www.jmscr.igmpuliction.org Impct Fctor 5.244 Index Copernicus Vlue: 83.27 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v4i12.16 A Study of Common nd Uncommon Eyelid Lesions - Telescoping Through Histopthology Authors Dr. Prdny S Bhdrge 1, Dr. Sonli S Dtr 2, Dr. Alok C Shrivstv 3, Dr. Prdeep S Ump 4, Dr. Anurdh V Shrikhnde 5 Deprtment of Pthology, Indir Gndhi Government Medicl College, Ngpur, Mhrshtr, Indi Corresponding Author Dr. Prdny S Bhdrge Emil: prdnyhdrge@gmil.com ABSTRACT Eyelid histology comprises of vrious structures tht gives rise to wide spectrum of pthologies. Eyelid lesions require surgicl tretment mostly; hence correct preopertive provisionl dignosis is required. Histopthologicl exmintion of the excised specimen with confirmtion of clinicl dignosis given plys n enormous role in treting eyelid lesions so s to improve ptients cre. We studied 25 cses of eyelid lesions retrospectively over period of yer. We cme cross epiderml cyst s most common lesion occurring in eyelid followed y cpillry hemngiom, derml nevus nd molluscum contgiosum. Uncommon lesions tht were dignosed were pilomtricom, tumorl clcinosis, cysticercosis which completely differed from the clinicl dignosis offered. In conclusion, ech nd every excised specimen should not e considered s wste mteril nd lwys e (without exception) sent for the histopthologicl exmintion for correct dignosis nd further mngement. Keywords- eyelid lesions, common nd uncommon, histopthology. INTRODUCTION Eyelid lesions re common concerns mongst ptients who presents to the ophthlmologists, dermtologists nd generl prctioners. Histologiclly eyelid is composed of skin nd sucutneous tissue including its dnex, strited muscle, trsus with the meiomin glnds, nd the plperl conjunctiv. Becuse of different tissues t eyelid level, vriety of tumorl types nd sutypes cn rise. [1] Therefore ophthlmic pthology is unique in mny spects s it encompsses wide rnge of tissues nd shows wide rnge of diseses. [2] Almost ll of the eyelid lesions cn e excised surgiclly ecuse of its superficil nture. Ech of the excised specimens should e exmined histopthologiclly so s to give exct dignosis nd to enhnce communiction etween ophthlmologist nd pthologist to correlte it with ptient s clinicl history, improving ptients cre. [3] AIM AND OBJECTIVES 1. To provide precise dignosis of the disese. 2. To help clinicins prioritizing their presumed clinicl dignoses ccording to the commonly presented lesions in the community. Dr Prdny S Bhdrge et l JMSCR Volume 4 Issue 12 Decemer 2016 Pge 14370
3. Evluting the reltive frequency of enign eyelid lesions presented to teching hospitl 4. To mke ophthlmologist wre of possiility of unusul lid lesion 5. To clssify eyelid lesions in common nd uncommon lesions MATERIAL AND METHODS A retrospective study ws crried out t our hospitl during period of yer from June 2015 to June 2016. Study included totl 25 cses who presented with eyelid lesions of vrying durtion to the ophthlmologist. The excised eyelid lesions with suspected clinicl dignoses were sent for histopthology for confirmtion. The received specimen smples were fixed in 10% formlin for 24 hours. Sections were tken depending on size of smple, processed, stined with Hemtoxyline nd Eosine (HE) stin d exmined for microscopic findings. RESULTS AND DISCUSSION A totl of 25 cses were studied with equl mle to femle rtio. Mximum numers of cses were found in the ge group of 21-30 yers. Only single cse ws reported in the ge group of 1-10 nd 61-70 yers (Fig 1) Fig.1- Chrt showing ge wise distriution of cses. 8 6 4 2 0 1-10 11-20 Age wise distriution of cses 21-30 31-40 41-50 51-60 61-70 Upper eyelid ws commonly involved (88%) s compred to lower eyelid (12%). Most of the ptients presented with grdully incresing, pinless swelling over eyelids. Most common lesion dignosed ws epiderml cyst (13) (52%) followed y cpillry hemngiom (5) (20%) nd derml nevus (3) (12%) respectively. A single cse (4%) ws contriuted y tumorl clcinosis, cysticercosis, molluscum contgiosum nd pilomtricom ech. Clinicl dignosis ws offered in most of the cses with clinico-pthologicl correltion of 84%. Clinicl dignosis ws not offered in cse. No mlignnt lesion ws found in the present study. (Tle 1) Tle 1 : Clinico-pthologicl correltion nd site wise distriution of eyelid cses Histophologicl Dignosis Cses % Clinicl dignosis given Site Epiderml cyst 13 52% 12 2 lower eyelid Hemngiom 5 20% 5 Upper eyelid Nevus 3 12% 3 Upper eyelid Pilomtricom 1 4% 0 1 lower eyelid Clcinosis cutis 1 4% 0 Upper eyelid Molluscum 1 4% 1 Upper eyelid contgiosum Cysticercosis 1 4% 0 Upper eyelid Totl 25 100% 21 Epiderml cyst- As per tle 1, more thn hlf of the cses dignosed were of epiderml cyst (52%). Age of presenttion of epiderml cyst rnged from 3 rd decde to 6 th decde. The only cse detected in 61-70 yer ge group ws epiderml cyst. Out of 13 cses of epiderml cyst, 12 cses correlted with the given clinicl dignosis. Two cses were present over lower eyelid while rest ws on upper eyelid. One cse hd no offered clinicl dignosis. Cliniclly it presents s smooth, dome shped swellings with punctum over fce, neck nd upper trunk. (Fig 2) Grossly epiderml cyst shows vrying sizes of cysts, soft to firm in consistency filled with pultceous mteril. Microscopiclly, it shows cyst lined y strtified squmous epithelium sometimes with dnex (clled s dermoid cyst) with undnt lminted kertin mteril. [4] (Fig2) No other study found such lrge numer of cses of epiderml cyst. In studies conducted y Pudsini S et l [5] nd Bstol P et l [6] epiderml cyst ccounted for 27.2% nd 35% ech, while the present study it ccounted for 52%. Dr Prdny S Bhdrge et l JMSCR Volume 4 Issue 12 Decemer 2016 Pge 14371
Fig.2,- Clinicl & microphotogrph of epiderml cyst (HE,100x) Cpillry hemngiom- Second common lesion ws cpillry hemngiom, enign vsculr tumor, contriuting five cses (20%). Most of the ptients were from 3 rd decde of ge. Clinicl dignosis ws offered in ll the cses nd ll correlted with histopthologicl dignosis. All cpillry hemngioms were on upper eyelid. Cliniclly hemngiom presents s red or purple, flt or rised lesions, generlly less thn 5 cm. (Fig3) Microscopiclly, it shows loules of numerous smll (cpillry sized) vsculr spces lined y plump endothelil cells with scnty intervening strom. [7] (Fig 3) Fig.3,- Clinicl & microphotogrph of cpillry hemngiom(he,100x), Inset(HE 200x) As per study crried out y Bstol et l [6] cpillry hemngiom ws 7% nd cvernous hemngiom ws 3.5%. While ccording to Rmy BS et l [8] cpillry hemngiom ws most common tumor of eyelid ccounting for 31.1% which is greter s compred to the present study. In the present study, no cvernous hemngiom ws dignosed. Intrderml nevus- Three cses (12 %) were contriuted y intrderml nevus, common enign melnocytic tumor. Incidence of intrderml nevi increses s ge dvnces. These rrely cn trnsform into melnom s compred to junctionl nd compound nevi. [9] All three cses were present over upper eyelid nd ptients were from the 4 th decde. Cliniclly, it involves ny prt of eyelid skin nd presents s flt or elevted, usully pigmented lesion.(fig4) Microscopiclly, it shows nests, cords or singly dispersed popultion of smll or round cells with round, ovl or spindle shped nuclei with or without melnin. [10] (Fig 4) Fig.4,- Clinicl nd microphotogrph of nevus (HE100x), Inset (200x) The findings of the present study correlted with study y Bstol et l [6] where they found intrderml nevus ccounting for 12.2%. While study y Rmy BS et l [8] showed tht nevi ere contriuting 20% of cses. But uthors hve not specified them into intrderml, junctionl or compound nevi. In the present study no junctionl or compound nevi were noted. Rest four cses were contriuted y pilomtricom, clcinosis cutis, molluscum contgiosum nd cysticercosis ech. Pilomtricom- Pilomtricom (pilomtrixom, clifying epitheliom of Mlhere) is enign dnexl tumor originting from hir root mtrix, first descried y Mlhere nd Chenntis in 1880. [11] Pilomtricom rises in dolescent nd young people, sometimes in dults hving propensity to occur in the hed nd neck region, often involving the eyelid or eyerow. [12] The clinicl picture of pilomtricom is often misleding, prompting for histopthologicl nlysis. In the present study, pilomtricom ws present over lower eyelid nd clinicl dignosis given ws infected dermoid cyst. (Fig5) Cliniclly, it presents s slow growing, firm nodule of 0.5-3 cm.microscopiclly, it shows loulted tumor usully in dermis, sometimes extending to sucutneous ft surrounded y pseudocpsule of compressed djcent connective Dr Prdny S Bhdrge et l JMSCR Volume 4 Issue 12 Decemer 2016 Pge 14372
tissue with overlying norml epidermis. Tumor loule shows vrile mixture of two types of cells, sloid cells nd ghost cells. Bsloid cells re smll nd uniform with round, vesiculr nuclei nd prominent nucleoli. With mturtion, these sloid cells trnsforms into ghost cells. Ghost cells hve undnt eosinophilc cytoplsm nd smll hyperchromtic nuclei. With dvncement, nuclei re lost nd only eosinophilic kertinous mteril with rely visile ghost outlines of tumor cells seen. [13] (Fig5) Only single cse ws reported in study y Pudsini et l which correlted our finding. [5] showed chrcteristic endophytic hyperplsi producing intrderml pseudotumor. Kertinocytes showed lrge intrcytoplsmic eosinophilic to sophilic inclusions displcing the nucleus to side. [15] [16] (Fig7) Pudsini S et l [5] nd Al-fky Y H [17] documented 9.1 % nd 3.2 % of cses of mollucscum contgiosum in their studies respectively, while in the present study it ws found to e 4%. Fig.6- Clcinosis cutis (HE100x) Fig.5,- Clinicl nd microphotogrph of pilomtricom (HE100x), Inset (200x) Clcinosis cutis- Clcinosis cutis is chrcterized y the deposition of morphous clcium nd phosphte slts under the epiderml lyer. [14] There re four types of clcinosis cutis i.e dystrophic, metsttic, itrogenic nd idiopthic. In our cse, 15 yer old mle ws presented with upper eyelid mss since month. Cliniclly, epiderml cyst ws the dignosis given. Histopthologiclly, it showed lrge deposits of clcium elow epidermis suggesting clcinosis cutis. Ptient retrogressively investigted for clcium nd phosphte levels which were within norml limits. Thus, dignosis offered ws idiopthic clcinosis cutis (Tumorl clcinosis). (Fig6) Molluscum contgiosum- Molluscum contgiosum is self limiting epiderml ppulr lesion cused y pox virus, usully presenting in the 1-10 yers of ge group. In the present study, seven yer old femle child ws presented with recurrent eyelid lesion to the ophthlmologist. With suspicion of molluscum contgiosum, for fster resolution lesion ws excised nd sent to histopthology which confirmed the dignosis. Histopthologiclly, it Fig.7-Molluscum contgiosum(he100x)inset(200x) Cysticercosis- Cysticercosis is systemic prsitic infesttion which is cused y lrve of Teni Solium (T. Solium) ffecting centrl nervous system, skeletl muscle, sucutneous tissue nd eye. In eye, eyelid is uncommon site for infesttion. [18] In the present study, three yer old mle child presented with upper eyelid swelling tking dermoid cyst s clinicl suspicion. (Fig8) The excised lesion demonstrted lrvl form of T Solium showing investing cuticle, sucuticulr tissue, one of sucker nd cudl end hving duct-like invgintions. (Fig8) It lso showed grnulomtous inflmmtory rection to lrv. [16] Fig.8,- Intr-opertive nd microphotogrph of cysticercus cellulose (HE100x) Dr Prdny S Bhdrge et l JMSCR Volume 4 Issue 12 Decemer 2016 Pge 14373
As we tke look on cliniclly presenting common eyelid lesions, chlzion tops in the list. Generlly, chlzion is self limiting disese of meomin glnd. In inflmed cses,symptomtic tretment like lid mssge, moist het or tropicl steroid suffice the resolution without ny need for surgery. On the other hnd, there could e possiility of correctly dignosing the chlzion cliniclly, which stin ophthlmologist from sending the specimen to histopthology. Therefore none of the cses received in histopthology cme out to e chlzion. We hve not received ny mlignnt lesion in the present study, s suspected mlignnt cses were directly referred to the plstic surgeons for tretment nd full workup in view of cosmetic concern of the ptient. In study y Rmy BS et l [8], uthors found seceous crcinom (41.4%) s the most common mlignncy involving eyelid, followed y sl cell crcinom (26.8%) nd squmous cell crcinom (21.9%). While Khlil MF et l [19] documented sl cell crcinom (65%) s most common mlignncy, followed y squmous cell crcinom (23%) nd seceous crcinom (12%). These different findings suggest multifctoril etiology. CONCLUSION Eyelid is heterogeneous tissue; hence we tend to see vriety pthologies including infective, inflmmtory, enign nd mlignnt. Ech nd every excised eyelid lesion should e sent for histopthologicl nlysis s there re mny conditions tht my misled clinicl dignosis. Aprt from common eyelid lesions like epiderml cysts, hemngioms, nevi, chlzion, molluscum contgiosum, some uncommon lesions like pilomtricom, clcinosis cutis, cysticercosis should e considered in the differentil dignosis of eyelid lesions. ACKNOWLEDGEMENT We would like to thnk Dr. Neh Mlviy for her help. REFERENCES 1. Mihel- Cristin Coroi, Elen Ro C, Griel Mu Iu, T. Coroi, Mrinel Bont. Eyelid tumors: histopthologicl nd clinicl study performed in County Hospitl of Orde etween 2000.2007. Romnin Journl of Morphology nd Emryology 2010, 51(1):111.115 2. Chuhn S, Shh S, Solnki P et l. Accurcy of clinicl dignosis of eyelid lesion in medicl college in Gujrt. Int l J Res Med 2013; 2: 114-7 3. Ophthlmic Pthology Service. Aville from: http//www.sms.ufflo.edu/ophthlmology/ clinicl Services/pthology_fed.html. Accessed Jnury, 2012 4. Clonje E, Brenn T, Lzr A, Mckee PH. Cutneous cysts. In : Mckee s Pthology of the Skin with clinicl correltion. Volume 2. Clonje E, Brenn T, Lzr A, Mckee PH, editors. Fourth edition. Elsevier Sunders; 2012.pp 1571-4 5. Pudsini S, Knskr I, Prsd KBR, Runiyr SK. A histopthologicl study of ophthlmic lesions. Nepl Med Coll J 2013; 15(1): 78-80 6. Bstol P, Koirl S, Pokhrel G, Ghimire P, Adhikri RK. A clinicohistopthologicl study of oritl nd oculr lesions; multicenter study. Journl of Chitwn Medicl College 2013; 3(4): 40-44 7. Clonje E, Brenn T, Lzr A, Mckee PH. Connective tissue tumors. In : Mckee s Pthology of the Skin with clinicl correltion. Volume 2. Clonje E, Brenn T, Lzr A, Mckee PH, editors. Fourth edition. Elsevier Sunders; 2012.pp 1714-5 8. Rmy B S,Dynnd S B, Chinmyee J T, Rghupthi A R. Tumours of the Eyelid- A Histopthologicl Study of 86 Cses in Tertiry Hospitl. Interntionl Journl of Scientific nd Reserch Pulictions, 2014;4(11):1-5 Dr Prdny S Bhdrge et l JMSCR Volume 4 Issue 12 Decemer 2016 Pge 14374
9. Pe er J. Pthology of eyelid tumors. Indin J Ophthlmol. 2016 Mr; 64(3): 177 190. 10. Zuzur B, Bstin B, Clonje E. Melnocytic nevi. In : Mckee s Pthology of the Skin with clinicl correltion. Volume 2. Clonje E, Brenn T, Lzr A, Mckee PH, editors. Fourth edition. Elsevier Sunders; 2012.pp 1156-63 11. Mlhere A, Chenntis J(1880) Note sur L'epitheliome clcife des glndes secees. Prog Med (Pris) 8:826 837. Google Scholr 12. Mthen L C, Olver J M. A lrge rpidly growing pilomtrixom on lower eyelid. Br J Ophthlmol 2000;84:1203 13. Clonje E, Brenn T, Lzr A, Mckee PH. Tumors of hir follicles. In : Mckee s Pthology of the Skin with clinicl correltion. Volume 2. Clonje E, Brenn T, Lzr A, Mckee PH, editors. Fourth edition. Elsevier Sunders; 2012.pp 1460-63 14. Llms-Velsco M, Eguren C, Sntigo D, et l. Clcinosis cutis nd Sjogren's syndrome. Lupus 2010;19:762-4 15. Schornck MM, Siemsen DW, Brdley EA, Slomo DR, Lee HB. Oculr mnifesttions of molluscum contgiosum. Clin Exp Optom 2006; 89: 6: 390 393 16. Gryson W. Infectious diseses of the skin. In : Mckee s Pthology of the Skin with clinicl correltion. Volume 2. Clonje E, Brenn T, Lzr A, Mckee PH, editors. Fourth edition. Elsevier Sunders; 2012. 760-895 17. Al-fky Y H. Epidemiology of enign eyelid lesions in ptients presenting to teching hospitl. Sudi Journl of Ophthlmology (2012) 26, 211 216 18. Foyc-Sit H, Slzr-Cmpos M, In ez-vlde s L. Cysticercosis of the Extroculr Muscles. Our Experience And Review Of The Medicl Literture. The Internet Journl of Neurology. 2012;14(1). 19. Khlil MF, delrzik ST. Mlignnt eyelid lesions: histopthologicl types nd degree of tissue invsion t the time of presenttion. J Egypt Ophthlmol Soc 2015;108:52-6 Dr Prdny S Bhdrge et l JMSCR Volume 4 Issue 12 Decemer 2016 Pge 14375