Linear nevus sebaceous syndrome

Ophthalmologic manifestations of organoid nevus syndrome: A series of 13 cases

Background

The organoid nevus syndrome is a rare neurocutaneous syndrome typified by cutaneous sebaceous nevus, seizures and epibulbar choristomas. The condition is associated with multiple ocular abnormalities. Herein, the authors aim to study and report the ophthalmic features of cases diagnosed with organoid nevus syndrome.

Methods

The authors retrospectively evaluated the records of patients with the organoid nevus syndrome who had presented to a tertiary care eye hospital in northern India. The ocular features were studied and entered in MS excel and the data were evaluated.

Results

Data of 13 patients with the organoid nevus syndrome were found. All 13 patients had cutaneous features in the form of Sebaceous nevus of Jadasson, 8 patients had alopecia of the scalp area, 2 had history seizures and 10 had arachnoid cysts on neuroimaging of the head. All 13 patients had a complex choristoma involving the ocular surface.

Conclusions

We conclude that the most common ophthalmologic features associated with organoid nevus are complex choristoma of the bulbar surface, scleral coat calcification and upper eyelid coloboma.

Line-Field Optical Coherence Tomography: Usefulness in the Non-Invasive Differential Diagnosis of Congenital Alopecia of Infancy

INTRODUCTION

Soon after birth, the clinical differential diagnosis between sebaceous of Jadassohn (NSJ), congenital triangular alopecia (CTA) and aplasia cutis congenita (ACC) may be challenging. A certain overlap of standard dermoscopic features can occur, especially in atypical cases, depending on scalp skin morphology and maturation age. The recently developed line-field confocal optical coherence tomography (LC-OCT) can provide morphological skin details with cellular resolution trough a rapid non-invasive examination.

OBJECTIVES

To assess the LC-OCT features of 6 cases of congenital alopecia of different aetiologies, with both typical and atypical clinical appearance.

METHODS

A non-invasive imaging examination combining standard dermoscopy, high-resolution videodermoscopy (HRVD) and LC-OCT was realized in 7 babies presenting for congenital alopecia with overlapping features, aged between 5 months and 5 years.

RESULTS

Based on the specific LC-OCT features, and supported by HRVD features, a diagnosis of NSJ, congenital triangular alopecia (CTA) and AC) were made in 4, 2 and 1 case, respectively.

CONCLUSIONS

The combined LC-OCT plus HRVD non-invasive imaging bring the advantage to have a real time diagnosis, to set the proper management and allows to avoid a skin biopsy in the perinatal age/first years of life at delicate skin site.

Calcified Sclero-Choroidal Choristomas in Mosaic RASopathies: A Description of a New Imaging Sign

PURPOSE

To evaluate the imaging and clinical features of unusual calcified lesions seen in the fundus of patients with mosaic RASopathy.

DESIGN

Single-center retrospective observational study.

SUBJECTS

Ten eyes with calcified fundus lesions in 7 patients with mosaic RASopathy.

METHODS

The lesions were evaluated with fundus photography, oral fundus fluorescein angiography, B-scan ultrasonography, magnetic resonance imaging (MRI), and computed tomography (CT) scan where available.

MAIN OUTCOME MEASURES

The imaging characteristics of calcified fundus lesions were assessed.

RESULTS

We found 7 patients with mosaic RASopathies, 5 men and 2 women (3 with linear sebaceous nevus syndrome, 3 with oculoectodermal syndrome, and 1 with encephalocraniocutaneous lipomatosis) with molecular confirmation in 5 cases, all 5 having KRAS-pathogenic variants. Calcified fundus lesions were identified in 10 eyes (bilateral in 3 patients), appearing as slightly elevated, creamy-yellow lesions around or adjacent to the optic nerve, extending supero-nasally; all but 2 of these lesions involved both the choroid and sclera, with 2 of them only involving the sclera at the time of examination. One case developed a choroidal neovascular membrane necessitating intravitreal bevacizumab injections. All 7 patients had B-scan ultrasonography, and the lesion appeared as a hyperechogenic area with an acoustic shadow posteriorly despite reduced gain. Five patients had MRI, and where fundus lesions were present, there was a focal defect in the sclero-choroidal layer. Four patients had a CT scan, and all 4 showed calcifications affecting both the posteromedial sclero-choroid and adjacent medial rectus muscle. Two of these patients had normal eye movements, 1 had a unilateral fixed adducted eye and a vestigial fibrous medial rectus muscle seen in imaging and intraoperatively, and the fourth had marked exotropia with a right gaze deficit affecting both eyes.

CONCLUSIONS

We propose that the lesions seen in this cohort are calcified sclero-choroidal choristomas and should be suspected in mosaic RASopathies when creamy-yellow lesions are seen in the fundus. If identified, the possibility of choroidal neovascularization should be considered during follow-up. In all cases where a CT scan was performed, a novel sign of sclero-muscular calcification involving the medial rectus muscle was seen.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Linear nevus sebaceous syndrome presenting as circumscribed choroidal hemangioma

A 4-year-old female with a unilateral circumscribed choroidal hemangioma and secondary total exudative retinal detachment. A nasal skin scar-like lesion incised to confirm a histopathologic diagnosis of linear nevus sebaceous. Further imaging disclosed asymmetry of the lateral ventricle frontal horns, suggestive of the diagnosis of linear nevus sebaceous syndrome. The choroidal hemangioma was treated with I-125 episcleral brachytherapy (apical dose of 45 Gy). At 6 months post-radiation, the tumor showed regression with total resolution of exudative retinal detachment.

Ocular features of the organoid nevus syndrome

PURPOSE

The purpose of the study was to demonstrate the ocular features of organoid nevus syndrome.

METHODS

A 10-day-old male infant was referred for management of retinoblastoma as a result of the presence of intraocular calcification. The examination showed a cutaneous lesion in the midline, epibulbar vascular lesions, and a cutaneous nodule at the lateral canthus. Fundus evaluation showed circumpapillary flat discoloration, which appeared hyperdense on ultrasound.

RESULTS

All these features were consistent with organoid nevus syndrome. The cutaneous lesion was consistent with nevus sebaceous, the epibulbar lesion with choristoma, and the fundus lesion with cartilaginous choristoma.

CONCLUSION

The presence of intraocular calcification often leads to a mistaken diagnosis in organoid nevus syndrome. Appropriate identification is important to diagnose this multisystem disorder.

Ocular manifestations and surgical management of lid coloboma in a Chinese infant with linear nevus sebaceous syndrome

An 8-month-old Chinese girl with linear nevus sebaceous syndrome had a right upper lid coloboma and right superior scleral ectasia. At 20 months old, successful surgical repair of the lid coloboma was performed with particular attention paid to the sclera ectasia.

Tc-99m HMPAO brain SPECT in linear nevus sebaceous syndrome

The authors present a case of linear nevus sebaceous syndrome (LNSS) with atrophy of bilateral frontotemporal areas of the brain, left cerebellum and hippocampus, and bilateral uncal dysplasia demonstrated by magnetic resonance imaging (MRI). Magnetic resonance angiography revealed bilateral internal carotid artery hypoplasia with absence of flow in the anterior and middle cerebral arteries. Tc-99m HMPAO brain SPECT demonstrated more areas of perfusion defects while MRI detected volume loss and gliosis in affected areas. Tc-99m HMPAO brain SPECT may be more useful for revealing absent or decreased perfusion areas of brain lesions than MRI in LNSS.

Loss of mismatch repair proteins in sebaceous gland tumors

BACKGROUND

Sebaceous gland neoplasms are rare tumors that are associated with visceral malignancies in patients with Muir-Torre syndrome (MTS). The majority of the MTS-associated tumors reveal mutations in DNA mismatch repair (MMR) genes (most often hMSH-2 and hMLH-1) and microsatellite instability. The sebaceous gland lesions in patients with MTS can often precede or occur concurrently with the visceral neoplasms. The early recognition of those lesions and their differentiation from sporadic sebaceous gland tumors are critical for proper patient management. Here we investigate the MMR gene expression in a variety of sebaceous gland tumors, with or without associated visceral malignancy.

METHODS

We studied the expressions of hMLH-1 and hMSH-2 in 10 consecutive sebaceous hyperplasias, 10 sebaceus nevi, 12 sebaceous adenomas, seven sebaceous carcinomas and the adjacent normal sebaceous glands using immunohistochemistry and paraffin-embedded sections.

RESULTS

The normal sebaceous glands and the glands of all the sebaceus nevi were positive for hMLH-1 and hMSH-2. Loss of hMSH-2 expression was found in 1/10 (10%) sebaceous hyperplasias, 3/12 (25.0%) sebaceous adenomas, and 2/7 (28.6%) sebaceous carcinomas. Loss of hMLH-1 expression was seen in 1/10 (10%) hyperplasias, 3/12 (25.0%) adenomas, and 1/7 (14.3%) carcinomas. No concurrent loss of both hMLH-1 and hMSH-2 was observed. Loss of MMR (either hMLH-1 or hMSH-2) was detected in 80% of the benign sebaceous lesions associated with malignancy. In comparison, only 23% of sebaceous lesions not associated with malignancy showed loss of MMR proteins. No loss of hMSH-2 protein was found in the visceral cancer in one patient with hMSH-2-negative sebaceous adenoma.

CONCLUSIONS

Our results confirm the previous reports of alterations of mismatch repair genes in the sebaceous neoplasms of patients with MTS. However, we showed that those changes also occur early at the stage of sebaceous hyperplasia, even in the absence of a visceral malignancy. This indicates the importance of the abnormal DNA mismatch repair in the progression of this disease.

Complex ocular choristomas in linear nevus sebaceus syndrome: a report of two cases

Two cases of linear nevus sebaceus syndrome (LNSS) are described in which ipsilateral facial nevus of Jadassohn was associated with complex ocular choristoma. One patient also had scleral osteomas, a rare occurrence in LNSS.

An unusual presentation of a linear epidermal nevus

We report an unusual presentation of a linear epidermal nevus in an adolescent male. Epidermal nevi most commonly appear in infancy and early childhood. They often are found in association with other organ system anomalies. We describe a palmar linear epidermal nevus that caused impairment of the patient's use of his hand. Therapeutic management involved surgical excision of the nevus and reconstruction of the area with a full-thickness skin graft.

Perioperative management of infants with the linear naevus sebaceous syndrome of Jadassohn: a report of two cases

Neurofibromatosis and tuberous sclerosis are the most well-recognized of the congential phakomatoses, a group of six hereditary neuro-oculo-cutaneous disorders. Although easily diagnosed at birth by a parasagittal line of facial sebaceous naevi, the linear naevus sebaceous syndrome (LNSS) of Jadassohn is the rarest phakomatosis, one often characterized by airway and anaesthetic considerations that do not apply to the other phakomatoses. In addition to its obvious cutaneous manifestations, LNSS is characterized by hemifacial asymmetry, an anatomic predictor of difficult trachael intubation, and intractable seizure activity, a condition that limits selection of anaesthetics. The perioperative management challenges of LNSS are depicted in the presentation of two cases of LNSS with different outcomes and contrasted with the major anaesthetic considerations in the perioperative management of other, more common phakomatoses.

Posterior scleral choristoma in the organoid nevus syndrome (linear nevus sebaceus of Jadassohn)

PURPOSE

To highlight the association of posterior osseous and/or cartilaginous ocular choristomas with epibulbar choristomas and the nevus sebaceus of Jadassohn.

DESIGN

Small case series.

PARTICIPANTS

Four patients with the organoid nevus syndrome.

METHODS

Clinical and histopathologic studies in four patients with epibulbar lesions and nevus sebaceus of Jadassohn.

MAIN OUTCOME MEASURES

Ophthalmoscopic findings of peripapillary lesions. Computed tomographic and ultrasonographic characteristic of posterior scleral lesions. Ocular histopathologic findings in one globe from one of the study subjects.

RESULTS

Three patients had the triad of posterior osseous/cartilaginous ocular choristomas, anterior epibulbar choristomas, and nevus sebaceus of Jadassohn and one patient had anterior epibulbar choristomas and posterior osseous/cartilaginous ocular choristomas. Ultrasonography and computed tomography were valuable in detecting scleral ossification or epibulbar cartilage or both. The ophthalmoscopic findings were similar to those of a choroidal osteoma.

CONCLUSIONS

The presence of posterior osseous/cartilaginous ocular choristomas in a patient with epilepsy or epibulbar lesions or both suggests the diagnosis of nevus sebaceus of Jadassohn. Osseous/cartilaginous ocular choristomas should be suspected in patients with nevus sebaceus of Jadassohn and peripapillary hypopigmented fundus lesions.

Complex limbal choristomas in linear nevus sebaceous syndrome

OBJECTIVE

This study aimed to describe the clinical and histopathologic findings in four patients with complex limbal choristomas associated with linear nevus sebaceous syndrome (LNSS), a rare disorder including nevus sebaceous, seizures, and mental retardation, and often accompanied by ocular anomalies.

DESIGN

Small observational case series.

METHODS

A retrospective review of the clinical and histopathologic records of four patients.

RESULTS

Each of four patients had complex limbal choristomas in the setting of clinical and histopathologic LNSS. The limbal choristomas were multiple in three patients and bilateral in two patients. Most choristomas involved the superotemporal limbus (6 of 10), although nasal (3 of 10) and inferior (1 of 10) limbal tumors also were present. Three patients had significant corneal astigmatism or involvement of the central cornea requiring surgical removal of their choristomas, one accompanied by a lamellar keratoplasty and another accompanied by two consecutive penetrating keratoplasties. Each graft eventually vascularized, reducing vision. One patient's vision was limited by amblyopia and another by occipital cortical dysgenesis with visual impairment. Histopathologic examination of the excised choristomas showed foci of lacrimal gland (3 of 4 patients), adipose tissue (3 of 4), neural tissue (1 of 4), cartilage (1 of 4), lymphoid follicles (1 of 4), skin adnexal tissue (1 of 4), and smooth muscle (1 of 4). Other associated ocular findings included an eyelid mass (1 of 4), colobomas of the eyelid (3 of 4), colobomas of the choroid and retina (2 of 4), nonparalytic strabismus (2 of 4), scleral ectasia (1 of 4), partial oculomotor palsy with ptosis and anisocoria (1 of 4), microphthalmia (1 of 4), hypertelorism (1 of 4), and cortical visual impairment (1 of 4).

CONCLUSIONS

Complex limbal choristomas, although rare, can occur in the setting of LNSS and can be associated with multiple ocular and systemic abnormalities. Visual prognosis appears poor in most cases despite aggressive management.

Ocular manifestations of the organoid nevus syndrome

BACKGROUND

The organoid nevus (sebaceous nevus) syndrome is characterized primarily by cutaneous sebaceous nevus, seizures, and epibulbar choristomas. Based on ophthalmoscopy and computed tomography (CT), a yellow fundus lesion recently observed in this syndrome has been called a coloboma by some authors or a choroidal osteoma by others. This study was undertaken to review the authors' personal experience with the organoid nevus syndrome, to review the English language literature on the subject, and to address some misconceptions regarding its ocular manifestations.

METHODS

The authors reviewed the records of patients with the organoid nevus syndrome who were personally evaluated by the authors. The ocular findings were studied in more detail, with emphasis on the epibulbar and fundus lesions.

RESULTS

The authors identified five patients with the organoid nevus syndrome. Four had a classic sebaceous nevus in the facial and scalp area and two had seizures and arachnoid cysts. All five patients had an epibulbar tumor, which proved to be a complex choristoma in one case that was studied histopathologically. A characteristic ophthalmoscopic feature, observed in the four patients with clear ocular media, was a flat, yellow discoloration of the posterior fundus, of variable size and shape, that appeared to correlate with a dense plaque noted on ultrasonography and CT. In one case, histopathologic studies showed that this posterior lesion contained intrascleral cartilage.

CONCLUSIONS

The authors' observations and a review of the literature indicated that the organoid nevus syndrome has varied manifestations. Just like the closely related phakomatoses, it often occurs as a forme fruste, without full expression of the syndrome. The most important ocular manifestations are an epibulbar mass, compatible with a complex choristoma, and focal, yellow discoloration in the fundus, probably related to intrascleral cartilage.

Coexistent orbital and cerebellar venous anomalies in linear sebaceous naevus syndrome

BACKGROUND

Orbital venous anomalies can result in significant morbidity and have been reported in association with other venous anomalies, some with the potential for serious complication.

METHODS/RESULTS

We present a case of an orbital venous anomaly coexistent with a large cerebellar venous angioma and a linear sebaceous naevus. Clinical features, associations, complications and management principles are presented.

CONCLUSION

Upon clinical recognition of an orbital venous anomaly, brain imaging and appropriate clinical assessment should be considered in light of the possibility of coexistence of potentially life-threatening lesions.

Developmental neural abnormalities and seizures in epidermal nevus syndrome

The epidermal nevus syndrome (ENS) is an unusual neurocutaneous disorder consisting of the combination of an epidermal nevus and a central nervous system (CNS), ophthalmological, and/or skeletal abnormality. The study reports four new patients with ENS. Each had a confirmatory biopsy of the epidermal nevus, abnormal neurological examination findings, and documented CNS anatomical studies by imaging or autopsy. The paper also reviews the literature in English to determine neurological abnormalities found in skin-biopsy-proven cases of ENS. Hemi-atrophy, hemimegalencephaly, migrational abnormalities and vascular anomalies were found to be the most frequent intracranial abnormalities associated with ENS. Seizures and/or disabling moderate to severe developmental delays were present in a majority of patients. Seizure onset during the neonatal period or early infancy was associated with major hemispheric malformations. Neuroectodermal-derived ocular lesions were often bilateral. No consistent relation between laterality of the nevus and laterality of CNS abnormalities was found, supporting the gene mosaicism theory of pathogenesis.

Linear sebaceous nevus syndrome: report of a patient with unusual associated abnormalities

A 9-year-old girl was diagnosed as having a linear sebaceous nevus syndrome (LSNS). The nevus sebaceus was located on the face, and the girl also had nevoid hypertrichosis on the neck, sensorineural deafness, partial anodontia, blocked tear ducts, labiopalatoschisis, and an area of micropolygyria in the left encephalic (cerebral) hemisphere. Electroencephalographic alterations were detected, but they were not accompanied by a history of seizures; furthermore, the child was not mentally retarded. This phenotypic pattern of LSNS is unusual for the rarity of associated abnormalities.

Ophthalmic features of the organoid nevus syndrome

BACKGROUND/PURPOSE

The organoid nevus (sebaceous nevus) syndrome is characterized primarily by cutaneous sebaceous nevus, seizures, and epibulbar choristomas. On the basis of ophthalmoscopic and computed tomographic studies, a yellow fundus lesion recently observed in this syndrome has been called a coloboma by some investigators and a choroidal osteoma by others. This study was undertaken to review our personal experience with the organoid nevus syndrome, to review the English language literature on the subject, and to address some misconceptions regarding its ocular manifestations.

METHODS

We reviewed the records of patients with the organoid nevus syndrome who were personally evaluated by the investigators. The ocular findings were studied in more detail, with emphasis on the epibulbar and fundus lesions.

RESULTS

We identified five patients with the organoid nevus syndrome. Four had a classic sebaceous nevus in the facial and scalp area, and 2 had seizures and arachnoid cysts. All 5 patients had an epibulbar tumor, which proved to be a complex choristoma in one case that was studied histopathologically. A characteristic ophthalmoscopic feature, observed in the 4 patients with clear ocular media, was a flat yellow discoloration of the posterior fundus, of variable size and shape, which appeared to correlate with a dense plaque noted on ultrasonography and computed tomography. In 1 case, histopathologic examination showed that this posterior lesion contained intrascleral cartilage.

CONCLUSIONS

Our observations and a review of the literature indicated that the organoid nevus syndrome has varied manifestations. Like the closely related phakomatoses, it often occurs as a forme fruste, without full expression of the syndrome. The most important ocular manifestations are an epibulbar mass, compatible with a complex choristoma, and focal yellow discoloration in the fundus, probably related to intrascleral cartilage.

Ophthalmologic abnormalities in encephalocraniocutaneous lipomatosis

Encephalocraniocutaneous lipomatosis (ECCL) is a sporadically occurring disorder that belongs to the group of neurocutaneous syndromes. Important characteristics of the case we present are: intracranial lipomas, a skull hamartoma, bilateral lipodermoids and jaw tumors (ossifying fibromas and compound odontomas). We propose four minimal criteria for the diagnosis of ECCL and review the ocular abnormalities reported to date.

Ocular and systemic manifestations of encephalocraniocutaneous lipomatosis

Encephalocraniocutaneous lipomatosis is a congenital neurocutaneous syndrome with epibulbar choristomas and connective tissue nevi of the eyelids as common ophthalmic manifestations. Systemic manifestations occur ipsilateral to the ocular lesions and include lipomas of the cranium and central nervous system, alopecia of the scalp, and abnormalities of the central nervous system. We treated a child with encephalocraniocutaneous lipomatosis who required removal of an epibulbar choristoma. Pathologic evaluation of the epibulbar choristoma in our patient showed the presence of ectopic lacrimal gland tissue and cartilage. Encephalocraniocutaneous lipomatosis should be considered, together with Goldenhar's syndrome and sebaceous nevus syndrome, in the differential diagnosis of conditions associated with epibulbar choristomas.

Epidermal nevus syndrome: case report and review of clinical manifestations

The epidermal nevus syndrome is a disorder characterized by epidermal nevi and associated neurologic, skeletal, and other abnormalities. We cared for a 3-month-old male with multiple epidermal nevi and severe central nervous system involvement.

Ocular choristomas

Choristomas are congenital lesions representing normal tissue(s) in an abnormal location. They are the most common epibulbar and orbital tumors in children. Epibulbar choristomas affect the cornea, limbus or subconjunctival space, and range in appearance from a small, flat lesion to a large mass filling most of the epibulbar region. Astigmatism is often present. Choristomas may be associated with coloboma, Goldenhar syndrome or epidermal nevus syndromes; those associated with the latter are often bilateral and extensive. Choristomas are occasionally familial. Surgery may be indicated to improve vision or cosmesis, or to impede growth. Although choristomas most commonly involve the epibulbar area, they can affect many areas of the eye and orbit, and often affect more than one area.

Choroidal osteoma

This review details the characteristic clinical features, diagnostic approaches, management, and prognosis of the choroidal osteoma. A comprehensive differential diagnosis is organized to help the ophthalmologist differentiate this tumor from conditions which can sometimes be clinically similar, such as amelanotic choroidal melanoma and nevus, metastatic choroidal carcinoma, choroidal hemangioma, metastatic and dystrophic intraocular calcification, and others. The pathology of the choroidal osteoma is illustrated and several theories of the pathogenesis of this tumor including the possibilities of a choristomatous, inflammatory, and hereditary etiology are discussed. The recently recommended therapeutic technique of photocoagulation of subretinal neovascularization associated with choroidal osteoma are discussed.

Late occurrence of additional ocular and intracranial pathologies in the linear naevus sebaceous (Feuerstein-Mims) syndrome

The linear naevus sebaceous syndrome of Feuerstein-Mims belongs to the phacomatoses and classically is composed of a linear cutaneous lesion associated with mental retardation and epilepsy, sometimes also with ocular dystrophies. During an unusually long follow-up of 32 years of such a case, which is reported here, the late occurrence of additional ocular and intracranial pathology are demonstrated: conjunctival and bulbar tumours with progressive deterioration of visual acuity, bilateral intracranial arachnoidal cysts, dilatation and tortuosity of the middle cerebral artery. As a consequence of these observations the prognosis in cases with this syndrome has to be given with special caution.

Epibulbar choristomas containing lacrimal tissue. Clinical distinction from dermoids and histologic evidence of an origin from the palpebral lobe

Three new cases of epibulbar choristomas, all containing lacrimal tissue, are presented and compared with those reported previously in the literature. The first and second cases were unilateral, complex choristomas, consisting of ectopic lacrimal tissue, smooth muscle, and cartilage; the first case was also remarkable for the presence of lesional tissue in the peripheral cornea and evidence of progressive growth during puberty. The third case was a bilateral, complex choristoma, manifesting epibulbar lacrimal tissue, cartilage, and smooth muscle; also associated were bilateral optic nervehead colobomas and a uniocular focus of posterior scleral cartilage demonstrated by computed tomography (CT) scanning. On clinical examination, all three lesions displayed highly vascularized thickenings of the conjunctiva with diagnostically useful gelatinous elevations, which corresponded microscopically to lobules of lacrimal tissue. In addition, all three cases had the interesting diagnostic feature of superficial corneal scarring or sclerosis, with a fine vascularity adjacent to the conjunctival lesional tissue. Electron microscopy of the third case demonstrated completely normal cytoarchitecture of the lacrimal tissue. Because of the frequent presence of Müller's smooth muscle in epibulbar lacrimal choristomas, the authors propose that these lesions represent embryologic ectopias or overly extensive field effects of the palpebral lobe of the lacrimal gland.