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Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of...

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Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015
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Page 1: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Grand Rounds

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

Sciences1/16/2015

Page 2: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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.

Page 3: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Presentation

PMHx: Full term with uncomplicated delivery; Asthma

Meds:Albuterol, Zyrtec

Allergies: Cephalexin

Page 4: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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

Page 5: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.
Page 6: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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

Page 7: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Surgical Course

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

Page 8: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Pathology

Page 9: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Pathology

Page 10: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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

Page 11: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Orbital Cysts of Childhood

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

Page 12: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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

Page 13: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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

Page 14: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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

Page 15: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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.

Page 16: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

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.

Page 17: Grand Rounds Brooke LW Nesmith, M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 1/16/2015.

Thank you.


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