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Case PCO

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Case PCO

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  1. Case PCO Juan G. Santiago, MD Ophthalmology Department University of Puerto Rico

  2. Chief Complaint • “Me duele el ojo izquierdo y tengo el párpado hinchado”

  3. Present History • PCO is a 86 y/o female with history of hypercholesterolemia in her usual state of health that refers left superior eyelid swelling and mass since 4-5 days ago, with associated pain, tenderness, redness and secretions that is worsening. Refers (-) visual loss, (+) occasional blurred vision, (+) eye pain, (-) diplopia, (+) pain with eye movements, (-) trauma, (-) insect bites, (-) recent illness, (-) fatigue, (-) weight loss, (-) respiratory problems.

  4. History • Eye history: Similar episode on October/06 • Surgeries: Cataract surgery both eyes • Childhood: None • Systemic history: ↑ Cholesterol • Family history: DM, HTN, ↑ Cholesterol

  5. Exam

  6. Exam

  7. Workup Labs: WBC  7.2 N%55.4 ESR  39 Hgb  13.5 L%  34.0 C-RP  4.3 H Hct  40.5 Plt  296 RPR  Non-rx Chest X Rays: HIV  Non-rx Normal study ACE levels  N/A No hilar lymphadenopathy

  8. CT Scan- Axial

  9. CT Scan - Axial

  10. CT Scan - Coronal

  11. CT Scan - Coronal

  12. CT Scan • Official Radiology Report • Enlargement of the left lacrimal gland, with associated inflammatory changes seen at the left eyelid. There is evidence of prior to cataratectomy bilaterally. The optic nerves and extra ocular muscles are intact. No radiopaque foreign bodies are identified. No abnormalities seen in the retroseptal, intra or extraconal compartment. Bilateral ethmoidal opacification and bilateral maxillary. Antrum mucosal thickening, more prominent on the left side, consistent with chronic sinusitis.

  13. Differential Diagnosis • Acute Dacryoadenitis • Infectious • Orbital inflammatory pseudotumor • Cellulitis • Preseptal vs Orbital • Lacrimal Gland tumors • Pleomorphic adenoma • Pleomorphic adenocarcinoma • Adenoid cystic carcinoma

  14. Dacryoadenitis • Inflammatory enlargement of the lacrimal gland • Acute dacryoadenitis • Unilateral, severe pain, redness, and pressure in the supratemporal region of the orbit • Rapid onset (hours to days) • Chronic dacryoadenitis • Can be bilateral, painless enlargement of the lacrimal gland present for more than a month

  15. Unilateral Firm and tender Conjunctival swelling + injection Discharge Erythema of eyelids Lymphadenopathy S-shaped lid Proptosis Ocular motility restriction Globe displacement inferiorly and medially CT scan Diffuse enlargement, oblong shape, and marked enhancement with contrast. No compressive changes in the contiguous bone or globe are noted. Acute Dacryoadenitis

  16. Infectious Bacterial Staphylococcus N. gonorrheae Viral Mumps /EBV / VZV Fungal Syphilis TB Inflammatory Orbital inflammatory pseudotumor Sarcoidosis Graves disease Sjögren syndrome Benign lymphoepithelial lesion Dacryoadenitis

  17. Dacryoadenitis

  18. Preseptal Cellulitis • Infection anterior to orbital septum • Skin trauma hx • Most common: S. aureus • Lid edema / erythema / pain • Fever • May progress • Treatment: Systemic antibiotics

  19. Orbital Cellulitis • Infection posterior to orbital septum • Most common: 2ry to sinusitis • Staph, Strep, Fungi • Fever / ↓ Vision • + RAPD / Proptosis • Movement pain + restriction • Periorbital swelling + chemosis

  20. Pleomorphic adenoma • Most common epithelial tumor of the LG • 4th-5th decade • Men > Women • Slow onset (6-12 mo) • Firm mass with painless proptosis • Eyeglobe displaced inferomedial • Growth may indent bone of lacrimal fossa

  21. CT Scan Well circumscribed but may have nodular configuration Pathology Proliferation of epithelial cells into a double layer, forming lumina with ductal and secretory elements. Ductal inner cells secretes mucus. Outer stromal cells give rise to fibrous stroma and osteoid metaplasia. Treatment Complete en bloc excision without biopsy Pleomorphic adenoma

  22. Malignant Mixed Tumor Rapid, progressive, painful proptosis Long history of mass in lacrimal fossa Occurs in elderly individuals Pathology Similar to benign mixed tumor but with foci of malignant change Treatment Radical orbitectomy and bone removal Pleomorphic adenocarcinoma

  23. Most common malignant tumor of the LG Highly malignant 4th decade Rapidly progressive proptosis, painful Paresthesia due to perineural invasion and bony destruction CT Scan Poorly circumscribed mass, bony destruction, calcifications Treatment Exenteration Removal of any bone that is involved Adjunctive radiation and chemotherapy Adenoid cystic carcinoma

  24. Adenoid cystic carcinoma • Pathology • Small, benign-appearing cells arranged in nest, tubules or in a cribiform pattern. • “Swiss-cheese” appearance

  25. 2 Days After Timentin IV…

  26. One week ago…