Grand Rounds

Brooke LW Nesmith, M.D.University of Louisville School of MedicineDepartment of Ophthalmology & Visual

Sciences1/16/2015

Presentation

CC: Enlargement of right upper eyelid mass x 2 months

HPI: 10mo male referred to oculoplastics clinic for evaluation of right upper eyelid mass. Patient has had fullness of right upper lid laterally since approx 2 months of age, has become progressively larger in the past 2 months.

Presentation

PMHx: Full term with uncomplicated delivery; Asthma

Meds:Albuterol, Zyrtec

Allergies: Cephalexin

Exam

Visual acuity: Central steady and maintained OUPupils: 4mm OU, no RAPD Motility: Full OUGlobes soft to palpation OU

External Exam: Soft firm mobile mass at superior aspect of right lateral orbital rim. No edema or erythema. No tenderness to palpation. No globe displacement.

Anterior Segment Exam: WNL OU

Assessment 10 month old male with congenital right

superolateral orbital mass of the upper eyelid with recent enlargement.

congenital cyst– dermoid– epidermal

Right anterior orbitotomy to excise lesion

Plan

Surgical Course

1 x 0.5cm tan-white to tan-yellow cyst was successfully excised near the right zygomaticofrontal suture line without rupture

Pathology

Pathology

Orbital Cysts of Childhood surface epithelium

dermoid- (epidermal and conjunctival)

simple epithelial (epidermal, conjunctival, respiratory, apocrine gland)

teratomatous neural (associated with ocular maldevelopment) secondary (mucocele) inflammatory (parastic) noncystic lesions with a cystic component

– adenoid cystic carcinoma, rhabdomyoscarcoma

Shields J, Shields C. Orbital cysts of childhood-classification, clinical features, and management. Surv Ophthalmol 2004;49:281-299

Orbital Cysts of Childhood

Shields J, Shields C. Orbital cysts of childhood-classification, clinical features, and management. Surv Ophthalmol 2004;49:281-299

Dermoid Cyst

Most common– 40% of all orbital lesions of childhood– 89% of all orbital cystic lesions of childhood that

come to biopsy or surgical removal

Congenital choristomas– embryonic epithelial nests – entrapped during

embryogenesis– along suture lines

Shields J, Shields C. Orbital cysts of childhood-classification, clinical features, and management. Surv Ophthalmol 2004;49:281-299

Dermoid Cyst Anterior lesions

– generally becomes apparent during 1st decade of life

– most common location – superolateral aspect of orbit at frontozygomatic suture

Shields J, Shields C. Orbital cysts of childhood-classification, clinical features, and management. Surv Ophthalmol 2004;49:281-299

Dermoid Cyst Deeper lesions

– may remain clinically occult until adulthood – present with painless, progressive proptosis, motility deficits, or diplopia

Shields J, Shields C. Orbital cysts of childhood-classification, clinical features, and management. Surv Ophthalmol 2004;49:281-299

Dermoid Cyst Dumbbell-shaped

– cyst in orbit and temporal fossa – connected by defect in bone

– pulsating proptosis with mastication

Missotten G, Van Santbrink-Bakker H., de Keizer R. Dumbbell-shaped dermoid cysts. Acta Ophthalmologica 2010;doi:10.111/j.1755-3768.2008.01409.

Dermoid Cyst Workup and Imaging

– classic dermoid cysts at frontozygomatic suture may be diagnosed clinically without imaging

– imaging required for medial lesions (rule out encephalocele or mucocele) and deep lesions

Treatment– surgical excision – remove with cyst wall intact

without causing iatrogenic rupture

Missotten G, Van Santbrink-Bakker H., de Keizer R. Dumbbell-shaped dermoid cysts. Acta Ophthalmologica 2010;doi:10.111/j.1755-3768.2008.01409.

Thank you.