Conger, Jordan R.; Grob, Seanna R.; Tao, Jeremiah
An 87-year-old woman presented with worsening right facial and periocular pain due to a large facial mass. She was diagnosed with squamous cell carcinoma 1.5 years before and received radiation therapy at an outside institution. Examination revealed a large 10 × 11 cm ulcerative facial lesion over the right temporal region extending to the lateral canthus with proptosis (Fig. A). Silver nitrate can be seen atop the lesion. Extraocular motility showed severe limitation in all directions. Imaging demonstrated tumor in the orbit, through the skull base, and down to the temporal lobe of the brain. Histopathologic analysis from previous biopsy demonstrated a well-differentiated invasive squamous cell carcinoma with keratoacanthomatous features. Given the extent of the lesion, poor overall physical condition, and advanced age, the patient opted for nonoperative care. In an attempt to palliate this invasive tumor, the patient received 8 infusions of pembrolizumab (Keytruda; anti-PD1, immunotherapy agent). Six months after, external examination showed significant regression of the lesion with cicatrization down to the temporal fossa with an exposed, escharred lateral zygomatic arch and lateral frontal bone (Fig. B).
Wolkow, Natalie; Freitag, Suzanne K.
Balloon cell nevi are rare variants of nevocellular nevi in which greater than 50% of nevus cells are large and foamy. They are most common in patients under age 30, affecting males and females equally when found in skin. The balloon changes are attributed to defects in melanogenesis that lead to malformed premelanosomes and degenerative changes. Clinically they are indistinguishable from more common nevi. Care needs to be taken in assessing for nuclear atypia in melanocytic lesions with balloon cells as some melanomas may display balloon cell changes.
Wilson, Caroline W.; Fisher, Mark T.; Pagedar, Nitin A.; Kass, Gretchen; Terry, William W.; Shriver, Erin M.
The aim of exenteration reconstruction is to stabilize the postsurgical wound bed to promote expeditious healing particularly in patients who are undergoing adjuvant radiation and/or chemotherapy. Porcine urinary bladder matrix has previously been used successfully as a wound-healing scaffold in treatment of burns and in acute, chronic, and surgical wounds, but the use of these products has not previously been reported in the exenterated orbit. The authors present a case of the novel use of porcine urinary bladder matrix in a pediatric patient who underwent exenteration for recurrent embryonal rhabdomyosarcoma, subsequent split-thickness skin grafting, and adjuvant radiation.
Ediriwickrema, Lilangi S.; Liu, Catherine Y.; Kikkawa, Don O.; Korn, Bobby S.
The authors describe a clinical case whereby a patient with metastatic cutaneous melanoma developed eyelash poliosis after undergoing treatment with combination immunotherapy with ipilimumab and nivolumab.
Everett, Lesley A.; Copperman, Thomas S.; Kersten, Robert C.
Ductal carcinoma of the lacrimal gland is a very rare and aggressive neoplasm, with clinical and histopathologic similarities to salivary ductal carcinoma. Of the 25 previously reported cases, 2 patients had metastases to local lymph nodes confirmed on pathologic examination. The authors now report the clinical presentation, histopathologic and immunohistochemical features, and the treatment of a third patient with lacrimal gland ductal carcinoma with spread to local lymph nodes. In contrast to ductal carcinoma, lymph node involvement has not been reported in the largest series of adenoid cystic carcinoma, a much more common lacrimal gland malignancy. This case highlights the need for possible lymph node surveillance in patients with lacrimal gland ductal carcinoma.
Kwan, Changyow C.; Prager, Alisa J.; Huang, Russell M.; Bryar, Paul J.; Thyparampil, Preeti J.
This is the first case of histopathologically proven blastomycosis involving the lacrimal gland. A 51-year-old woman with a history of disseminated blastomycosis involving her lungs and skin, on oral itraconazole, presented with 3 days of right upper eyelid swelling, erythema, and pain concerning for recurrent dacryoadenitis. MRI showed enlargement of the right lacrimal gland with a cystic lesion at the anterior aspect of the gland with a radiographic differential diagnosis of abscess versus cyst. After no improvement with intravenous antibiotics, orbitotomy with lacrimal gland biopsy and incision and drainage of the cystic lesion were performed. Culture and pathology of the drained fluid demonstrated an abscess with both viable and nonviable broad-based budding yeast consistent with partially treated blastomycosis. The patient’s symptoms improved after the surgery and continued itraconazole therapy.
Bradfield, Yasmin; Burkat, Cat N.; Albert, Daniel M.; Potter, Heather A.D.
A 7-year-old healthy girl presented for an evaluation of a left vascular scleral mass. The lesion appeared spontaneously with no history of trauma, coagulopathy, or topical medication use. It was nontender, enlarging, and did not extend intraocularly. Her OS vision was 20/20, and the remainder of her eye examination was normal. Evaluation of the ocular mass included B-scan ultrasound, ultrasound biomicroscopy, anterior segment optical coherence tomography (OCT), and orbital MRI. The anterior segment OCT demonstrated vessels within the mass with no defined capsule. The orbital MRI confirmed a lesion isolated to the scleral layers of the globe, with low blood flow. The patient had a partial response to oral propranolol. Because the lesion vessels began to extend into her corneal endothelium, there was a concern for malignancy. A biopsy confirmed a benign intrascleral capillary hemangioma. Discontinuation of the propranolol demonstrated stability of the lesion 6 months later.
Vahdani, Kaveh; Rose, Geoffrey E.
Over a 2-year period, a 68-year-old woman suffered multiple recurrences of left giant fornix syndrome during the repeated tailing of intensive topical steroids and antibiotics; she had also undergone surgery to reduce the left upper fornix. After a further recurrence during tailing of topical therapy for bilateral disease, treatment with 4 times daily preservative-free povidone-iodine 5% eyedrops was started—with a marked improvement of symptoms and signs within a week. The patient is maintained, symptom-free, on once-daily povidone-iodine drops and dexamethasone 0.1% drops. The dramatic improvement on topical povidone-iodine therapy might suggest that, as an initial therapy, this might be more effective than the previously-recommended regime of hourly potent topical steroids and antibiotics.
Hodson, Trevor; Cho, Raymond I.
Chronic inflammatory demyelinating polyneuropathy is known to cause enlargement of the cranial nerves, particularly the trigeminal nerve. Several cases of orbital neuromas associated with this condition have been published, but surgical treatment has not been reported. The authors present a case of bilateral supraorbital neuromas associated with chronic inflammatory demyelinating polyneuropathy that underwent surgical excision and histopathologic examination.
Charles, Norman C.; Belinsky, Irina
A 37-year-old woman underwent excision of a congenital melanocytic nevus of the right lower eyelid margin for cosmetic reasons. She suffered from a severe dry eye syndrome which was partially alleviated with various topical eye drops. Histopathology of the excised tissue displayed flecks of calcium that were present within the immediate subepithelial conjunctival fibrous tissue but not the nevocytes or the cutaneous surface. Unlike calcinosis cutis, wherein calcium is deposited within the cutaneous dermis, calcification of the conjunctival substantia propria is rare and may be related to the dry eye state.