Isolated infantile myofibromatosis of the upper eyelid: uncommon localization and long-term results after surgical management

Myofibroma, the most common juvenile fibrous disorder in infancy, usually manifests as a solitary soft tissue tumor and less commonly as simultaneous multiple tumors in both soft tissue and bones. Infantile myofibromatosis is well described in the head and neck, but cutaneous lesions rarely occur in the periorbit and orbit, where fast growth and bone damage can mimic malignant tumors. We describe a case of a solitary periorbital myofibroma in a newborn. Treatment consisted of partial excision of the tumor. Histologic and immunohistochemistry analyses provided the diagnosis of infantile myofibromatosis. The patient remains disease-free at 10 years of age, but with some visual impairment. Infantile myofibromatosis is an uncommon tumor with exceptional periorbital involvement. Differential diagnosis can be difficult when it is solely based on histologic assessment. Immunohistochemistry evaluation demonstrating cytoplasmic actin filaments in neoplastic spindle cells confirms the diagnosis. As soon as the diagnosis is made, chest and abdominal imaging must be performed to evaluate the overall prognosis and direct treatment. The treatment of choice is early conservative surgery to minimize functional and/or esthetic damage. Complete tumor excision is not always possible. Lengthy ophthalmologic monitoring is required to detect the onset of amblyopia.

[Kissing nevus, a rare form of palpebral nevus--case report]

Kissing naevus is a rare form of congenital nevocellular naevus. We present the cases of three young girls. One of them was 9 years old and had an asymptomatic homogeneously pigmented round-oval naevus on the right eye and two girls (12 and 20 years old) who had the same kind of naevus of different sizes on the left eye, symmetrically situated on the two eyelids. The lower part of the naevus were bigger than the upper part in all the three cases. Histological they are compound or dermal nevus As treatment, ones recommend early excision, others contraindicates any surgical interventions.

Divided naevus of the eyelid, seven cases

Divided naevus of the upper and lower lids is an infrequent congenital naevus of the human eyelids. It is also known as kissing naevus or split ocular naevus. The histological types of divided naevi may be melanocytic, cellular or compound. Until now about 30 such cases have been reported in the literature. In our clinic, in the last 20 years we have seen seven patients with divided naevus, four female and three male. Three patients, two children of 10 and 11 years and a 77-year-old nun, did not accept any treatment. The remaining four patients, three female and one male, accepted surgical treatment. None of them had received any treatment in the past. Three of these divided naevi were cellular and one was melanocytic. Treatment included a two stage reconstruction in three cases and a single stage procedure in one case. The lower eyelid was usually treated first, and upper eyelid full thickness grafts were mostly used. Lid shortening was common, particularly in the cellular naevi. The results were aesthetically and functionally good. No major complications were observed.

[Isolated palpebral tumor revealing Von Recklinghausen's neurofibromatosis: a case report]

INTRODUCTION

Von Recklinghausen's neurofibromatosis is the most frequent of phakomatoses. Its incidence is 1/2,500-3,000 births. It is inherited through a dominant autosomal mode with a strong prevalence and changing expression. Eye and skin signs are essential to diagnosis and this case provided a noteworthy example of a unilateral upper palpebral tumor revealing this disease.

CLINICAL CASE

We report a case of a 6-year-old boy whose original clinical manifestation was a tumor on the upper eyelid of the right eye, present at birth. According to the anamnesis, this palpebral tumor gradually increased in size, causing a full ptosis. A biopsy exeresis of the tumor was carried out with an anatomicopathological study of the biopsy specimen, confirming the diagnosis.

CONCLUSION

The anatomicopathological study of the biopsy specimen enabled diagnosis of a neurofibromatosis revealed by this isolated palpebral localization responsible for significant aesthetic and functional damage.

The panda naevus: management of synchronous upper- and lower-eyelid pigmented naevi

We report four patients presenting with rare synchronous upper- and lower-eyelid naevi. The distributions and appearances of these naevi resemble the distinctive periorbital pigmentation of the panda. The possible embryological origin of this naevus and an approach to management are discussed.

[Congenital divided compound nevi of the eyelids]

BACKGROUND

Congenital divided nevi of the eyelids are a rare melanocytic lesion. Only 30 patients are reported in literature. We report on a 6-year-old boy and a 41-year-old male with this lesion and give a short overview of the literature.

CASE REPORTS

Patient 1: A 6-year-old boy presented with a pigmented divided nevus of the left eye involving the upper and lower lid naselly. The lesion had increased in size in the last one year. Otherwise the results of ophthalmological examination were unremarkable. The divided nevus was completely excised. Histopathological studies revealed a melanocytic compound nevus. Patient 2: A 41-year old male presented in our department with a divided pigmented nevus on his left eye involving the upper and lower lid laterally. The lesion had gradually increased since birth. Otherwise the results of ophthalmological examination were unremarkable. A subtotoal excision and debulking procedure was performed. The defect in the lower eyelid was covered using a transposition flap from the upper eyelid. Histopathological examination revealed a melanocytic compound nevus.

CONCLUSION

Divided nevi of the eyelids may be disfiguring and include the possibility of deprivation amblyopia when reaching a certain size in childhood. Malignant changes of this lesion were not observed so far. Total excision or subtotal excision and a debulking procedure may be helpful.

[Prevention of amblyopia in acute eyelid closure--a new method for keeping the optical axis open by insertion of a small tube]

BACKGROUND

Complete eyelid closure by capillary eyelid hemangioma or ptosis in the first months of life is an indication for acute measures to prevent amblyopia. Since it is sometimes not possible to hold up the affected upper eyelids with adhesive tape (mechanical obstacle, danger of skin maceration in involvement of the forehead) or not sufficiently (intense divergence), an alternative method will be presented for emergency treatment of blockade of the optical axis.

METHODS

The eyelids are kept open mechanically with a cylindrical tube of perspex (scleral immersion shell), which is normally used for echography of the anterior segment and for biometry (immersion technique). After surface anesthesia, it can be readily inserted. Its area of contact to the sclera has the form of a scleral shell. A drop of lubricant is applied into the tube at intervals of about five minutes.

PATIENTS AND RESULTS

In a six-week-old girl with complete eyelid closure owing to a facial hemangioma, adequate eyelid opening could only be achieved by insertion of the scleral immersion shell. In an eleven-months-old boy with complete ptosis and divergence as well as vertical deviation, the optical axis could only be kept open by insertion of the scleral immersion shell and by simultaneous displacement to the temporal side (adhesive tape). The uncomplicated performance for up to two hours daily was initially carried out in the hospital and later by the parents, and could be terminated after five and three and a half weeks, respectively, thanks to improvement due to therapy or spontaneous improvement.

CONCLUSIONS

Mechanical eyelid opening by insertion of a scleral immersion shell serves to bridge over the time interval to the onset of spontaneous improvement or the success of a causal therapy. The advantages consist in the good handling, also for parents, the low danger of injury and the ubiquitous and rapid availability (basic equipment of an ophthalmological ultrasonography unit).

Divided nevus of the eyelid: a case report

Divided nevus of the eyelid as a rare pathologic entity and develops during fetal growth, when the two eyelids are still fused together. Its surgical treatment is mostly based on full thickness skin grafts. We report a case of a 22-year-old woman with a congenital divided nevus affecting the left upper and lower eyelid. The patient was treated in our Department because of the onset of a purple red nodule in the lower part of the nevus. We examined the case from embryological, histopathological, clinical, and diagnostic standpoints, and discuss surgical options in order to reach an optimal functional and aestetic result.

Congenital extraskeletal Ewing's sarcoma of the face: a case report

This is the first reported case of congenital extraskeletal Ewing's sarcoma (EES) in the head and neck region. The tumor arose from the medial aspect of the right lower eyelid and rapidly increased in size despite surgery and chemotherapy. Accurate histologic diagnosis is emphasized, and the differential diagnosis, pathology, and treatment are discussed.

Dermoid cyst connected with the lacrimal canaliculum

An infant had a 3 x 1.5-cm congenital, slow-growing, lobulated tumor below the right inferior eyelid. The mass transilluminated, and needle aspiration yielded tears. Dacryocystography showed a large cystic area connected with the lower lacrimal canaliculum. Histologically, the tumor proved to be a dermoid cyst. This association has not been reported previously. Surgical excision and suture of the pedicule resulted in permanent cure.

[Divided nevus--an embryological experiment of nature]

A "divided naevus" (or "kissing naevus") is defined as a congenital melanocytic naevus that occurs on adjacent parts of the upper and lower eyelid and may give the appearance of a single lesion when the eye is closed. We report on four cases of this rare naevus. Two of these were examined histologically and showed the features of compound naevi. The unique occurrence in nature of the divided naevus allows conclusions on the site and time of origin not only of the divided naevus, but possibly also of other congenital melanocytic naevi. The divided naevus must originate at the latest during the period of lid fusion, between the 9th and 20th week of gestation. The fact that the fusion involves only epithelial tissue suggests an epithelial origin of congenital melanocytic naevi, which may later develop secondarily into compound or intradermal naevi by way of "dropping-off".

[Congenital malformations of the eyelids]

Congenital malformations of the eyelids have been classified in many ways, considering their various origins. The author proposes hereby a simplified classification concentrated on the therapy: 1. isolated malformations of one or two eyelids 2. palpebral anomalies associated with a more extensive craniofacial malformative syndrome 3. congenital tumors On this basis the author examines the most frequent malformations: blepharoptosis, coloboma, epicanthus, blepharophimosis, microblepharism and some congenital tumors. For each of these lesions, a surgical treatment is proposed and illustrated.

The successful treatment of a divided nevus on a young patient using a modified Kunhnt-Szymanowski procedure

A 16-year-old boy underwent excision of a congenital divided nevus on his left eyelids. The defect of the lower eyelid was repaired utilizing a modified Kuhnt-Szymanowski procedure, and the part of the nevus on the upper eyelid was removed by simple horizontal excision and suture. The symmetry of both of his eyelids was successfully preserved without ectropion or conspicuous scars. This procedure is especially effective even in a young patient when removing a lesion extending to the lower ciliary border.

Congenital palpebral lipoblastoma. First report of a case

Lipoblastoma, an uncommon benign tumor of adipose tissue, occurs in infants and young children. Anatomic sites usually involved include extremities, neck, trunk, retroperitoneum, and mediastinum. To our knowledge, no cases involving the eyelids have previously been reported. Its clinical presentation and appearance are not distinctive; diagnosis and differentiation from other lipocytic tumors are achieved via routine light-microscopic studies. Lipoblastoma is composed of fat cells exhibiting a broad spectrum of differentiation. Simple excision suffices as treatment.

Neuroglial choristoma presenting as congenital lid tumor

A 12-month-old boy presented with a diffuse solid tumor of the nasal portions of the lower lid, which had caused almost complete narrowing of the interpalpebral fissure since birth. Clinically, it was suspected to be a mesenchymal tumor. Radiological studies revealed no bony defects in the orbit. The computerized tomographic (CT) scan disclosed a porencephalic cyst in the ipsilateral cerebral hemisphere. Excisional biopsy of the lid tumor revealed ectopic neuroglial tissue. The immunocytochemical demonstration of glial fibrillary acidic protein (GFAP) was consistent with the electron microscopic findings that disclosed fibrillary astrocytes with an abundance of typical 9- to 10-nm glial filaments. Heterotopic neuroglial tissue should be part of the differential diagnosis of congenital lid tumors; its occurrence may be associated with other anomalies of cerebral organogenesis.

Congenital divided naevus of the eyelids

A newborn infant presenting with a divided congenital melanocytic naevus of the eyelid is described. Because of the severe disfigurement, risk of later malignant change in the lesion, and the possibility of deprivation amblyopia, early surgical treatment is recommended for all medium and large congenital melanocytic naevi of the eyelid. Surgery in the first few months of life gives the best cosmetic results.

Large congenital melanocytic nevus. Light and electron microscopic findings

The family of a 10-month-old black girl with a large periocular congenital melanocytic nevus (CMN) was given markedly differing advice from experienced physicians regarding how the lesion should be managed. The nevus was eventually removed surgically because of concern about the risk of malignant transformation and because of its cosmetic appearance. Histologically, the lesion was a dermal nevus, but extended deeply into subcutaneous tissue and had neuroid features. The ultrastructural characteristics of melanocytes varied according to the depth at which they resided, but cells did not differ basically from melanocytes found in smaller acquired nevi. Given the limited understanding of the biologic basis for malignant transformation, large size remains the most important risk factor in CMN.

Small lymphangiomas of the eyelids

Three patients are described with focal lymphangiomatous lesions of their eyelids. A child with a partially regressed, congenital lesion presented with evidence of recent hemorrhage, while, of two adults with acquired tumors, one had a blue lesion suggesting a malignant melanoma, and the other had a more obviously cystic lesion, suggesting an epidermal or adnexal cyst. In one case, the lesion was situated entirely within the marginal orbicularis striated muscle, and in the other two cases the lesion was restricted to the dermis of the lid. Abrupt change in the coloration of a lesion in the lid should suggest hemorrhage into a preexistent tumor. Hemorrhage into lymphangiomas is extremely common, and therefore this vascular tumor should be included in the differential diagnosis of previously nondiscolored lesions. Other vascular tumors, such as capillary, cavernous or venous angiomas would be expected to have a longstanding reddish-blue hue.

Encephalocraniocutaneous lipomatosis: a recently described neurocutaneous syndrome

The authors report a 1-year-old Japanese boy, who was noted to have unilateral alopecia and a cloudy cornea since birth. Additional features included mild spasticity and mental retardation, DQ being 70. A non-communicating cystic lesion was found in the right middle cerebral fossa by metrizamide CT scan, and resection of the lesion by craniotomy revealed an arachnoid cyst. The case was diagnosed as encephalocraniocutaneous lipomatosis, a recently described neurocutaneous syndrome.

Disorders of the lids

Included in the discussion is the management of anomalies of abnormal formation of the lid folds, disorders of differentiation of the lid margins, and disorders of tissue differentiation. Also discussed are lid involvement with bacterial lesions and viral diseases.

[Congenital solitary fibromatosis of the eyelid (author's transl)]

Clinical and histopathological findings in a case of localized congenital fibromatosis of the lower eyelid are presented. The histological and electron-microscopic features point to the hamartomatous origin of this tumor with partial differentiation of its cells towards myofibroblasts. In spite of the diffusely infiltrating growth and the tendency for local recurrences, metastases have never been observed. Therefore, local excision is the appropriate therapy.

Phakomatous choristoma of the lower eyelid with psammoma body formation: a light and electron microscopic study

A firm, round tissue mass, measuring approximately 12 mm in diameter, was excised from a 5-month-old boy who had a history of a gradually enlarging swelling in the left lower nasal eyelid since birth. Histologically and ultrastructurally, the lesion appeared benign and was composed of a dense connective tissue stroma in which nests, lobules, tubules, cords, and sheets of large, pale-staining cuboidal and elongated epithelial cells were surrounded by an irregular, thick PAS-positive basement membrane having focal excrescences. The interior of the epithelial islands contained "bladder" cells, cellular debris, granuloamorphous material, and foci of dystrophic calcification; an unusual feature of the lesion was the formation of numerous psammoma bodies. Tumors of lenticular anlage are rare and probably result due to displacement of migration of the inferior lens placode cells; alternatively, it may originate from an additional locus of lens vesicle in the primitive surface ectoderm of the lower lid. The lesion enlarges because of the differentiation of the ectopic lenticular cells in an abortive attempt to form a lens within the extraocular and mesodermal environment of the lid.

Orbital rhabdomyosarcoma in a neonate

A newborn with a pleomorphic rhabdomyosarcoma of the eyelid was treated by chemotherapy, surgery, and radiation therapy and experienced a good response. The nine previous cases in the literature are reviewed and this patient's therapy discussed.

Phakomatous choristoma of lower eyelid. A lenticular anlage tumour

A female infant was found to have a congenital, firm, pea-sized tumour nasally in the lower left eyelid. A dermoid cyst was suspected, but microscopy showed structures simulating a lens. The tumour has been considered to have an origin in surface ectoderm induced to dip down into the mesoderm of the lid, there forming lenticular anlage structures. This so-called phakomatous choristoma has only been reported five times previously, all cases outside Europe.

Phakomatous choristoma of eyelid: electron microscopical confirmation of lenticular derivation

This article presents the sixth recorded example of phakomatous choristoma of the eyelid. The tumor occurred in a 4-month-old boy and was located in the lower lid near the inner canthus. The findings from light microscopy included epithelial, tubular structures with associated patches of thick, irregular basement membrane. The results of electron microscopy (ie, epithelial cells with a scarcity of organelles, homogeneous type of basement membrane, cytoplasmic microfilaments, segments of fascia occludens, and degenerated cells with peculiar interdigitations of their plasmalemmas) are all consistent with lenticular derivation, as originally proposed by Zimmerman.

Giant hairy nevus: preventable cause of amblyopia

An infant with a congenital giant hairy nevus causing occlusion of the visual axis of the right eye is presented. The nevus was removed at the early age of three weeks because of concern that the child would develop deprivation amblyopia. Since such nevi can undergo malignant changes, early removal may be justified for that reason alone.