Periocular granuloma annulare

[Secondary eyelid pockets: Pitfalls in blepharoplasty surgery]

INTRODUCTION

Requests for cosmetic eyelid surgery are frequent. The surgeon must carry out a complete clinical examination in order to rule out any orbital pathologies responsible for eyelid pockets.

METHODS

Study of ten patients who have consulted in the oculopalpebral surgery department of La Fondation Ophtalmologique de Rothschild for cosmetic surgery of the eyelid pockets and in whom an underlying pathology was diagnosed.

RESULTS

The clinical examination allows to look for signs of alarms, such as medical history, unilateral involvement, pain and the presence of exophthalmos. These should lead to perform orbital imaging and surgical biopsy if an orbital mass has been identified for histological analysis which will make the diagnosis. We identified four cases of orbital lymphoma, one foreign body granuloma, chronic bilateral dacryoadenitis, sarcoidosis involvement, AAPOX syndrom, cavernous hemangioma, and simple fatty hernia.

CONCLUSION

These cases shows the importance of not ignoring an underlying orbital pathology before proposing cosmetic surgery for eyelid pockets.

Bilateral epibulbar pseudorheumatoid nodulosis with a review of ocular adnexal palisading granulomas

We describe the clinical, histopathologic, and immunohistochemical characteristics of episcleral/conjunctival pseudorheumatoid nodulosis, a new granulomatous entity that belongs among a group of related lesions. Specifically, pseudorheumatoid nodulosis should be differentiated from solitary rheumatoid nodules, rheumatoid nodulosis, accelerated rheumatoid nodules and nodulosis, and solitary pseudorheumatoid nodules. A 53-year-old man presented with bilateral painless, large, faintly yellow-gray, partially immobile, solid, circumscribed, and occasionally confluent episcleral nodules of several months' duration. He had never had clinical rheumatoid arthritis and was rheumatoid factor negative. Biopsy revealed multiple, merging episcleral/conjunctival, nonulcerated, palisading granulomas with variably sized central zones of necrobiosis of collagen. Abundant palisading CD68/163 + histiocytes admixed with fibroblasts surrounded the necrobiotic foci, which failed to stain with Alcian blue for mucopolysaccharides. No fibrinoid deposits were detected. Numerous CD3+ T lymphocytes, fewer CD 20 + B lymphocytes, and a smaller subpopulation of CD138 + plasma cells were present. Numerous CD1a + Langerhans cells were scattered among the palisading histiocytes and overlying epithelium. Immunohistochemical stains for immunoglobulins revealed concentrations of IgG, IgM, and IgA, but not IgE, in the necrobiotic zones. Special stains did not reveal evidence of infection nor did polarization microscopy display any foreign material. An extensive systemic and serologic workup was negative. We review simulating palisading or other nonrheumatic granulomas that should be distinguished from pseudorheumatoid nodules or nodulosis and explore therapeutic options.

Periocular granuloma annulare: a case report and review of literature

Granuloma annulare (GA) is a granulomatous dermatosis that rarely presents on the face and is extremely uncommon in the periocular region. We report our experience with the presentation and management of GA lesions on the eyelids of a 17-year-old girl. We performed a review of published literature and identified 13 cases of pediatric periocular GA. One additional case was identified upon review of all pediatric GA cases at the Cleveland Clinic Foundation. Review of these cases suggests that periocular GA is a benign condition that spontaneously regresses within a few months. GA nodules have a predilection for the upper eyelids. A greater incidence is noted in African American children. Awareness of the self-resolving nature of this condition can prevent unnecessary surgical excisions in affected children.

Granulomatous dacryoadenitis in regional enteritis (crohn disease)

PURPOSE

To evaluate the clinical and immunopathologic features of 2 patients with bilateral dacryoadenitis associated with regional enteritis.

DESIGN

Retrospective, clinicopathologic study.

METHODS

Clinical records, photographs, and imaging studies were reviewed and microscopic sections of lacrimal gland biopsy samples were critically re-evaluated. The microscopic slides were stained with hematoxylin and eosin, special stains for organisms, and a range of immunohistochemical biomarkers, including CD3, CD4, CD5, CD8, CD20, CD68, CD138, CD1a, and immunoglobulins Ig G, IgG4, and IgA.

RESULTS

Both patients were young women with a well-established diagnosis of regional enteritis. Histopathologic examination of biopsy samples disclosed moderate intraparenchymal fibrosis and lymphoplasmacytic infiltrates without lymphoid follicles. Small to medium intraparenchymal, noncaseating granulomas lacking multinucleated giant cells and, in 1 patient, CD68-positive and CD1a-negative palisading granulomas in widened interlobular fibrous septa were detected. Vasculitis and IgG4 plasma cells were not observed. Additional immunohistochemical studies revealed that CD8 T lymphocytes (suppressor or cytotoxic subset) predominated over CD4-positive T lymphocytes (helper cells) surrounding the necrobiotic foci and were intermixed with the CD68-positive histiocytes in the absence of CD20 B lymphocytes. Special stains for organisms demonstrated negative results.

CONCLUSIONS

Dacryoadenitis is the rarest form of ocular adnexal involvement in regional enteritis, which affects the orbit far more frequently than ulcerative colitis. It is a granulomatous process with the possibility of palisading necrobiotic foci. In contrast, ulcerative colitis causes an interstitial lymphocytic and nongranulomatous myositis. Sarcoidosis, Wegener granulomatosis, and pseudorheumatoid nodules must be ruled out. Treatment options entail a wide variety of agents with selection based on empirical considerations and tailored to the patient's symptoms.

Orbital granuloma annulare as presentation of systemic sarcoidosis

PURPOSE

To report a unique case of an orbital mass with atypical histopathologic features that although overlap with other granulomatous disorders, likely represents orbital involvement of systemic sarcoidosis.

METHODS

Observational case report.

RESULTS

A 51-year-old woman presented with an orbital mass and was found to have mild proptosis and restriction of ocular motility. The remainder of her ophthalmic exam was unremarkable. Excisional biopsy revealed ill-defined granulomas with central necrosis, chronic inflammation and sclerotic collagen; several features consistent with granuloma annulare. Further systemic workup including laboratory and radiologic studies were compatible with a diagnosis of systemic sarcoidosis.

CONCLUSION

Our case emphasizes the importance of a complete systemic workup with the detection of an orbital granuloma to ensure accurate diagnosis and appropriate management.

Periocular pseudo-rheumatoid nodules commonly affect the orbital rim

PURPOSE

To describe the typical presenting clinical characteristics and histopathology for periocular pseudo-rheumatoid nodules.

METHODS

Clinical case-note and histopathological review for patients presenting to the Orbital Clinic at Moorfields Eye Hospital between 1994 and 2002.

RESULTS

Four females with biopsy-proven periocular pseudo-rheumatoid nodules presented between the ages of 22 and 33 years (mean 26.8 years), having a 4-month to 3-year history of newly formed (or recurrent) subcutaneous nodules-these overlying the superotemporal orbital rim and rarely tender. One patient had insulin-dependent diabetes for 22 years and one patient had bilateral disease. The masses were excised in all patients, with a minor recurrence in one, not requiring further treatment; one patient defaulted from follow-up.

CONCLUSIONS

Periocular pseudo-rheumatoid nodules appear to typically present in young females, possibly more commonly with type I diabetes mellitus, and form a rather characteristic slowly growing, firm, occasionally slightly tender, subdermal nodule overlying the superolateral rim of the orbit. Surgical excision improves the condition in many cases, although spontaneous regression might also occur.

Deep dermal granuloma annulare presenting as an eyelid tumor in a child, with review of pediatric eyelid lesions

A case of deep dermal granuloma annulare (GA) involving the eyelid of a child is reported. GA presenting in the periocular region is rare and may mimic other lesions. The differential diagnosis of pediatric eyelid lesions is reviewed.

Granuloma annulare of the eyelid: a case report and review of the literature

Granuloma annulare is a benign, relatively common dermatosis of childhood. Lesions typically occur on the extremities and resolve spontaneously over a period of several months to years. Localized facial involvement is rare. We report a case of granuloma annulare confined to the left eyelid. The literature on periocular granuloma annulare is reviewed. This diagnosis should be considered for any acquired papules of the periorbital area, especially if there is a history of antecedent trauma. Unnecessary surgical excision can then be avoided.