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Giant epidermal cyst of the tarsal plate.
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MedLine Citation:
PMID:  22569383     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
A 35-year-old male patient presented with a right upper eyelid mass with mechanical ptosis. The patient gave no history of trauma or surgery. On examination, there was a huge cystic mass fixed to the tarsal plate. Excisional biopsy with tarsectomy was done. Histopathology sections demonstrated a keratin-filled cyst arising from the tarsus. A thorough Pubmed search did not reveal an epidermal cyst of the tarsal plate of this size which was successfully managed. The incision was made in such a way that postoperative ptosis would be avoided. Excess skin was removed during the surgery.
Authors:
Mohana Majumdar; Rekha Khandelwal; Anne Wilkinson
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  Indian journal of ophthalmology     Volume:  60     ISSN:  1998-3689     ISO Abbreviation:  Indian J Ophthalmol     Publication Date:    2012 May-Jun
Date Detail:
Created Date:  2012-05-09     Completed Date:  2012-09-27     Revised Date:  2013-06-25    
Medline Journal Info:
Nlm Unique ID:  0405376     Medline TA:  Indian J Ophthalmol     Country:  India    
Other Details:
Languages:  eng     Pagination:  211-3     Citation Subset:  IM    
Affiliation:
Department of Ophthalmology, NKPSIMS & Lata Mangeshkar Hospital, Nagpur, Maharashtra, India.
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MeSH Terms
Descriptor/Qualifier:
Adult
Biopsy
Blepharoplasty
Diagnosis, Differential
Epidermal Cyst / pathology*,  surgery
Eyelid Diseases / pathology*,  surgery
Eyelids / pathology*,  surgery
Follow-Up Studies
Humans
Male
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Indian J Ophthalmol
Journal ID (iso-abbrev): Indian J Ophthalmol
Journal ID (publisher-id): IJO
ISSN: 0301-4738
ISSN: 1998-3689
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
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Copyright: © Indian Journal of Ophthalmology
open-access:
Received Day: 08 Month: 10 Year: 2010
Accepted Day: 16 Month: 6 Year: 2011
Print publication date: Season: May-Jun Year: 2012
Volume: 60 Issue: 3
First Page: 211 Last Page: 213
ID: 3361817
PubMed Id: 22569383
Publisher Id: IJO-60-211
DOI: 10.4103/0301-4738.95874

Giant epidermal cyst of the tarsal plate
Mohana Majumdaraff1
Rekha Khandelwalaff1
Anne Wilkinson1
Department of Ophthalmology, NKPSIMS & Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
1Department of Pathology, NKPSIMS & Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
Correspondence: Correspondence to: Dr. Mohana Majumdar, 29, Poonam Vihar, Swavalambi Nagar, Nagpur, Maharashtra, India. E-mail: mohana.magic@gmail.com

Most cysts of the eyelid are diagnosed as epidermal inclusion cysts, dermoid cysts, pilar/sebaceous cysts or as a chalazion. The diagnosis of epidermal cyst of the tarsal plate is not made very often. This differential should be kept in mind while operating on a cyst of the upper eyelid. A definitive diagnosis depends upon a histopathologic examination, and an en bloc excision with tarsectomy, including the base of the cyst, is the definitive treatment.


Case Report

A 35-year-old male patient presented with a swelling of the right upper eyelid of 10 years’ duration. The swelling which was initially the size of a peanut started increasing in size since the last 1 year, causing drooping of the upper eyelid. There was no associated pain or redness. There was no history of ocular trauma, previous surgery or any systemic illness. On examination, there was a mechanical ptosis with zero vertical interpalpebral fissure height and zero levator function. The lid showed a large round swelling of 2 cm in diameter [Fig. 1]. On palpation, the tumor was well defined, cystic but firm, and free from skin and bony margins. There were no signs of inflammation and the overlying skin appeared normal. On retraction of the upper eyelid, only 2 mm of the lower cornea was seen which appeared normal [Fig. 2]. The left eye examination was normal. Computed tomography (CT) scan of the right orbit did not reveal any bony attachments on bone and soft tissue window. There were no cysts elsewhere like on face, neck and trunk, and rest of the systemic examination was also normal. The patient was posted for excisional biopsy. A horizontal skin incision was made, inferior to the lid crease. Subcutaneous tissue was separated from the center toward periphery. Careful superior and inferior separation of the cyst from subcutaneous tissue was done [Fig. 3]. Inferiorly, the cyst had reached the lid margin as the hair follicles were visible during dissection. As the dissection proceeded posteriorly, the cyst was found to be attached to the tarsal plate. Hence, a 3–4 mm tarsectomy was done to remove the cyst in toto [Fig. 4]. The tarsoconjunctival suturing was done with 8-0 Vicryl. Excess skin was excised and skin was sutured with interrupted sutures using Proline. The patient was started on oral antibiotics and anti-inflammatory drugs. There was lid edema on the 1st postoperative day. He was started on topical antibiotics. By the 10th postoperative day, the edema had totally subsided, the levator function had returned to normal and there was no ptosis [Fig. 5]. The patient has shown no recurrence in the follow-up period of 5 months and has a best corrected vision of 20/30 post surgery. Histopathology reports showed, on gross appearance, a round to oval 2.5 × 2 × 2 cm cystic, grayish-brown mass. Microscopy revealed a cyst lined by stratified squamous epithelium devoid of keratohyaline granules. The cyst lumen contained string-like keratin [Figs. 6 and 7]. The cyst wall was composed of bland collagenous tissue devoid of inflammation. Part of the tarsal plate and the underlying conjunctiva was attached to the cyst wall. The histopathologic features were consistent with epidermal cyst of the tarsal plate.


Discussion

Cysts of the epidermis are the second most common type of benign periocular cutaneous lesions, accounting for approximately 18% of excised benign lesions.[1] Most of these are epidermal inclusion cysts which are slow growing, elevated, round and smooth, and filled with keratin. Very few cases of epidermal cysts of the tarsal plate have been reported. Vagefi et al. in 2008 discussed various theories of development of epidermoid cysts.[2] Since there is no history of trauma or surgery in our patient, the most likely theory is the sequestration of epidermal rests during the embryonic development of the eyelid, as was the case in Vagefi's report. Lucarelli et al. reported cases of intratarsal epidermal inclusion cysts which were initially diagnosed as chalazions and for which incision and curettage was done.[3] They were ultimately diagnosed as having originated from the tarsus and protruding into the skin. Finally, the base of the cyst with the tarsus had to be excised to prevent recurrence. Hence, incision and curettage or superficial shave biopsies may not give the exact diagnosis in all cases of lid tumors. A full thickness biopsy of the tarsal plate is diagnostic. Jakobiec et al. presented cases of intratarsal cyst of meibomian gland.[4] The average age of patients was 62.5 years. The authors did an immunohistochemical study with the help of which they distinguished it from the epidermal cysts. To avoid lid retraction, 20–24 mm of skin should be left between the brows and the lid margin.[5] The upper eyelid also requires 4 mm of tarsus along the eyelid margin to ensure stability. This allows us to recruit any excess superior tarsus beyond 4 mm into a defect. In more extensive defects of the tarsus, procedures like eyelid sharing procedure, contralateral upper eyelid tarsoconjunctival grafting or tarsoconjunctival substitutes like hard palate mucoperiosteum could be used. In our patient, the tumor size was 2 cm in diameter and the amount of tarsus that was sacrificed along with the conjunctiva was about 3–4 mm. Five millimeter skin excision was done and no skin graft was required. The layers of the upper eyelid from anterior to posterior, between the lid margin and the lid crease consist of skin, orbicularis muscle, levator aponuerosis, tarsus and conjunctiva. These layers are held tightly together by fibers of the levator aponuerosis that cross the orbicularis and insert into the dermis.[6] The upper eyelid crease is formed by the most superior of these attachments. Since the incision given was inferior to the attachment of the levator palpebrae superioris to the skin, the lid crease was not compromised and ptosis was nil. Jakobeic et al. have documented the first eyelid epidermoid cyst displaying malignant transformation in a 72-year-old woman.[7] Hence, no matter how benign any eyelid cyst may appear, they all should be sent for histopathologic examination.


References
1. The Eye M.D. Association, American Academy of Ophthalmology, Section 7: Orbit, Eyelids, and Lacrimal System, 2007-08.
2. Vagefi MR,Lin CC,McCann JD,Anderson RL. Epidermoid cyst of the upper eyelid tarsal plateOphthal Plast Reconstr SurgYear: 2008243234
3. Lucarelli MJ,Ahn HB,Kulkarni AD,Kahana A. Intratarsal Epidermal Inclusion CystOphthal Plast Reconstr SurgYear: 2008243579
4. Jakobiec FA,Mehta M,Iwamoto M,Hatton MP,Thakker M,Fay A. Intratarsal keratinous cysts of the Meibomian gland: distinctive clinicopathologic and immunohistochemical features in 6 casesAm J OphthalmolYear: 2010149829419875094
5. Kulwin DR,Kirsten RC. Dortzbach RKBlepharoplasty and brow elevationOphthalmic Plastic surgery: Prevention and management of complicationsYear: 1994New YorkRaven press91111
6. Anderson RL,Beard C. The levator aponuerosis. Attachments and their clinical significanceArch OphthalmolYear: 1977951437889520
7. Jakobiec FA,Zakka FR,Hatton MP. Eyelid basal cell carcinoma developing in an epidermoid cyst: A previously unreported eventOphthal Plast Reconstr SurgYear: 2010264914

Figures

[Figure ID: F1]
Figure 1 

Preoperative photograph showing a huge mass (2 cm diameter) of the upper eyelid, causing mechanical ptosis



[Figure ID: F2]
Figure 2 

Photograph showing the under surface of the mass which appears round, well defined and without any signs of inflammation; rest of the ocular structures could not be examined



[Figure ID: F3]
Figure 3 

Intraoperative photograph showing a cystic mass free from the skin and subcutaneous tissue



[Figure ID: F4]
Figure 4 

Cyst removed in toto



[Figure ID: F5]
Figure 5 

10th postoperative day showing normal levator function



[Figure ID: F6]
Figure 6 

Histopathology demonstrated a cyst lined by squamous epithelium and containing keratin (H and E, ×400)



[Figure ID: F7]
Figure 7 

Photomicrograph showing epidermal cyst wall with keratin in the lumen (H and E, ×100)



Article Categories:
  • Brief Communications

Keywords: Blepharoptosis, epidermal cyst, excision, eyelid.

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