MANAGEMENT OF A CASE OF LIMBAL DERMOID

1. THE HAIRY EYEBALL-
LIMBAL DERMOID
DR.PAWAN N. JARWAL,
DR.KINJAL H. DESAI,
THIRD YEAR RESIDENTS
DEPARTMENT OF OPHTHALMOLOGY
S. S. G. HOSPITAL,VADODARA

2. INTRODUCTION:
• The estimated worldwide incidence of limbal dermoid is 1 per 10,000 to 3
per 10,000.
• Limbal dermoid are benign congenital tumours that contain choristomatous
tissue (tissue not found normally at that site).
• They appear most frequently at the inferior temporal quadrant of corneal
limbus and remain localised mostly to the superficial layer of the cornea and
sclera.
• They may contain a varity of histologically aberrant tissues, including
epidermal appendages, connective tissue,skin,fat,sweat gland,lacrimal gland
,muscle ,teeth,cartilage,bone,vascular structure and neurologic tissue
including the brain. Malignant degeneration is extremely rare.

3. • Limbal dermoid are thought to arise from an early embryological
anomaly (occurring at 5-10 weeks gestation)resulting in metaplastic
transformation of mesoblast between the rim of optic nerve and
surface ectoderm .
• Limbal dermoid are present at birth but may not be recognized until
the first or second decade of life . They may appear to enlarge as the
body mature.

4. MATERIALS AND METHODS:
• A 30 year old man presented with a mass in his left
eye that was present since birth and gradually
increased in size . He did not have pain, but the mass
caused vision defect, sensation of presence of a
foreign body, discomfort on blinking and cosmetic
disfigurement. There was no family history of
similar lesion.

5. • Examination revealed a solid reddish-
yellow, round, mass measuring 5x5x3
mm having rough surface with partly
keratinized epithelium and hair
involving the infero-temporal limbus
and cornea .No associated regional or
systemic abnormalities were found
.Visual acuity was 6/6 in right eye and
6/60 in left eye. The finding on slit-lamp
examination,fundoscopy and ocular
USG were within normal limit and IOP
was normal .

6. • After obtaining consent from patient the lesion
was dissected off the cornea and limbus under
local anaesthesia with meticulous attention for
preservation of normal tissue. A cleavage plane
was fashioned, and the dermoid was removed
from the cornea first, with movement towards
the limbus. Removed section was sent for
histopathologic examination where section
showed histology of flattened epidermis. Dermis
contained occasional sebaceous gland lobule
with hair follicle and adnexal glands in a loose
collagenised tissue.

7. • The surgical result was very reasonable from a cosmetic result, and
the patient recovered well from his symptoms .As expected there was
little improvement in visual acuity after surgery because of the
amblyopia and induced astigmatism.

8. DISCUSSION:
• Anatomically limbal dermoids have been classified into three grades.
This form of grading allows clinicians to take a more stepwise
approach to the clinical and surgical management of such lesion.
*Grade 1 limbal dermoid are superficial lesion measuring less than 5
mm and are localized to limbus. Such lesion may lead to development
of anisometropic amblyopia ,with slow growth resulting in oblique
astigmatism and flattening of cornea adjacent to the lesion.
*Grade 2 limbal dermoids are larger lesion covering most of the cornea
and extending deep to the stroma down to Descemet's membrane
without involving it.
*Grade 3 limbal dermoids ,the least common of all the presenting
dermoids ,are larger lesion covering the whole cornea and extending
through the histological structures between the anterior surface of the
eye ball and the pigmented epithelium of iris .

9. • Visual morbidity in limbal dermoid mainly results from
encroachment of the lesion into the visual axis, development of
astigmatism or formation of lipid infiltration of the cornea, which
obstructs the visual axis . Large Limbal dermoid can be cosmetically
disfiguring. In some cases staphyloma formation adjacent to dermoid
has been reported and may be associated with spontaneous
perforation of cornea or sclera.
• A varity of surgical techniques has been described in the literature ,
ranging from simple excision to lamellar and/or penetrating keratoplasty
with relaxing corneal incision, depending on the grade of lesion.
Depth,size,and site of such lesion are critical factor .Other techniques
include corneal-limbal scleral donor graft transplantation and surgical
resection followed by reconstructive multi-layered amniotic membrane
transplantation.

10. Conclusion:
• Treatment of limbal dermoid may consist of periodic removal of
irritating cilia, topical lubrication to prevent foreign body sensation, or
excision of the lesion if it causing significant cosmetic disfigurement
or interfering with vision.
• Attempts at complete removal are unnecessary because lesion may
extend into the deeper structure of the eye and risk of perforation
increase if attempts are made to remove lesion completely. If a deep
excision is necessary, then a lamellar keratoplasty can be performed to
reinforce the site of excision.

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