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Each winter, Kim Moss* joins her friends at the local “polar bear” club for some ice swimming. One day after a crisp dip, one of her fellow polar bears noticed she had more right upper eyelid droopiness than usual and new right upper eyelid swelling. Her swelling and droopiness worsened over three weeks. When her right eyelid was nearly swollen shut, she decided to visit her ophthalmologist.
We Get a Look
Upon questioning, Ms. Moss denied any recent trauma. However, she did recall that her eyelid had drooped a bit after endoscopic sinus surgery five years earlier. She also disclosed a medical history of Hashimoto’s thyroiditis and psoriasis.
Her BCVA was 20/40 in the right eye and 20/25 in the left. External ophthalmologic examination revealed significant swelling, induration and fullness in the area of the right medial canthus with extension down to the lower eyelid. There was a yellowish hue to the right upper lid. Marginal reflex distance was 0 mm on the right and 1.5 mm on the left. Pupils, extraocular muscles and the rest of the ophthalmologic exam were normal (Fig. 1).
An MRI was obtained to further evaluate the ocular and periocular structures (Fig. 2). This revealed evidence of sinusitis and induration of soft tissue in the right upper lid. We saw no evidence of an orbital mass. Ms. Moss was started on oral antibiotics and monitored. One week later, she demonstrated no improvement of her periorbital signs. A decision was made to biopsy the indurated area.
Sections showed fibrous tissue and skeletal muscle fiber infiltrated by a granulomatous process. The granulomas were coalescing, with scattered multinucleated giant cells, and lacked a peripheral rim of lymphocytes (Fig. 3
). Polymorphic clear spaces were surrounded by histiocytes (Fig. 4
) and could be seen within multinucleated giant cells (Fig. 5
). No acid-fast bacilli or fungal organisms were identified. There was no evidence of neoplasia.
The differential diagnosis of this granulomatous inflammation included infectious diseases and collagen vascular diseases, including sarcoidosis. Given the patient’s history of autoimmune-induced thyroiditis and psoriasis, collagen vascular disease might have been a reasonable diagnosis; however, no systemic manifestations were present. Tests for ANA and rheumatoid factor were negative.
What’s Your Diagnosis?
|WE GET A LOOK. Ms. Moss is a “polar bear” ice swimmer. (Fig. 1) She was referred to us after a swelling of her right eye had gotten progressively worse. (Fig. 2) Her MRI showed evidence of sinusitis and right upper lid soft tissue induration. |
|WE ORDER A BIOPSY. (Fig. 3) The granulomas were coalescing and lacked a peripheral rim of lymphocytes. (Fig. 4) Polymorphic clear spaces were surrounded by histiocytes. (Fig. 5) There were scattered multinucleated giant cells. |
We asked a veteran pathologist to review the pathology slides. Astutely, he asked if the patient had undergone sinus surgery and attributed the granulomatous infiltration to the use of postsurgical petrolatum gauze packing.
Petrolatum products are composed of saturated “n-alcane” hydrocarbons and include lubricating substances such as paraffin, petroleum jelly and mineral oil. Foreign body granulomatous reactions can develop in response to petrolatum depositions. The lesions have been described in the literature by a variety of names, such as paraffinomas, ointment granulomas, oil granulomas and sclerosing lipogranulomas. Interestingly, most patients injected with petroleum jelly–type compounds do not have a clinically significant inflammatory response, and the factors that lead to a symptomatic inflammatory response remain unknown.1
While petrolatum foreign-body reactions can develop anywhere in the body, ophthalmologists tend to encounter them in patients who have undergone sinus and oculoplastic procedures involving the intraoperative use of petrolatum-impregnated gauze. Common sources of petrolatum include Vaseline or antibiotic ointments that contain petrolatum or a mineral oil base. It is suspected that the petrolatum migrates into the anterior orbit and eyelids through fractures in the lamina papyracea of the medial orbit.1
Clinical diagnosis can be difficult due to the variable delay in presentation and intensity of foreign-body reaction. While a delay in response has been reported to vary from weeks to decades, the reaction usually peaks at three months.2 The triad of an inflammatory reaction involving the medial orbit region, past sinus surgery and a granulomatous reaction with polymorphic clear spaces should be considered highly suspicious for peri- ocular petrolatum deposition. Also, the overlying skin sometimes acquires a yellowish hue, and an orbital CT may reveal ovoid hypodense material. While systemic corticosteroids may have limited therapeutic effect, surgical excision is the definitive treatment. It should be noted, though, that recurrences are not uncommon.1,2
Ms. Moss’ Follow-Up
Ms. Moss was placed on a course of high dose oral steroids with slow taper. The induration resolved completely, and her eyelid returned to its preinflammation position. She subsequently underwent a successful ptosis repair and is back in the icy water.
* Patient name is fictitious.
1 Merkur, A. B. et al. Ophthal Plast Reconstr Surg 2005;21:23–31.
2 Feldmann, R. et al. J Am Acad Dermatol 1992;26:833–835.
Dr. Hester is a resident at the California Pacific Medical Center in San Francisco. Dr. Silkiss is chief of the oculofacial plastic, reconstructive and orbital surgery division at CPMC. Dr. Spencer is the emeritus director of ocular pathology at CPMC.