Dermoid Cyst of Conjunctival Origin

Developmental Cysts of the Orbit With Mixed Conjunctival and Cutaneous Epithelial Phenotypes

AIM

To describe the characteristics of patients presenting with congenital orbital cysts containing epithelia of both cutaneous phenotype-that is, epidermis with or without keratin, and at least one dermal structure (sweat gland or pilosebaceous unit)-and conjunctival phenotype (with goblet cells); these cysts with mixed lining are termed "dermo-conjunctival" cysts.

PATIENTS AND METHODS

Review of clinical records for patients having dermo-conjunctival cysts that were treated between 1997 and 2017; patients with cysts of solely conjunctival or solely cutaneous origin were omitted. Data recorded included gender, age at presentation, laterality, orbital location, ophthalmic features, surgical and radiological data, and light microscopic findings.

RESULTS

Of 241 patients with congenital orbital cysts, 22 (9%) contained both cutaneous and conjunctival epithelium; unlike the relatively common congenital cysts lined with solely cutaneous epithelia, these dermo-conjunctival cysts typically occupied the superonasal or nasal quadrants of the orbit (p < 0.000001). Fifteen (68%) of the 22 patients were male, and the group presented at a median age of 22 years (range 8-51 years), with symptoms for a median duration of 5 years (range 1 month-33 years). Fourteen (64%) had noted an orbital mass, 3 (14%) had inflammatory pain, and 1/22 (4%) had reduced acuity. Globe displacement was axial in 7 patients (32%) and nonaxial in 13 (59%), and ocular motility was restricted in 4/22 (18%). Of 17 patients with imaging, 9 (53%) had bone expansion, and the cyst was intimately related to the trochlea in 10 (59%). By definition, all cysts contained conjunctival epithelium with goblet cells: hair shafts were present in 13/22 (59%) specimens, sebaceous units in 18 (82%), sweat glands in 6 (27%), and keratinized epithelium was present in 8 (36%). Fourteen (63%) of cysts had mild chronic inflammation within the cyst wall, and granulomas were present in 8 (36%).

CONCLUSION

Congenital dermo-conjunctival orbital cysts are rare and favor a medial location-this suggesting an origin from sequestered caruncular tissues, the only postseptal source of both dermal and conjunctival structures. Unlike pure cutaneous cysts that typically present as superficial masses in childhood, dermo-conjunctival cysts are often postseptal and present in adults.

Clinical features of intratarsal keratinous cysts

PURPOSE

Intratarsal keratinous cysts (IKCs) have been frequently misdiagnosed as chalazia or epidermal cysts. We reviewed a series of cases of IKCs to identify clinical features that distinguish IKCs from other eyelid diseases.

METHODS

We retrospectively reviewed the medical records of 17 suspected IKC patients between January 2004 and September 2014.

RESULTS

Seventeen patients who were clinically suspected to have IKC were enrolled. All patients presented with non-inflamed eyelid nodules fixed to the tarsus. Among them, 12 biopsy specimens were available and 11 patients (91.7%) were diagnosed with IKC, with a pathological finding of stratified squamous cell lining with keratin material. The mean patient age was 55.1 years (31-71). Six patients had a surgical history of incision or incomplete excision of the lesion, followed by recurrence. On eyelid eversion, five patients showed a white-yellow nodule, and three patients had a bluish cystic lesion. The diameter of the nodules ranged from 4 to 10 mm. The intracystic material was a milky white fluid. Ten patients underwent a complete surgical excision including partial tarsectomy and there was no recurrence.

CONCLUSIONS

IKC can be distinguished from other intratarsal lesions by a characteristic tarsal nodule fixed to the tarsus. To prevent recurrence, complete excision with partial tarsectomy is needed.

The cytologic composition of dacryops: an immunohistochemical investigation of 15 lesions compared to the normal lacrimal gland

PURPOSE

To define the cytologic composition of the double-layered epithelial lining of dacryops (lacrimal duct cyst), improve histopathologic diagnosis, and better understand pathogenesis.

DESIGN

Clinicopathologic retrospective study with immunohistochemical studies of 15 lesions compared with normal lacrimal gland.

METHODS

Clinical data from 14 patients were reviewed and microscopy was performed with routine stains and immunohistochemical probes for epithelial membrane antigen (EMA), gross cystic disease fluid protein-15 (GCDFP-15), cytokeratin 7 (CK7), and smooth muscle actin (SMA).

RESULTS

The major lacrimal gland was involved in 13 lesions; 2 lesions arose in an accessory gland of Krause. One case was bilateral; the average age of the patients was 50.7 years. Neither visual acuity nor motility was disturbed. No lesion was discovered to have recurred after excision. Microscopically, in all dacryops specimens goblet cells and luminal pseudoapocrine apical cytoplasmic projections were identified. Lacrimal acinar cells immunoreacted with GCDFP-15 and CK7, whereas the normal ducts and the epithelium of the dacryops lesions reacted diffusely only with CK7. SMA-positive myoepithelial cells were found in the acini but not in the normal ducts or dacryops epithelium.

CONCLUSIONS

Negative GCDFP-15 staining ruled out apocrine metaplasia in dacryops. Normal ducts and dacryops showed no immunohistochemical evidence for the presence of myoepithelial cells. Pathogenetic theories of dacryops that implicate a failure of ductular "neuromuscular" contractility must therefore be revised. A dysfunction of the rich neural plexus around the ductules may play a role in the development of dacryops in conjunction with periductular inflammation and induced scarring.

Palpebro-orbital apocrine cystadenoma: immunohistochemical verification of a unique variant with a critical differential diagnosis

PURPOSE

To describe a unique apocrine cystadenoma of the superonasal eyelid and anterior orbit.

METHODS

Clinical evaluation with axial and coronal CT; histopathologic and immunohistochemical studies including sections stained with hematoxylin-eosin, periodic acid Schiff, alcian blue, mucicarmine, and Prussian blue for iron; and monoclonal antibodies against cytokeratin-7, epithelial membrane antigen, smooth muscle actin for myoepithelial cells, gross cystic disease fluid protein-15 for apocrine differentiation, and CD-68 and lysozyme for histiocytes.

RESULTS

The cyst possessed a multilaminar lining composed of polygonal to low cuboidal cells. A stalk of solid tumor ingrowth from the wall was composed of adenomatous units of eosinophilic cells with apical snouts ("decapitation secretion"). No goblet cells were discovered. Both the cyst's lining cells and the adenoma expressed gross cystic disease fluid protein-15 indicative of apocrine differentiation. The adenoma displayed inner adlumenal cells that were CK-7 and epithelial membrane antigen positive, and outer myoepithelial cells that were smooth muscle actin positive. Simple local excision was curative.

CONCLUSION

This unique lesion is the first example in the ophthalmic and dermatopathologic literatures of a solid adenoma encompassed by an apocrine cyst, which more typically features short or blunt papillae. It must be distinguished from other eyelid and/or anterior orbital cystic lesions including eccrine hydrocystomas; classical and extratarsal dermoid cysts; congenital and acquired conjunctival cysts and dermoids; dacryocystocoeles/mucoceles; canaliculops and lacrimal gland dacryops; and congenital cystic odontogenic choristomas.