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Ophthalmology-cyst A case presentation.pptx
- 2. Date and time of interview: March 22, 2022 at 10am Source of information: Patient and patient’s father Reliability: 85% Referral: None
- 3. IDENTIFYING DATA ● Pt. Lozano, Paul Dave ● 15 years old ● Male ● born on October 23, 2006 ● Filipino ● Roman Catholic ● lives in Dagami, Leyte
- 5. HISTORY OF PRESENT ILLNESS 2 years PTC • painless mass on the left lower eyelid and nasal area approximately 1 cm in diameter with lacrimation • no other associated symptoms noted • no consult done, no medications taken Interim • gradual growth noted seldom accompanied with tolerable pain and lacrimation • due to pandemic, not able to seek consult 9 months PTC • increasing size of the mass still noted • redness and pus on the medial left lower eyelid, prompted consult in this institution • advised to undergo surgery • antibiotic eye ointment was prescribed but lost to follow up 1 month PTC • persistent growth of the mass still noted • sought consult in this institution and MRI was requested with this result: inferior orbital cyst, primary consideration is nasolacrimal duct mucocele, another consideration, albeit less considered, is a dacrocystocele. Small right maxillary retention cyst. • advised for surgery
- 6. PAST MEDICAL HISTORY • Complete immunization • (-) childhood illness • (-) history of surgical operation • (-) known allergy to food and drugs • (-) previous traumatic injuries
- 7. FAMILY HISTORY • an only child • (+) history of diabetes mellitus and hypertension • no other heredofamilial diseases such as neoplasms and asthma
- 8. Developmental/Behavioral History ● Home: His parents separated 8 years ago and both his parents have partners. Prior to the pandemic, he lives with his mother and her common-law partner in Burauen, Leyte. He currently lives with his father and his common law partner and will go back to stay with her mother when face-to-face classes start. He claimed to have no complaints with the situation. ● Education: He is currently Grade 10 student at Burauen Comprehensive High School. The patient used to be fond of engaging in extra-curricular activities during the face-to-face classes. ● Eating: He is not a picky eater.
- 9. Developmental/Behavioral History ● Activities: He used to hang out with his friends and cousins during his free time but due to pandemic, it was limited. The patient is active on social media. ● Drugs: His father is a smoker and occasional alcoholic beverage drinker. The patient does not drink alcoholic beverages, smoke, and use illicit drugs. ● Sexuality: He is more fond being friends with girls and currently is not in a romantic relationship. ● Suicide/depression: The mass does not concern him at all but hoping that it will be removed before the face-to-face classes start. He has no history of depression and no suicidal thoughts and ideations.
- 10. Review of Systems • General: (-) weakness, (-) easy fatigability, (-) loss of appetite, (-) fever • Cutaneous: (-) rashes, (-) hair loss, (-) skin pigmentation, (-) pruritus • HEENT: (-) dizziness, (-) headache, (-) visual difficulties, (-) lacrimation, (-) hearing loss, (-) aural discharge, (-) nasal discharge, (-) epistaxis, (-) toothache, (-) salivation, (-) sore throat. • Cardiovascular: (-) orthopnea, (-) cyanosis, (-) fainting spells. • Respiratory: (-) chest pain, (-) difficulty of breathing • Gastrointestinal: (-) vomiting, (-) diarrhea, (-) constipation, (-) abdominal pain, (-) jaundice • Genitourinary: (-) dysuria, (-) urinary frequency • Endocrine: (-) no palpitations, (-) heat/cold intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia. • Nervous/ Behavioral: (-) tremors, (-) memory loss, (-) mood changes
- 11. Physical Examination General Survey: ● The patient is an ectomorphic adolescent. He was examined awake, conscious, coherent, oriented to time, place and person, fairly-groomed and not in cardiorespiratory distress. Vital Signs Actual Ideal Interpretation Temperature 36.5 0C, axillary 36.5 – 37.5°C Afebrile Pulse rate 89 bpm 55 – 85 bpm Normal Respiratory rate 16 cpm 12 – 18 cpm Normal Blood pressure 110/80 mmHg @ left arm 110-135/65-85 mmHg Normotensive
- 12. Physical Exam Head: Face - symmetrical facial expression noted, (+) firm, movable painless mass on the medial left lower eyelid and nasal area, with smooth regular border, approx. 3 x 2 cm Eye: VA: OU - 20/20 left medial canthus slightly displaced superiorly Eyebrows: Symmetrical, equal movement upon raising of eyebrows, fine, and black. Eyelids: (+) redness on medial left lower eyelid, no inward or outward turning of eyelids, no lagging and with adequate closure Eyelashes: Black in color and are evenly distributed with outward curving along the lid margins Conjunctiva: (+) redness medial bulbar conjunctiva, OS Sclera: anicteric Cornea: no ulcerations, no scars Iris and Pupil: Iris is round, flat, evenly brown colored. Pupils are symmetrical, 3mm in diameter and reactive to direct light and consensual light reflex EOM: Full EOM movement ROR: (+), OU Tonometer (manual): firm, OU (-) LAI
- 13. Salient Features Demograph ics HPI Other History Findings ROS/PE 15 years old Male CC: inferior orbital mass • 2-year history of gradually growing mass on the left lower eyelid and nasal area • seldom accompanied with tolerable pain and lacrimation • History of redness and pus on the medial left lower eyelid Pertinent negative: - No fever - No referred pain - No palpable lymph nodes • No history of any childhood illness • No family history of neoplasms • (+) firm, movable painless mass on the left lower eyelid and nasal area, with regular borders, approx. 3 x 2 cm • left medial canthus slightly displaced superiorly • (+) redness on medial left lower eyelid • (+) redness medial bulbar conjunctiva • (-) Jones Dye Test
- 15. Rule in Rule out 2-year history of gradually growing mass on the left lower eyelid and nasal area inferior orbital mass (+) firm, movable painless mass on the left lower eyelid and nasal area, with regular borders, approx. 3 x 2 cm left medial canthus slightly displaced superiorly X 15 years old X (-) LAI Dermoid Cyst https://www.ncbi.nlm.nih.gov/books/NBK560573/
- 16. Rule in Rule out inferior orbital mass 2-year history of gradually growing mass on the left lower eyelid and nasal area seldom accompanied with tolerable pain History of redness and pus on the left lower eyelid (+) firm, movable painless mass on the left lower eyelid and nasal area, with regular borders, approx. 3 x 2 cm left medial canthus slightly displaced superiorly (-) LAI X Male (more common in female) X 15 years old (first year of life) - Cannot completely rule out Nasolacrimal Duct Mucocele https://www.ncbi.nlm.nih.gov/books/NBK560573/
- 17. Rule in Rule out inferior orbital mass 2-year history of gradually growing mass on the left lower eyelid and nasal area seldom accompanied with tolerable pain History of redness and pus on the left lower eyelid (+) firm, movable painless mass on the left lower eyelid and nasal area, with regular borders, approx. 3 x 2 cm left medial canthus slightly displaced superiorly (-) LAI X 15 years old (first 5 years of life) - Cannot completely rule out Dacryocystocele https://www.ncbi.nlm.nih.gov/books/NBK560573/
- 18. Diagnostic Tests
- 19. Dye disappearance test (DDT) and lacrimal irrigation ● simplified approach ● usually followed by Jones I test then Jones II test Contrast dacryocystography and dacryoscintigraphy ● alternative methods of evaluation
- 20. CT Scan or MRI ● useful in the evaluation of craniofacial injury, congenital craniofacial deformities, or suspected neoplasia ● MRI done with result (03/03/2022): inferior orbital cyst, primary consideration is nasolacrimal duct mucocele, another consideration, albeit less considered, is a dacryocystocele. Small right maxillary retention cyst.
- 21. Nasolacrimal Duct Obstruction secondary to Dacryocystocele
- 23. Management
- 24. Surgical Management Dacryocystorhinostomy (DCR) • treatment of choice • indications: = recurrent dacryocystitis = chronic mucoid reflux = painful distention of the lacrimal sac = bothersome epiphora • 2 approaches: = internal (endonasal) DCR = external DCR
Editor's Notes
- The presence of dye in the inferior meatus indicates a positive result of Jones I; the dye presumably flowed from the tear lake to the inferior meatus via a patent lacrimal system. A negative test suggests an obstructed lacrimal system.
- A dermoid cyst is a benign cutaneous developmental anomaly that arises from the entrapment of ectodermal elements along the lines of embryonic closure. Dermoid cysts usually tend to grow slowly. A lower lid dermoid cyst may be evident as a painless, gradually enlarging swelling of the lower lid.[10] Dermoid cysts in the medial canthal area may present as masses adherent to lacrimal canaliculi. They are usually asymptomatic, non-pulsatile, and non-compressible. However, Dermoid cysts are usually congenital, with about 70% of cases discovered in children five years old or younger.
- Nasolacrimal duct mucoceles (NLDMs) are encountered almost exclusively in the pediatric population. Nasolacrimal duct mucocele typically presents as a bulging in the lower medial canthus of the eye, associated with epiphora.
- Dacryocele is also known as a dacryocystocele, amniotocele, amniocele, or mucocele. It is formed when a distal blockage (usually membranous) of the lacrimal sac causes distention of the sac, which also kinks and closes off the entrance to the common canaliculus.
- the clinical evaluation of the lacrimal drainage system historically comprised a dye disappearance test (DDT) followed by the Jones I test (swabbing the inferior meatus to see if dye passes through physiologically) and the Jones II test (irrigating with saline and assessing the passage of fluid and presence or absence of dye). Although some clinicians continue to rely on formal Jones testing, most use a simplified approach involving only the DDT and lacrimal irrigation. The DDT is useful for assessing the presence or absence of adequate lacrimal outflow, especially in unilateral cases. Lacrimal drainage system irrigation is most frequently performed immediately after the DDT to determine the level of lacrimal drainage system occlusion A, Complete canalicular obstruction. The cannula is advanced with difficulty, and irrigation fluid refluxes from the same canaliculus. B, Complete common canalicular obstruction. A “soft stop” is encountered at the level of the common canaliculus, and irrigated fluid refluxes through the opposite punctum and sometimes partially from the same canaliculus as well. C, Complete nasolacrimal duct obstruction (NLDO). The cannula is easily advanced to the medial wall of the lacrimal sac; then a “hard stop” is felt, and irrigation fluid refluxes through the opposite punctum. Often, the refluxed fluid contains mucus and/or pus. With a tight valve of Rosenmüller, lacrimal sac distention without reflux of irrigation fluid may occur. D, Partial NLDO. The cannula is easily placed, and irrigation fluid passes into the nose as well as refluxing through the opposite punctum. E, Patent lacrimal drainage system. The cannula is placed with ease, and most of the irrigation fluid passes into the nose.
- CT and MRI are CT is superior for the evaluation of suspected bony abnormalities, such as fractures. MRI is superior for the evaluation of suspected soft- tissue disease, such as malignancy. Either CT or MRI may be helpful in evaluating concomitant sinus or nasal disease that may contribute to excess tearing.
- Lacrimal pump mechanism. A, In the relaxed state, the puncta lie in the tear lake, and the lacrimal sac is filled with tears. B, With eyelid closure, contraction of the pretarsal orbicularis closes the puncta and canaliculi. The preseptal orbicularis fibers, which insert onto the sac, also compress the sac, creating positive pressure that propels tears through the duct. C, With eyelid opening, the orbicularis relaxes, and the puncta and sac open, creating negative pressure that draws tears into the canaliculi and lacrimal sac. As the eyelids close, the cycle repeats.
- A DCR is the treatment of choice for most patients with acquired NLDO. Surgical indications include recurrent dacryocystitis, chronic mucoid reflux, painful distention of the lacrimal sac, and bothersome epiphora. Recent data indicate similar success rates for the 2 approaches. The advantages of an internal (endonasal) DCR include lack of a visible scar, a shorter recovery period, and less discomfort. An external DCR may allow better exposure for management of canalicular stenosis, unexpected neoplasm, or dacryoliths. Intubation and stenting Partial stenosis of the NLD with symptomatic epiphora may respond to surgical intubation of the entire lacrimal drainage system. This procedure should be performed only if the tubes can be passed easily. In cases of complete NLDO, intubation alone is not effective, and a DCR should be considered. Endoscopic lacrimal duct recanalization The use of a microendoscope allows for exploration and direct visualization of NLDOs, as well as focal excision and reconstruction of the obstruction, and has had success rates as high as those for DCR. The use of this technology is not widespread, and further study will help define its role in the treatment of NLDO.