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Pseudotumor of Lacrimal SAC
136
NOTES, CASES, INSTRUMENTS REFERENCES
1. Elwyn, H.: Diseases of the Retina. New York, Blakiston, 1953. 2. Troncoso, M. U.: Internal Diseases of the Eye and Atlas of Ophthalmoscopy. Philadelphia, Davis, 1942. 3. Sorsby, A. : Systemic Ophthalmology. St. Louis, Mosby, 1957. 4. Hogan, M. J., and Zimmerman, L. E.: Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1962. 5. Duke-Elder, W. S.: Textbook of Ophthalmology: The Ocular Adnexa. St. Louis, Mosby, 1952, v. 5.
PSEUDOTUMOR O F LACRIMAL SAC
histologically proved case of pseudotumor of the lacrimai sac.
J. GORDON COLE,
M.D.
CASE HISTORY
ALVIN BRACKUP,
M.D.
J. B., a 43-year-old woman, was admitted to the New York Eye and Ear Infirmary on September 24, 1961, because of a painless mass in the lower part of the medial canthal area of the right eye. She had first observed the mass 14 months earlier but had not noted any trauma or infection previous to its appearance. Physical examination disclosed a firm, nonmovable ovoid mass in the region of the right lacrimai sac, not extending outside the immediate site. While the mass was not adherent to the overlying skin, it felt as though it were attached to the un derlying bone. The globe was not displaced and there was no epiphora. Pressure over the mass did not cause régurgitation of pus or mucus through either punctum. As shown in Figure 1, lipiodol in jected into the right lower punctum passed freely through an apparently normal nasolacrimal duct. Blood and urine examinations were normal except for a sedimentation rate of 37 mm. On September 25, 1961, a firm mass at the site
J. S W I F T HANLEY,
M.D.
AND GEORGE K. HIGGINS,
M.D.
New York Primary tumors of the lacrimai sac are rare. Duke-Elder5 has collected 117 cases from the literature. Of these, 26 were pseudotumors or chronic inflammatory masses, 54 were epithelial tumors, 23 were mesenchymal tumors, 11 were reticuloses and three were malignant melanomas. Jones7 presented six cases of true tumor of the lacrimai sac and considered that the total number had ( 1956) exceeded 100. Review of the more recent literature on the lacrimai apparatus discloses a few pa pers on true tumors of the lacrimai sac, in cluding Bourgas' 1 presentation of polyps of the lacrimai sac, Crawford's 3 report of papilloma of the lacrimai sac and Davis' 4 paper on epidermal carcinoma of the lacrimai sac. No recent reports on pseudotumor of the lacrimai sac have been found, although Brandt 2 believes that true polyps of the lacrimai sac are rare and that many which are so reported should be more properly classed as pseudotumor. Finally, Ingalls'6 review of 26 cases of pseudotumor of the orbit includes none located in the lacrimai sac. It, therefore, seems unlikely that any pathologically verified cases have been re ported since some of the considerably ear lier cases reviewed by Duke-Elder. For this reason, it appeared important to present a
Fig. 1 (Cole, et al.). Lipiodol injected into the right lower punctum showed patency and anatomi cally normal appearance of the right lacrimai drain age apparatus.
NOTES, CASES, INSTRUMENTS
137
Fig. 2 (Cole, et al.). Photograph, showing discrete mass measuring 1.8 by 0.9 cm.
Fig. 4 (Cole, et al.). Low-power photomicrograph, showing lymphoid tissue.
of the lacrimai sac was removed. Although the mass appeared to be encapsulated, some of the un derlying bone was also removed from the fossa of the lacrimai sac. Recovery was uncomplicated. The gross specimen (figs. 2 and 3) was a discrete mass measuring 1.8 by 0.9 cm. The section showed that it consisted of white, hard tissue, suggesting tumor, which extended to the margins of the speci men. Microscopic examination (figs. 4 and 5) dis closed a lymphoid type of tissue with abundant
lymphocytes and large discrete follicles containing reticulum cells. Some of these were pale phagocytic cells. Plasma cells were scattered throughout the specimen. No atypical cells suggesting tumor were
Fig. 3 (Cole, et al.). Cross section, showing white, hard tissue as it appeared in gross specimen.
NOTES, CASES, INSTRUMENTS
138
identified. The pathologist's diagnosis was chronic nonsuppurative inflammation. The lesion suggested the hyperplastic follicular inflammatory reaction of lymph nodes. However, the cavity of the lacrimai sac and some epithelium could be identified. DISCUSSION 5 7
Authorities " agree with our clinical ex perience that benign and malignant tumors, polyps and pseudotumors present symptoms which are so similar that differential diag nosis without pathologic identifications usually is impossible unless a probe pushes a small polyp into the nose or the lower punctum, or unless the mass extends clearly beyond the lacrimai sac. The initial sign is usually suggestive of dacryocystitis, and epiphora is a nearly con stant sign. Tumor is often suspected first when the surgeon attempts to reduce a sup posed inflammatory stenosis. The passages are, however, likely to be permeable to syringing, at least until the lesion is quite advanced but is less often unresistant to probing. Following the state of dacryocys titis, a swelling suggestive of mucocele or cyst usually appears. Little or no pain tends to accompany further development of the mass. Our case is unusual in that it did not present the usual first stage resembling dac ryocystitis with tearing. While the drainage
apparatus is often permeable to fluids, the fully normal appearance of the passages in a fairly sizeable mass is quite remarkable and undoubtedly explains the absence of the ordinary initial symptoms. Ingalls' measurements of 24 pseudotu mors of the orbit showed that among the largest was one measuring 3.5 by 1.0 by 1.0 cm. The pseudotumor in our case would then be about medium size. Histologically, Ingalls describes pseudotumors as chronic inflammatory tissue consisting of lympho cytes, usually of two sizes. Colonies of small round cells stand out against surrounding stroma of edematous tissue undergoing fibrosis and hyaline degeneration. This le sion follows Ingalls' description in that it is a chronic polyblastic type of lesion. How ever, it tends to be proli ferative with less degeneration than the ones in Ingalls' de scription. SUMMARY
A case of pseudotumor of the lacrimai sac is presented. The diagnosis was made by means of histologie examination. Pseudo tumors of the lacrimai sac are rare. We have found none reported within recent time which have been pathologically verified. 780 Park Avenue (21).
REFERENCES
1. Bougas, A.: Polyps of the lacrimai sac. AMA Arch. Ophth., 66:236-340, 1961. 2. Brandt, L: Symptomatology and operation for polyps of lacrimai sac. Klin. Monatsbl. Augenh., 118: 172-175, 1951. 3. Crawford, J. S.: Papilloma of the lacrimai sac. Am. J. Ophth., 51:1303, 1961. 4. Davis, R. J.: Epidermal carcinoma of lacrimai sac. AMA Arch. Ophth., 55:21-22, 1956. 5. Duke-Elder, S.: Textbook of Ophthalmology. St. Louis, Mosby, 1952. v. 5, pp. 5345-5358. 6. Ingalls, R. G.: Tumors of the Orbit. Springfield, 111., Thomas, 1953, chap. 3, pp. 51-72. 7. Jones, I. S.: Tumors of the lacrimai sac. Am. T. Ophth., 42:561-566, 1956.
CORNEAL E P I T H E L I A L WRINKLING W I T H CONTACT LENSES J. WILLIAM ROSENTHAL,
M.D.
New Orleans, Louisiana
When a cornea stains after use of corneal contact lenses, the condition has been de-
scribed as deep epithelial abrasion, superfi cial punctate staining, arcuate cuts, super ficial abrasion with edema, linear stains from foreign bodies under the lens and limbal abrasions. In the corneas of patients wearing corneal contact lenses, I have noted, in addition, pooling of fluorescein-laden tears in fur-
NOTES, CASES, INSTRUMENTS REFERENCES
1. Elwyn, H.: Diseases of the Retina. New York, Blakiston, 1953. 2. Troncoso, M. U.: Internal Diseases of the Eye and Atlas of Ophthalmoscopy. Philadelphia, Davis, 1942. 3. Sorsby, A. : Systemic Ophthalmology. St. Louis, Mosby, 1957. 4. Hogan, M. J., and Zimmerman, L. E.: Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1962. 5. Duke-Elder, W. S.: Textbook of Ophthalmology: The Ocular Adnexa. St. Louis, Mosby, 1952, v. 5.
PSEUDOTUMOR O F LACRIMAL SAC
histologically proved case of pseudotumor of the lacrimai sac.
J. GORDON COLE,
M.D.
CASE HISTORY
ALVIN BRACKUP,
M.D.
J. B., a 43-year-old woman, was admitted to the New York Eye and Ear Infirmary on September 24, 1961, because of a painless mass in the lower part of the medial canthal area of the right eye. She had first observed the mass 14 months earlier but had not noted any trauma or infection previous to its appearance. Physical examination disclosed a firm, nonmovable ovoid mass in the region of the right lacrimai sac, not extending outside the immediate site. While the mass was not adherent to the overlying skin, it felt as though it were attached to the un derlying bone. The globe was not displaced and there was no epiphora. Pressure over the mass did not cause régurgitation of pus or mucus through either punctum. As shown in Figure 1, lipiodol in jected into the right lower punctum passed freely through an apparently normal nasolacrimal duct. Blood and urine examinations were normal except for a sedimentation rate of 37 mm. On September 25, 1961, a firm mass at the site
J. S W I F T HANLEY,
M.D.
AND GEORGE K. HIGGINS,
M.D.
New York Primary tumors of the lacrimai sac are rare. Duke-Elder5 has collected 117 cases from the literature. Of these, 26 were pseudotumors or chronic inflammatory masses, 54 were epithelial tumors, 23 were mesenchymal tumors, 11 were reticuloses and three were malignant melanomas. Jones7 presented six cases of true tumor of the lacrimai sac and considered that the total number had ( 1956) exceeded 100. Review of the more recent literature on the lacrimai apparatus discloses a few pa pers on true tumors of the lacrimai sac, in cluding Bourgas' 1 presentation of polyps of the lacrimai sac, Crawford's 3 report of papilloma of the lacrimai sac and Davis' 4 paper on epidermal carcinoma of the lacrimai sac. No recent reports on pseudotumor of the lacrimai sac have been found, although Brandt 2 believes that true polyps of the lacrimai sac are rare and that many which are so reported should be more properly classed as pseudotumor. Finally, Ingalls'6 review of 26 cases of pseudotumor of the orbit includes none located in the lacrimai sac. It, therefore, seems unlikely that any pathologically verified cases have been re ported since some of the considerably ear lier cases reviewed by Duke-Elder. For this reason, it appeared important to present a
Fig. 1 (Cole, et al.). Lipiodol injected into the right lower punctum showed patency and anatomi cally normal appearance of the right lacrimai drain age apparatus.
NOTES, CASES, INSTRUMENTS
137
Fig. 2 (Cole, et al.). Photograph, showing discrete mass measuring 1.8 by 0.9 cm.
Fig. 4 (Cole, et al.). Low-power photomicrograph, showing lymphoid tissue.
of the lacrimai sac was removed. Although the mass appeared to be encapsulated, some of the un derlying bone was also removed from the fossa of the lacrimai sac. Recovery was uncomplicated. The gross specimen (figs. 2 and 3) was a discrete mass measuring 1.8 by 0.9 cm. The section showed that it consisted of white, hard tissue, suggesting tumor, which extended to the margins of the speci men. Microscopic examination (figs. 4 and 5) dis closed a lymphoid type of tissue with abundant
lymphocytes and large discrete follicles containing reticulum cells. Some of these were pale phagocytic cells. Plasma cells were scattered throughout the specimen. No atypical cells suggesting tumor were
Fig. 3 (Cole, et al.). Cross section, showing white, hard tissue as it appeared in gross specimen.
NOTES, CASES, INSTRUMENTS
138
identified. The pathologist's diagnosis was chronic nonsuppurative inflammation. The lesion suggested the hyperplastic follicular inflammatory reaction of lymph nodes. However, the cavity of the lacrimai sac and some epithelium could be identified. DISCUSSION 5 7
Authorities " agree with our clinical ex perience that benign and malignant tumors, polyps and pseudotumors present symptoms which are so similar that differential diag nosis without pathologic identifications usually is impossible unless a probe pushes a small polyp into the nose or the lower punctum, or unless the mass extends clearly beyond the lacrimai sac. The initial sign is usually suggestive of dacryocystitis, and epiphora is a nearly con stant sign. Tumor is often suspected first when the surgeon attempts to reduce a sup posed inflammatory stenosis. The passages are, however, likely to be permeable to syringing, at least until the lesion is quite advanced but is less often unresistant to probing. Following the state of dacryocys titis, a swelling suggestive of mucocele or cyst usually appears. Little or no pain tends to accompany further development of the mass. Our case is unusual in that it did not present the usual first stage resembling dac ryocystitis with tearing. While the drainage
apparatus is often permeable to fluids, the fully normal appearance of the passages in a fairly sizeable mass is quite remarkable and undoubtedly explains the absence of the ordinary initial symptoms. Ingalls' measurements of 24 pseudotu mors of the orbit showed that among the largest was one measuring 3.5 by 1.0 by 1.0 cm. The pseudotumor in our case would then be about medium size. Histologically, Ingalls describes pseudotumors as chronic inflammatory tissue consisting of lympho cytes, usually of two sizes. Colonies of small round cells stand out against surrounding stroma of edematous tissue undergoing fibrosis and hyaline degeneration. This le sion follows Ingalls' description in that it is a chronic polyblastic type of lesion. How ever, it tends to be proli ferative with less degeneration than the ones in Ingalls' de scription. SUMMARY
A case of pseudotumor of the lacrimai sac is presented. The diagnosis was made by means of histologie examination. Pseudo tumors of the lacrimai sac are rare. We have found none reported within recent time which have been pathologically verified. 780 Park Avenue (21).
REFERENCES
1. Bougas, A.: Polyps of the lacrimai sac. AMA Arch. Ophth., 66:236-340, 1961. 2. Brandt, L: Symptomatology and operation for polyps of lacrimai sac. Klin. Monatsbl. Augenh., 118: 172-175, 1951. 3. Crawford, J. S.: Papilloma of the lacrimai sac. Am. J. Ophth., 51:1303, 1961. 4. Davis, R. J.: Epidermal carcinoma of lacrimai sac. AMA Arch. Ophth., 55:21-22, 1956. 5. Duke-Elder, S.: Textbook of Ophthalmology. St. Louis, Mosby, 1952. v. 5, pp. 5345-5358. 6. Ingalls, R. G.: Tumors of the Orbit. Springfield, 111., Thomas, 1953, chap. 3, pp. 51-72. 7. Jones, I. S.: Tumors of the lacrimai sac. Am. T. Ophth., 42:561-566, 1956.
CORNEAL E P I T H E L I A L WRINKLING W I T H CONTACT LENSES J. WILLIAM ROSENTHAL,
M.D.
New Orleans, Louisiana
When a cornea stains after use of corneal contact lenses, the condition has been de-
scribed as deep epithelial abrasion, superfi cial punctate staining, arcuate cuts, super ficial abrasion with edema, linear stains from foreign bodies under the lens and limbal abrasions. In the corneas of patients wearing corneal contact lenses, I have noted, in addition, pooling of fluorescein-laden tears in fur-