgery was discussed, and she seemed to understand this; however, postoperatively, she clearly was not able to think rationally. Other well-respected authors believe that there should be a graded response depending on the type and severity of the deformity. In Morselli and Boriani’s recent letter to the editor in Plastic and Reconstructive Surgery,13 they delineate classification of the disorder based on the severity of the deformity and whether the deformity is objective (unanimously agreed on by all observers) or subjective (not agreed on by all observers). Graded treatment options range from surgery and psychological support by the surgeon to psychotherapy.13 It is important for surgeons to keep in mind the prevalence of BDD in their patient population, considering the elevated rates of dissatisfaction and escalation, in addition to the mental health comorbidities present in these patients. The first step in helping patients with BDD is to spread awareness of the disorder and the possibility for tragic outcomes. Surgeons main method for aiding patients is surgery, and for this reason, it is difficult for them not to offer “help” doing what they do best.13 Surgeons tend to rely on surgeries for problem solving and in turn neglect to ask the question of “Why?” In his book How Doctors Think, Groopman states that “finding something may be satisfactory, but not finding everything is suboptimal.”14 By including BDD in this thought process when interacting with patients who seek aesthetic surgery, physicians are less likely to hastily schedule a patient for surgery. In the future, a better understanding of the criteria for diagnosis of BDD, the etiology, and the spectrum of successful treatments will allow for a holistic approach to care for patients such as the 3 presented in this case series. Physicians must overcome the “tendency toward action rather than inaction,” which may be sparked by patient pressure, and stop to consider the patient’s best interest.14 The decision of whether to operate is ultimately the surgeon’s responsibility.13 One must remember one of the principle precepts of medical ethics: “first, do no harm.”
ACKNOWLEDGMENT The authors would like to acknowledge the contributions of Ms. Patricia Duffel and Dr. David T. Tse.
e6
REFERENCES 1. Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283–7. 2. Massry GG. Aesthetic abstracts and citations. Ophthal Plast Reconstr Surg 2013;29:234–5. 3. Castle DJ, Rossell S, Kyrios M. Body dysmorphic disorder. Psychiatr Clin North Am 2006;29:521–38. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association, 2013. 5. Altamura C, Paluello MM, Mundo E, et al. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci 2001;251:105–8. 6. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996;169:196–201. 7. Mackley CL. Body dysmorphic disorder. Dermatol Surg 2005;31:553–8. 8. Phillips KA, Rogers J. Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions. Child Adolesc Psychiatr Clin N Am 2011;20:287–304. 9. Jakubietz M, Jakubietz RJ, Kloss DF, et al. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007;119:1924–30. 10. Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J 2012;32:999–1009. 11. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members. Aesthet Surg J 2002;22:531–5. 12. Goin JM, Goin MK. Changing the Body: Psychological Effects of Plastic Surgery. Baltimore, MD: Williams & Wilkins; 1981. 13. Morselli PG, Boriani F. Should plastic surgeons operate on patients diagnosed with body dysmorphic disorders? Plast Reconstr Surg 2012;130:620e–622e. 14. Groopman J. How Doctors Think. New York, NY: Houghton Mifflin Company, 2007.
Granular Cell Tumor Masquerading as a Chalazion: A Case Report Ryan T. Scruggs, M.D.*†, and Evan H. Black, M.D., F.A.C.S.*† Abstract: Granular cell tumors were first described in the 1920s and since then have been commonly found throughout the body. They are rarely found in periorbital, orbital, and ocular structures. The authors present a patient with a 2-year history of a lesion that had been previously excised as a presumed chalazion without pathologic analysis. The lesion recurred, and histopathological analysis following complete resection revealed a granular cell tumor. This case is an example of a rare periocular tumor. Although only an isolated case, it provides support for the recommendation that excised lesions be sent to pathologic study, particularly those with an atypical clinical course.
G
ranular cell tumors are a relatively common lesion throughout the body; however, they are rarely found in the globe and periorbital tissues. Granular cell tumors of the orbit are also
Accepted for publication August 21, 2013. *Department of Ophthalmology, Ophthalmic Plastic, Orbital and Reconstructive Surgery, Kresge Eye Institute, Wayne State University School of Medicine, Detroit; and †Department of Ophthalmology, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Ryan T. Scruggs, M.D., Department of Ophthalmology, Kresge Eye Institute, Detroit, MI 48201. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
FIG. 1. Recurrent elevated lesion of the right upper eyelid following previous excision. Anterior location with no apparent tarsal involvement.
FIG. 2. A, B, Nodular proliferation of cells with moderate-to-abundant granular eosinophilic cytoplasm and small round nuclei (hematoxylin-eosin). C, Positive vimentin staining. D, Positive S100 staining.
considered rare, and there are 21 case reports of orbital granular cell tumors available in the literature.1–21 Reports of granular cell tumors of the eyelid are rarer, consisting of a few case reports and a small case series. None have been reported for the past 16 years.11,22 A case of a granular cell tumor of the upper eyelid was reported following misdiagnosis as a chalazion. The data and photos herein were collected and presented in a manner compliant with Health Insurance Portability and Accountability Act.
CASE REPORT A 43-year-old African-American human presents with a 1-year history of a recurrent left upper eyelid lesion (Fig. 1). Two years prior, the patient had a similar appearing lesion in the same location. As per the patient, it was diagnosed as a chalazion and treated surgically with incision and drainage without histopathologic analysis. He reported the lesion had recurred and had been increasing in size over the past year. On presentation, the lesion was 9 × 6 mm, elevated, extending to the lash line with minimal
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e7
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
madarosis. The lesion appeared cystic with yellowish content. There was no evidence of tarsal or conjunctival involvement. The lesion was completely excised, and the defect was repaired with an anterior lamellar pedicle flap. His postoperative course was uncomplicated, and he had no recurrence at his 1-month follow-up appointment. Histopathology showed a nodular proliferation of cells with moderate-to-abundant granular eosinophilic cytoplasm and small round nuclei (Fig. 2). There was positive staining for S100 and vimentin but negative smooth muscle actin immunostain. There was no evidence of malignancy, and the margins were clear.
DISCUSSION Although granular cell tumors were first described in 1926, there has been debate on the cellular origin. Recently, it is thought that they most likely originate from Schwann cells.11,22 The theory of Schwann cell origin is supported by the presence of S100 protein, intracytoplastmic myelin, and basement membrane. Previous reviews have shown that they can occur in the lacrimal sac, conjunctiva, uvea, eyelids, and orbits11; however, they are still more common in other areas throughout the body. Many lesions classically masquerade as chalazion; however, physicians often do not routinely biopsy these lesions. Though this tumor was benign, granular cell tumors can rarely be malignant. Muqit et al.23 recently showed that chalazion was the most common cause of misdiagnosis and delay in diagnosis of eyelid sebaceous cell carcinoma. Lesions that were diagnosed within 6 months had a 14% 5-year mortality, whereas those that were >6 months had a 38% 5-year mortality. Ozdal et al.24 compared clinical and histological diagnosis and reported that 6.4% of lesions diagnosed as chalazion are misdiagnosed lesions. Most of these lesions are benign; however, 0.2% were found to be malignant. This patient had a 2-year delay in diagnosis and treatment. One could argue that given the relative rarity of malignant lesions misdiagnosed as chalazion at the time of excision in the Ozdal et al.24 study, routine biopsy is not warranted. However, the Muqit et al.23 study did show that 43% of sebaceous cell carcinomas were diagnosed as chalazion, and chalazion was the most common cause of delay in diagnosis. Although this patient was not found to have a malignant disease, if the lesion had previously been completely excised and evaluated by pathologic study, the patient could have avoided an additional operation and the potential for further morbidity.
REFERENCES 1. González-Almaraz G, de Buen S, Tsutsumi V. Granular cell tumor (myoblastoma) of the orbit. Am J Ophthalmol 1975;79:606–12. 2. Müller W, Dahmen HG. Granular cell tumor of the optic nerve. Albrecht Von Graefes Arch Klin Exp Ophthalmol 1978;207:181–8. 3. Drummond JW, Hall DL, Steen WH Jr, et al. Granular cell tumor (myoblastoma) of the orbit. Arch Ophthalmol 1979;97:1492–4. 4. Karcioglu ZA, Hemphill GL, Wool BM. Granular cell tumor of the orbit: case report and review of the literature. Ophthalmic Surg 1983;14:125–9. 5. Singleton EM, Nettleship MB. Granular cell tumor of the orbit: a case report. Ann Ophthalmol 1983;15:881–3. 6. Ueda N, Yoshida A, Yokota T, et al. Granular cell tumor of the orbit. Appl Pathol 1986;4:179–85. 7. Morgenstern C, Lipman H, Grüntzig J. [Granular cell tumor of the orbits. Diagnosis and therapy]. Laryngol Rhinol Otol (Stuttg) 1986;65:691–2. 8. Dolman PJ, Rootman J, Dolman CL. Infiltrating orbital granular cell tumour: a case report and literature review. Br J Ophthalmol 1987;71:47–53. 9. Jaeger MJ, Green WR, Miller NR, et al. Granular cell tumor of the orbit and ocular adnexae. Surv Ophthalmol 1987;31:417–23. 10. Kocks W, Mohr C, Richter HJ, et al. [Granular cell tumor of the orbit]. Neurochirurgia (Stuttg) 1988;31:213–5.
e8
11. Moseley I. Granular cell tumour of the orbit: radiological findings. Neuroradiology 1991;33:399–402. 12. McNab AA, Daniel SE. Granular cell tumours of the orbit. Aust N Z J Ophthalmol 1991;19:21–7. 13. Rodríguez-Ares T, Varela-Durán J, Sánchez-Salorio M, et al. Granular cell tumor of the eye (myoblastoma): ultrastructural and immunohistochemical studies. Eur J Ophthalmol 1993;3:47–52. 14. Allaire GS, Laflamme P, Bourgouin P. Granular cell tumour of the orbit. Can J Ophthalmol 1995;30:151–3. 15. Ahdoot M, Rodgers IR. Granular cell tumor of the orbit: magnetic resonance imaging characteristics. Ophthal Plast Reconstr Surg 2005;21:395–7. 16. Golio DI, Prabhu S, Hauck EF, et al. Surgical resection of locally advanced granular cell tumor of the orbit. J Craniofac Surg 2006;17:594–8. 17. Sterker I, Hagert-Winkler A, Gradistanac T, et al. [Granular cell tumor of the orbit]. Ophthalmologe 2007;104:803–5. 18. Poyraz CE, Kiratli H, Söylemezoğlu F. Granular cell tumor of the inferior rectus muscle. Korean J Ophthalmol 2009;23:43–5. 19. Guerriero S, Giancipoli G, Sborgia A, et al. Orbital granular cell tumor in a patient with Churg Strauss syndrome: the importance of biopsy. Orbit 2011;30:30–3. 20. Ribeiro SF, Chahud F, Cruz AA. Oculomotor disturbances due to granular cell tumor. Ophthal Plast Reconstr Surg 2012;28: e23–7. 21. Fernandes BF, Belfort Neto R, Odashiro AN, et al. Clinical and histopathological features of orbital granular cell tumor: case report. Arq Bras Oftalmol 2012;75:137–9. 22. Bregman DK, Hodges T, La Piana FG. Granular cell tumor of the eyelid. Ann Ophthalmol 1991;23:106–7. 23. Muqit MM, Foot B, Walters SJ, et al. Observational prospective cohort study of patients with newly-diagnosed ocular sebaceous carcinoma. Br J Ophthalmol 2013;97:47–51. 24. Ozdal PC, Codère F, Callejo S, et al. Accuracy of the clinical diagnosis of chalazion. Eye (Lond) 2004;18:135–8.
Epiblepharon-Induced Head Tilt Masquerading as Torticollis Benjamin P. Erickson, M.D., and Wendy W. Lee, M.D. Abstract: A 10-month-old girl presented for ocular evaluation carrying a provisional diagnosis of torticollis. Her family reported that for the past 5 months, she consistently tilted her head to the left while twisting her chin toward the right shoulder. Her adnexal examination was notable for epiblepharon, with greater ciliary-corneal contact in the OS. It was therefore hypothesized that this posture was adopted to minimize ocular irritation. Her symptoms resolved immediately following a Hotz-Celsus procedure. To the best of the authors’ knowledge, this is the first report of asymmetric ciliary-corneal contact from epiblepharon, resulting in preference for a head position mimicking a musculoskeletal abnormality such as torticollis.
CASE REPORT The mother of a 10-month-old girl presented to our institution, seeking a second opinion. The girl had no other ocular history but had been diagnosed with torticollis at 5 months of age due to a strong preference for tilting her head to the left while twisting her chin toward the right shoulder. She was born fullterm via spontaneous vaginal delivery and had consistently met all developmental milestones. She had been otherwise healthy Accepted for publication August 21, 2013. Bascom Palmer Eye Institute, Miami, Florida, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Benjamin P. Erickson, M.D., Bascom Palmer Eye Institute, Miami, Florida 900 NW 17th St., Miami, FL. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Case Reports
delving deeper into her emotional state. Recommending psychiatric evaluation to a patient is a very sensitive subject that must be approached carefully and tactfully. Goin and Goin12 propose taking a nonthreatening approach by saying something along the lines of: “Operations that change the shape of the body may have all sorts of psychological effects—many that are beneficial but some that can be quite disturbing. You and I need some help in figuring out how this operation is going to affect you. Making up your mind to have an elective surgical operation is a major decision, one we shouldn’t make lightly. I would like to refer you to a psychiatrist who is an expert in helping people understand their feelings about their bodies and how they may react to operations that change the body.” A patient’s refusal to accept referral to a psychiatrist for evaluation could be considered a contraindication for surgery, as it demonstrates a lack of insight on the part of the patient.10 The patients in Cases 2 and 3 were lost to follow up, and in retrospect, they should have been offered a psychiatric consultation. There are different opinions on the role of surgery in treating BDD patients with actual anatomical defects. Some believe that the diagnosis of BDD is an absolute contraindication to surgery, while others believe that the patients with BDD and anatomic or perceived defects may benefit from surgery.9,13 The authors’ experience with the patient in Case 2 lead them to agree with Jakubietz et al.9 and favor BDD as a contraindication to surgical intervention. Preoperatively, the possibility that the patient in Case 2 may remain unemployed despite undergoing surgery was discussed, and she seemed to understand this; however, postoperatively, she clearly was not able to think rationally. Other well-respected authors believe that there should be a graded response depending on the type and severity of the deformity. In Morselli and Boriani’s recent letter to the editor in Plastic and Reconstructive Surgery,13 they delineate classification of the disorder based on the severity of the deformity and whether the deformity is objective (unanimously agreed on by all observers) or subjective (not agreed on by all observers). Graded treatment options range from surgery and psychological support by the surgeon to psychotherapy.13 It is important for surgeons to keep in mind the prevalence of BDD in their patient population, considering the elevated rates of dissatisfaction and escalation, in addition to the mental health comorbidities present in these patients. The first step in helping patients with BDD is to spread awareness of the disorder and the possibility for tragic outcomes. Surgeons main method for aiding patients is surgery, and for this reason, it is difficult for them not to offer “help” doing what they do best.13 Surgeons tend to rely on surgeries for problem solving and in turn neglect to ask the question of “Why?” In his book How Doctors Think, Groopman states that “finding something may be satisfactory, but not finding everything is suboptimal.”14 By including BDD in this thought process when interacting with patients who seek aesthetic surgery, physicians are less likely to hastily schedule a patient for surgery. In the future, a better understanding of the criteria for diagnosis of BDD, the etiology, and the spectrum of successful treatments will allow for a holistic approach to care for patients such as the 3 presented in this case series. Physicians must overcome the “tendency toward action rather than inaction,” which may be sparked by patient pressure, and stop to consider the patient’s best interest.14 The decision of whether to operate is ultimately the surgeon’s responsibility.13 One must remember one of the principle precepts of medical ethics: “first, do no harm.”
ACKNOWLEDGMENT The authors would like to acknowledge the contributions of Ms. Patricia Duffel and Dr. David T. Tse.
e6
REFERENCES 1. Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283–7. 2. Massry GG. Aesthetic abstracts and citations. Ophthal Plast Reconstr Surg 2013;29:234–5. 3. Castle DJ, Rossell S, Kyrios M. Body dysmorphic disorder. Psychiatr Clin North Am 2006;29:521–38. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association, 2013. 5. Altamura C, Paluello MM, Mundo E, et al. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci 2001;251:105–8. 6. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996;169:196–201. 7. Mackley CL. Body dysmorphic disorder. Dermatol Surg 2005;31:553–8. 8. Phillips KA, Rogers J. Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions. Child Adolesc Psychiatr Clin N Am 2011;20:287–304. 9. Jakubietz M, Jakubietz RJ, Kloss DF, et al. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007;119:1924–30. 10. Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J 2012;32:999–1009. 11. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members. Aesthet Surg J 2002;22:531–5. 12. Goin JM, Goin MK. Changing the Body: Psychological Effects of Plastic Surgery. Baltimore, MD: Williams & Wilkins; 1981. 13. Morselli PG, Boriani F. Should plastic surgeons operate on patients diagnosed with body dysmorphic disorders? Plast Reconstr Surg 2012;130:620e–622e. 14. Groopman J. How Doctors Think. New York, NY: Houghton Mifflin Company, 2007.
Granular Cell Tumor Masquerading as a Chalazion: A Case Report Ryan T. Scruggs, M.D.*†, and Evan H. Black, M.D., F.A.C.S.*† Abstract: Granular cell tumors were first described in the 1920s and since then have been commonly found throughout the body. They are rarely found in periorbital, orbital, and ocular structures. The authors present a patient with a 2-year history of a lesion that had been previously excised as a presumed chalazion without pathologic analysis. The lesion recurred, and histopathological analysis following complete resection revealed a granular cell tumor. This case is an example of a rare periocular tumor. Although only an isolated case, it provides support for the recommendation that excised lesions be sent to pathologic study, particularly those with an atypical clinical course.
G
ranular cell tumors are a relatively common lesion throughout the body; however, they are rarely found in the globe and periorbital tissues. Granular cell tumors of the orbit are also
Accepted for publication August 21, 2013. *Department of Ophthalmology, Ophthalmic Plastic, Orbital and Reconstructive Surgery, Kresge Eye Institute, Wayne State University School of Medicine, Detroit; and †Department of Ophthalmology, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Ryan T. Scruggs, M.D., Department of Ophthalmology, Kresge Eye Institute, Detroit, MI 48201. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
FIG. 1. Recurrent elevated lesion of the right upper eyelid following previous excision. Anterior location with no apparent tarsal involvement.
FIG. 2. A, B, Nodular proliferation of cells with moderate-to-abundant granular eosinophilic cytoplasm and small round nuclei (hematoxylin-eosin). C, Positive vimentin staining. D, Positive S100 staining.
considered rare, and there are 21 case reports of orbital granular cell tumors available in the literature.1–21 Reports of granular cell tumors of the eyelid are rarer, consisting of a few case reports and a small case series. None have been reported for the past 16 years.11,22 A case of a granular cell tumor of the upper eyelid was reported following misdiagnosis as a chalazion. The data and photos herein were collected and presented in a manner compliant with Health Insurance Portability and Accountability Act.
CASE REPORT A 43-year-old African-American human presents with a 1-year history of a recurrent left upper eyelid lesion (Fig. 1). Two years prior, the patient had a similar appearing lesion in the same location. As per the patient, it was diagnosed as a chalazion and treated surgically with incision and drainage without histopathologic analysis. He reported the lesion had recurred and had been increasing in size over the past year. On presentation, the lesion was 9 × 6 mm, elevated, extending to the lash line with minimal
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e7
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
madarosis. The lesion appeared cystic with yellowish content. There was no evidence of tarsal or conjunctival involvement. The lesion was completely excised, and the defect was repaired with an anterior lamellar pedicle flap. His postoperative course was uncomplicated, and he had no recurrence at his 1-month follow-up appointment. Histopathology showed a nodular proliferation of cells with moderate-to-abundant granular eosinophilic cytoplasm and small round nuclei (Fig. 2). There was positive staining for S100 and vimentin but negative smooth muscle actin immunostain. There was no evidence of malignancy, and the margins were clear.
DISCUSSION Although granular cell tumors were first described in 1926, there has been debate on the cellular origin. Recently, it is thought that they most likely originate from Schwann cells.11,22 The theory of Schwann cell origin is supported by the presence of S100 protein, intracytoplastmic myelin, and basement membrane. Previous reviews have shown that they can occur in the lacrimal sac, conjunctiva, uvea, eyelids, and orbits11; however, they are still more common in other areas throughout the body. Many lesions classically masquerade as chalazion; however, physicians often do not routinely biopsy these lesions. Though this tumor was benign, granular cell tumors can rarely be malignant. Muqit et al.23 recently showed that chalazion was the most common cause of misdiagnosis and delay in diagnosis of eyelid sebaceous cell carcinoma. Lesions that were diagnosed within 6 months had a 14% 5-year mortality, whereas those that were >6 months had a 38% 5-year mortality. Ozdal et al.24 compared clinical and histological diagnosis and reported that 6.4% of lesions diagnosed as chalazion are misdiagnosed lesions. Most of these lesions are benign; however, 0.2% were found to be malignant. This patient had a 2-year delay in diagnosis and treatment. One could argue that given the relative rarity of malignant lesions misdiagnosed as chalazion at the time of excision in the Ozdal et al.24 study, routine biopsy is not warranted. However, the Muqit et al.23 study did show that 43% of sebaceous cell carcinomas were diagnosed as chalazion, and chalazion was the most common cause of delay in diagnosis. Although this patient was not found to have a malignant disease, if the lesion had previously been completely excised and evaluated by pathologic study, the patient could have avoided an additional operation and the potential for further morbidity.
REFERENCES 1. González-Almaraz G, de Buen S, Tsutsumi V. Granular cell tumor (myoblastoma) of the orbit. Am J Ophthalmol 1975;79:606–12. 2. Müller W, Dahmen HG. Granular cell tumor of the optic nerve. Albrecht Von Graefes Arch Klin Exp Ophthalmol 1978;207:181–8. 3. Drummond JW, Hall DL, Steen WH Jr, et al. Granular cell tumor (myoblastoma) of the orbit. Arch Ophthalmol 1979;97:1492–4. 4. Karcioglu ZA, Hemphill GL, Wool BM. Granular cell tumor of the orbit: case report and review of the literature. Ophthalmic Surg 1983;14:125–9. 5. Singleton EM, Nettleship MB. Granular cell tumor of the orbit: a case report. Ann Ophthalmol 1983;15:881–3. 6. Ueda N, Yoshida A, Yokota T, et al. Granular cell tumor of the orbit. Appl Pathol 1986;4:179–85. 7. Morgenstern C, Lipman H, Grüntzig J. [Granular cell tumor of the orbits. Diagnosis and therapy]. Laryngol Rhinol Otol (Stuttg) 1986;65:691–2. 8. Dolman PJ, Rootman J, Dolman CL. Infiltrating orbital granular cell tumour: a case report and literature review. Br J Ophthalmol 1987;71:47–53. 9. Jaeger MJ, Green WR, Miller NR, et al. Granular cell tumor of the orbit and ocular adnexae. Surv Ophthalmol 1987;31:417–23. 10. Kocks W, Mohr C, Richter HJ, et al. [Granular cell tumor of the orbit]. Neurochirurgia (Stuttg) 1988;31:213–5.
e8
11. Moseley I. Granular cell tumour of the orbit: radiological findings. Neuroradiology 1991;33:399–402. 12. McNab AA, Daniel SE. Granular cell tumours of the orbit. Aust N Z J Ophthalmol 1991;19:21–7. 13. Rodríguez-Ares T, Varela-Durán J, Sánchez-Salorio M, et al. Granular cell tumor of the eye (myoblastoma): ultrastructural and immunohistochemical studies. Eur J Ophthalmol 1993;3:47–52. 14. Allaire GS, Laflamme P, Bourgouin P. Granular cell tumour of the orbit. Can J Ophthalmol 1995;30:151–3. 15. Ahdoot M, Rodgers IR. Granular cell tumor of the orbit: magnetic resonance imaging characteristics. Ophthal Plast Reconstr Surg 2005;21:395–7. 16. Golio DI, Prabhu S, Hauck EF, et al. Surgical resection of locally advanced granular cell tumor of the orbit. J Craniofac Surg 2006;17:594–8. 17. Sterker I, Hagert-Winkler A, Gradistanac T, et al. [Granular cell tumor of the orbit]. Ophthalmologe 2007;104:803–5. 18. Poyraz CE, Kiratli H, Söylemezoğlu F. Granular cell tumor of the inferior rectus muscle. Korean J Ophthalmol 2009;23:43–5. 19. Guerriero S, Giancipoli G, Sborgia A, et al. Orbital granular cell tumor in a patient with Churg Strauss syndrome: the importance of biopsy. Orbit 2011;30:30–3. 20. Ribeiro SF, Chahud F, Cruz AA. Oculomotor disturbances due to granular cell tumor. Ophthal Plast Reconstr Surg 2012;28: e23–7. 21. Fernandes BF, Belfort Neto R, Odashiro AN, et al. Clinical and histopathological features of orbital granular cell tumor: case report. Arq Bras Oftalmol 2012;75:137–9. 22. Bregman DK, Hodges T, La Piana FG. Granular cell tumor of the eyelid. Ann Ophthalmol 1991;23:106–7. 23. Muqit MM, Foot B, Walters SJ, et al. Observational prospective cohort study of patients with newly-diagnosed ocular sebaceous carcinoma. Br J Ophthalmol 2013;97:47–51. 24. Ozdal PC, Codère F, Callejo S, et al. Accuracy of the clinical diagnosis of chalazion. Eye (Lond) 2004;18:135–8.
Epiblepharon-Induced Head Tilt Masquerading as Torticollis Benjamin P. Erickson, M.D., and Wendy W. Lee, M.D. Abstract: A 10-month-old girl presented for ocular evaluation carrying a provisional diagnosis of torticollis. Her family reported that for the past 5 months, she consistently tilted her head to the left while twisting her chin toward the right shoulder. Her adnexal examination was notable for epiblepharon, with greater ciliary-corneal contact in the OS. It was therefore hypothesized that this posture was adopted to minimize ocular irritation. Her symptoms resolved immediately following a Hotz-Celsus procedure. To the best of the authors’ knowledge, this is the first report of asymmetric ciliary-corneal contact from epiblepharon, resulting in preference for a head position mimicking a musculoskeletal abnormality such as torticollis.
CASE REPORT The mother of a 10-month-old girl presented to our institution, seeking a second opinion. The girl had no other ocular history but had been diagnosed with torticollis at 5 months of age due to a strong preference for tilting her head to the left while twisting her chin toward the right shoulder. She was born fullterm via spontaneous vaginal delivery and had consistently met all developmental milestones. She had been otherwise healthy Accepted for publication August 21, 2013. Bascom Palmer Eye Institute, Miami, Florida, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Benjamin P. Erickson, M.D., Bascom Palmer Eye Institute, Miami, Florida 900 NW 17th St., Miami, FL. E-mail: [email protected]
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