Correspondence Table 1—Immunohistochemical profile of (cytokeratin-negative and vimentin-positive) spindle cell neoplasm of the orbit Spindle cell tumour

CD34

S100

SMA

Melan A

Solitary fibrous tumour Fibrous histiocytoma Fibroma Leiomyoma Spindle cell lipoma Melanoma Neurofibroma Schwannoma Angiosarcoma

þþþ – þ/– – þ – þ þ þþ

– – – – – þ þ þ –

þ/– þ/– – þ – – – – –

– – – – – þ – – –

the skull. Lymphatic invasion and distant metastases have also been reported.6 Our case presented no clinical, radiologic, or histologic evidence of aggressiveness. Most authors recommend complete removal of the lacrimal sac tumour.13 Some malignant tumours require postoperative radiation or chemotherapy.14 However, several such tumours (e.g., adenocarcinomas) are chemoresistant.6 Because solitary fibrous tumours are chemoresistant, total excision is the preferred treatment. In cases of partial resection, local recurrence or malignant transformation may occur.1 Although in the case of benign lacrimal sac tumours, complete surgical excision leads to a cure, the outcome of malignant tumours depends on the tumour stage, appropriateness of treatment, and the pathologic characterization of the tumour.6 Although early-stage tumours confined to the lacrimal sac have good prognoses, in advanced cases with tumours extending beyond the lacrimal sac, the prognoses are less favourable. The prognosis of solitary fibrous tumour is difficult to predict. The tumour may recur locally after incomplete excision.1 Malignant transformation and a large size are also associated with poor prognosis.14 Hence longterm follow-up in all cases is advisable.

Traumatic complete evulsion of the globe and optic nerve Evulsion means “extraction by force.” It is derived from the Latin verb vellere, meaning “to pull or pluck,” along with the prefix e, meaning “out.” Numerous cases of auto-enucleation have been previously reported in the psychiatric literature. However, evulsion of the globe as a result of trauma rarely has been described in the literature. We found only 14 previously documented patients in the English literature with evulsion of the eye as a result of injuries that were not selfinflicted. The documented mechanisms for evulsion include motor vehicle crash, eye pulled out by assailant, martial arts blow, train crash, falling onto corner of entertainment unit,

Presented as poster at the Canadian Ophthalmology Society Annual Meeting in Montreal, Que., June 14–17, 2013.

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Maher Kurdi, Larry Allen, Bret Wehrli, Subrata Chakrabarti Western University, London, Ont Correspondence to: Subrata Chakrabarti, MBBS: [email protected]

REFERENCES 1. Woo KL, Suh YL, Kim YD. Solitary fibrous tumor of the lacrimal sac. Ophthal Plast Reconstr Surg. 1999;15:450-3. 2. Flanagan JC, Stokes DB. Lacrimal sac tumours. Ophthalmology. 1978;85:1282-7. 3. Pe’er JJ, Stephanyszyn MA, Hidayat AA. Nonepithelial tumors of the lacrimal sac. Am J Ophthalmol. 1994;118:650-8. 4. Stephanyszyn MA, Hidayat AA, Pe’er JJ, Flanagan JC. Lacrimal sac tumors. Ophthalmic Plast Reconstr Surg. 1994;10:169-84. 5. Cole SH, Ferry AP. Fibrous histiocytoma (fibrous xanthoma) of the lacrimal sac. Arch Ophthalmol. 1978;96:1647-9. 6. Ni C, D’Amico DJ, Chi QF, Kuo PK. Tumors of the lacrimal sac: a clinicopathological analysis of 82 cases. Int Ophthalmol Clin. 1982;22:121-40. 7. Harry J, Ashton N. The pathology of tumors of the lacrimal sac. Trans Ophthalmol Soc UK. 1969;88:19-35. 8. Sen DK, Mohan H, Chatterjee PK. Neurilemmoma of the lacrimal sac. Eye Ear Nose Throat. 1971;50:56-7. 9. Filipowicz-Banachowa A, Sidorowicz E. Neurofibroma of the lacrimal sac. Klin Oczna. 1991;93:271-2. 10. Westra WH, Gerald WL, Rosai J. Solitary fibrous tumour. Am J Surg Pathol. 1994;18:281-7. 11. DeBacker CM, Bodker F, Putterman AM, Beckmann E. Solitary fibrous tumour of the orbit. Am J Opthalmol. 1996;121:447-9. 12. Lucas DR, Campbell RG, Fletcher CDM, et al. Solitary fibrous tumour of the orbit. Int J Surg Pathol. 1995;2:193-8. 13. Milder B. Neurofibroma of the lacrimal sac. Am J Ophthalmol. 1962;53:1016-8. 14. Hornblass A, Gabry JB. Diagnosis and treatment of lacrimal sac cysts. Ophthalmology. 1979;86:1655-61. Can J Ophthalmol 2014;49:e108–e110 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.05.011

and getting hit by a cow horn.1–10 This report details an additional case of traumatic evulsion of the globe. A 68-year-old male was referred from the emergency department to the on-call ophthalmology service. The patient reported falling out of bed and hitting his right orbit on the blunt stand of a floor lamp. He described no broken glass or damage to the lamp. On examination, right complete evulsion of the globe and optic nerve with sheath was noted. There was presence of a large orbital hematoma but no active bleeding (Fig. 1). We were unable to differentiate tissue or muscle clinically. His medical history included hypertension, pacemaker installation, and anticoagulant use. There was no history of psychiatric illness, psychiatric consultation, or medication use. Radiologic imaging showed no presence of an intraorbital foreign body (Figs. 2 and 3). The patient brought in a “clean” globe and nerve in a plastic freezer bag on ice (Fig. 4). The globe was then sent to pathology for a report. Pathologic record showed an

CAN J OPHTHALMOL — VOL. 49, NO. 5, OCTOBER 2014

Correspondence

Fig. 3 — Radiologic imaging of orbit.

Fig. 1 — Orbital hematoma.

optic nerve measuring 32 mm with 4 clean cuts where the muscles inserted onto the globe. No tethering structures, attached conjunctiva, tenons, or orbital tissue was found. Although there was no active bleeding, the patient was on anticoagulants and unable to return home to New Jersey because of Hurricane Sandy. An examination under anaesthesia was performed to control any bleeding and implant an orbital prosthesis (Fig. 5). During intraoperative exploration, we noted no eyelid injuries, no orbital injuries, and conjunctiva had “clean,” surgical-like edges. There was no tissue loss of conjunctiva or tenons capsule. Both lateral and inferior rectus were isolated and had “clean” insertion ends without any shearing injuries. The patient was healing well postoperative day 1 and returned home for follow-up.

Fig. 2 — Radiologic imaging of orbit.

Several cases of auto-enucleation have been described in the literature. Krauss et al.11 described 19 cases of bilateral and 31 cases of unilateral auto-enucleation. The majority of cases seemed satisfied and happy with their actions often because of religious reasons or guilt. Most cases of auto-enucleation demonstrated an underlying psychotic illness and presented with severing of the optic nerve near the orbital apex. Traumatic evulsion, however, rarely has been elucidated. Morris et al.7 describe 3 possible mechanisms for evulsion of the globe including insertion of a straight-edged object into the medial orbit, creating a lever

Fig. 4 — Gross pathology specimen. CAN J OPHTHALMOL — VOL. 49, NO. 5, OCTOBER 2014

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Correspondence Ritesh Gupta, * Jerrod S. Kent, † Yasser A. Khan † *

Faculty of Medicine, University of Toronto, Toronto; McMaster University, Hamilton, Ont.

†

Correspondence to: Ritesh Gupta, BHSc: [email protected] REFERENCES

Fig. 5 — Orbital prosthesis implant.

effect with the fulcrum at the anterior portion of the nasal bone, and thus causing severance near the insertion of optic nerve into the globe. Two alternate mechanisms described include entrance of an angular-shaped object along the medial aspect of the orbit to create a wedge effect in the orbit, or severing of the optic nerve and sheath by direct laceration or compression of these structures against the posterior orbital bones by the sharp corner of the incoming object. These 2 latter described mechanisms would lead to a longer disrupted optic nerve. A recent German article in Ophthalmologe12 reported 2 cases of traumatic enucleation where the proposed accident did not match the injury. Both cases were cleared by psychiatry and raised the question whether interdisciplinary evaluation should be initiated in cases with suspicious traumatic injury as in cases of known auto-enucleation. Although our patient did not admit either psychiatric disorder or an assault, his history and mechanism are quite suspicious. We believe he was the victim of an assault because of the clean surgical cuts, lack of tethering structures, and long, intact optic nerve.

Unilateral primary cutaneous amyloidosis of the eyelid masquerading as a chalazion Amyloidosis is a constellation of disease entities that are characterized by the abnormal extracellular deposition and accumulation of protein and protein derivatives. Amyloidosis can be systemic (involving multiple organs) or it may present as a localized, organ-specific condition. In this correspondence, we report an unusual case of a primary localized amyloidosis of the eyelid, not involving the conjunctiva and without systemic amyloidosis or myeloma, but previously diagnosed and treated as a lower lid chalazion. A 32-year-old Asian-Indian male presented with a painless, nodular mass on the right lower eyelid measuring Presented as a poster at the combined 28th Congress of Asia Pacific Academy of Ophthalmology and 71st Annual Conference of All India Ophthalmological Society in Hyderabad, India, 17–20 January, 2013.

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1. Pillai S, Mahmood MA, Limaye SR. Complete evulsion of the globe and optic nerve. Br J Ophthalmol. 1987;71:69-72. 2. Arkin MS, Rubin PA, Bilyk JR, et al. Anterior chiasmal optic nerve avulsion. Am J Neuroradiol. 1996;17:1777-81. 3. Kiratli H, Tümer B, Bilgiç S. Management of traumatic luxation of the globe: a case report. Acta Ophthalmol Scand. 1999;77:340-2. 4. Middleton TH III, Smith RR. Optic nerve avulsion secondary to traumatic enucleation. Neurosurgery. 1987;21:89-91. 5. Walsh FB, Hoyt WF. Craniocerebral trauma, hypoxia, and injuries by other physical agents. In: Walsh FB, editor. Walsh and Hoyt’s Clinical Neuro-ophthalmology (Vol. 3). 3rd ed. Baltimore, Md. Williams & Wilkins; 1969:2369-70 6. Al-Sharif AM, Al-Mansouri S, Shamsi FS, Chaudhry IA. Traumatic transection of the optic nerve and evulsion of the eye globe: case report and review of literature. Neuroophthalmology. 2008;32:13-6. 7. Morris WR, Osborn FD, Fleming JC. Traumatic evulsion of the globe. Ophthal Plast Reconstr Surg. 2002;18:261-7. 8. Hollander DA, Stewart JM, DeAngelis DD, Seiff SR. Re: Traumatic evulsion of the globe. Ophthal Plast Reconstr Surg. 2003;19:253, author reply 254. 9. Roldan-Valadez E, Corona-Cedillo R, Rojas-Marin C, ValdiviesoCardenas G, Sanchez-Sanchez JM, Quiroz-Mercado H. Tomographic findings in traumatic globe evulsion caused by blunt head trauma. Br J Radiol. 2007;80:e247-9. 10. Tuncbilek G, Isci E. Traumatic evulsion of the globe: a very rare complication of maxillofacial trauma. J Craniofac Surg. 2008;19: 313-5. 11. Krauss HR, Yee RD, Foos RY. Autoenucleation. Surv Ophthalmol. 1984;29:179-87. 12. Strassburger P, Varadi G. Traumatic enucleation: accident or selfmutilation? Ophthalmologe. 2013;110:451-4. Can J Ophthalmol 2014;49:e110–e112 0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.06.004

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6
3 mm extending from the lateral to medial canthus (Fig. 1A). No ulceration, bleeding, or loss of lashes was present. There was no family history of multiple myeloma or any lymphoproliferative disorder. The increase in size of the mass was insidious and painless. He had been treated earlier with warm compresses and local antibiotic ointment application as treatment for a multiple chalazia of the lower lid. Slit-lamp examination showed normal anterior segments in both eyes; in particular, no conjunctival lesion was seen. An incisional biopsy was performed on the nodular lid mass. Hematoxylin and eosin–stained slides revealed subcutaneous deposits of amorphous eosinophilic material. Examination of the Congo red–stained slides showed red–orange staining of the deposits (Fig. 1B), which under polarized light exhibited apple-green birefringence, confirming the presence of amyloid deposits (Fig. 1C). Clinical examination of all systems was normal. Systemic

CAN J OPHTHALMOL — VOL. 49, NO. 5, OCTOBER 2014