Ali, Mohammad Javed; Gupta, Shweta
Varices are abnormally dilated and tortuous vessels of an existing venous structure. A female patient, 58 years of age, presented with right-sided epiphora of 5-year duration and left-sided epiphora of 1-year duration. Clinical examination revealed bilateral punctal and canalicular stenosis with right-sided primary acquired nasolacrimal duct obstruction and left-sided partial primary acquired nasolacrimal duct obstruction. There was no history of hemolacria. Lacrimal sacs were not palpable. Bilateral endoscopic dacryocystorhinostomy with bicanalicular Crawford intubation was advised. Right-sided dacryocystorhinostomy was uneventful. However, during the surgery for the left side, following osteotomy, the lacrimal sac and nasolacrimal duct walls were noted to have focal areas of grossly dilated and tortuous vessels. Their location was on the antero-inferior wall of the lacrimal sac and medial wall of the nasolacrimal duct (Fig. A). The lacrimal sac varices were more tortuous, whereas that of nasolacrimal duct (black arrow, Fig. A) were more dilated. The underlying lacrimal sac wall was bluish in color reflecting a full thickness variceal presence (Fig. B). Nasal mucosa did not show any varices. Hemostasis was achieved following sac marsupialization by compression, and a portion of the anterior sac wall was sent for histopathologic examination. Microscopic examination revealed large dilated vascular structures with the sac wall showing features of chronic inflammation (Fig. C). The vessel walls lacked gross muscular elements without any proliferative features and were dilated with a pool of red blood cells, suggestive of varices.
Mancera, Norberto; Applebaum, Robert J.; Margo, Curtis E.
A 57-year-old man with allogeneic liver transplant and gastric mucosa associated lymphoid tissue lymphoma was evaluated for a 1-day history of left eye pain and redness. A motile, white, coiled worm was observed within inflamed, chemotic conjunctiva (Fig. A). The worm was removed through a small incision under topical anesthetic. The patient, who had not traveled outside the southeastern United States in 20 years, had no other ocular, cutaneous, or systemic evidence of parasitic infection. His eye returned to normal within 1 week. The worm was identified as Dirofilaria spp (Figs. B, C), most likely tenuis, based on size and morphology of regional filarial organisms. Dirofilaria tenuis is a roundworm commonly found in racoons that is transmitted to humans via a bite from an infected mosquito. Humans are dead-end hosts. Raccoons are ubiquitous where our patient lives, and we are unsure how he contracted this unusual parasite.
Patel, Poorav; Hemond, Michael; Silkiss, Rona Z.
A 94-year-old woman with advanced dementia presented to the emergency department with a progressive growth on the left eye resulting in a several month history of constant rubbing. On examination, the cornea was not visible (Fig. A). CT demonstrated an intact globe with homogenous tissue anterior to the cornea of the left eye (Fig. B). Histopathology demonstrated a bland undulating, moderately inflamed squamous lesion consistent with a squamous papilloma (Fig. C). Flow cytometry showed no suggestion of lymphoma. The lesion was debulked.
Dave, Tarjani Vivek; Cicinelli, Maria Vittoria; Dave, Vivek Pravin; Pappuru, Rajeev Reddy; Naik, Milind N; Mishra, Dilip K.
Congenital microphthalmos belongs to a spectrum of diseases ranging from true anophthalmos to congenital clinical anophthalmos to microphthalmos. These conditions are frequently associated with an orbitopalpebral cyst, and pathologically, this represents a failure in the closure of the embryonic fissure at the 7–14 mm stage of gestation. The cyst develops as an outpouching from the eyeball and is generally helpful as it provides a stimulus for the orbit to expand. The general management guideline is to retain the cyst till it provides a stimulus for the orbit to expand and then to consider aspiration and sclerotherapy once orbital expansion is achieved. However, in eyes that have visual potential, sclerotherapy is contraindicated. The authors present an unusual case of a mildly microphthalmic eye with visual potential and a communicating cyst that was excised with a good result. The challenges faced in the excision of the communicating cyst with a wide pedicle and the management of the case are highlighted.
Aseem, Fazila; Pace, S. Tyler; Onajin, Oluwakemi; Sangueza, Omar P.; Yeatts, R. Patrick
A 54-year-old woman presented with a 2-year history of a slow-growing subcutaneous nodule of the medial right lower eyelid adjacent to the inferior canaliculus. The patient reported right-sided epiphora suggesting lacrimal outflow obstruction. The surgically excised nodule was consistent with a chondroma. A rare tumor, soft tissue chondroma, is most often seen in the extremities, but has also been observed in the head and neck region. To their knowledge, this is the first reported case of a soft tissue chondroma of the eyelid.
Leung, Vannessa; Dunn, Hamish; Newey, Allison; O’Donnell, Brett Less
Sinusitis complicated by orbital apex syndrome is rare. The majority of cases are due to mucormycosis in immunocompromised patients. The authors report a case of orbital apex syndrome secondary to Pseudomonas sinusitis. The patient was a 79-year-old Type 2 diabetic woman who underwent left-sided functional endoscopic sinus surgery. Three months postprocedure, she presented with a 3-week history of gradual vision loss and constant temporal headache on the ipsilateral side. Examination revealed light perception vision, a relative afferent pupillary defect, absent corneal reflex, and disc pallor. Imaging revealed opacification of the posterior ethmoidal air cells extending to involve the orbital apex. Urgent orbital and sinonasal decompression was performed. Intraoperative specimens grew Pseudomonas aeruginosa. The patient was treated with liposomal amphotericin B, posaconazole, and piperacillin/tazobactam. The patient recovered with no visual sequelae. Pseudomonas is an important mimicker to consider in sinusitis causing orbital apex syndrome, and it may occur following functional endoscopic sinus surgery.
Godfrey, Kyle J.; McConville, Thomas H.; Miko, Benjamin A.; Kazim, Michael
Orbital infection can be caused by numerous pathogens, and accurate diagnosis informs appropriate therapy. The authors report a case of a 78-year-old man with well-controlled diabetes mellitus and recurrent sino-orbital infection following multiple surgical procedures with negative microbiologic results. This case presented a diagnostic and treatment challenge and was aided by the use of internal transcribed spacer sequencing for pathogen identification. The fungal pathogen, Tilletiopsis minor, has not previously been described as a human pathogen in the sinus and orbit. This report describes a novel orbital pathogen and highlights the importance of diagnostic diligence and utilizing internal transcribed spacer sequencing in the workup of atypical orbital infection.
Li, Emily; Distefano, Alberto; Sohrab, Mahsa
A 69-year-old woman with orbital cellulitis secondary to odontogenic Streptococcus constellatus was transferred to the authors’ institution for surgical management of infection refractory to intravenous antibiotics. She underwent debridement with preservation of the globe, recovering full motility. Visual recovery was limited by optic nerve ischemia. This case supports the importance of urgent surgical drainage in necrotizing orbital infections secondary to odontogenic Streptococcus constellatus.
Li, Emily; Distefano, Alberto; Sinard, John; Wong, Amanda; Pointdujour-Lim, Renelle
A 41-year-old woman presented with several days of right eye pain and blurred vision. Examination and radiologic workup were consistent with a veno-lymphatic malformation, including demonstration of cystic fluid–fluid levels on imaging. Histopathology supported the presence of cystic spaces but revealed the final diagnosis of lacrimal epithelial–myoepithelial carcinoma, a rare neoplasm typically associated with the salivary gland. This represents the first reported case of lacrimal epithelial–myoepithelial carcinoma presenting with pain and evidence of intralesional cysts on radiographic and histopathologic evaluation. Better characterization will enable recognition, complete surgical excision, and potential adjuvant radiation therapy.
Bortz, John G.; Zhang, Paul J. L.; Eagle, Ralph C. Jr; Yong, Jennifer J.; Milman, Tatyana
Secretory carcinoma is a salivary gland malignancy that recapitulates secretory carcinoma of the breast, along with its shared ETV6-NTRK3 gene fusion. Characterization of histopathologic, immunohistochemical, and molecular genetic features of this neoplasm has led to reclassification of a heterogeneous group of salivary gland carcinomas as secretory carcinoma and to identification of this neoplasm in other gland-containing tissues. The authors describe a 52-year-old man who presented with a 2-week history of diplopia and a well-circumscribed right orbital mass. The tumor was resected via lateral orbitotomy approach. Pathologic evaluation demonstrated secretory carcinoma, previously not described in the main lacrimal gland. Recognition of lacrimal gland secretory carcinoma may lead to reappraisal of morphologically similar, but biologically heterogeneous lacrimal gland neoplasms, providing an insight into this tumor’s clinical presentation and prognosis. Accurate diagnosis of this malignancy has important management and prognostic implications, particularly with emergence of targeted therapies.