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| CASE REPORT |
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| Year : 1992 | Volume
: 40
| Issue : 4 | Page : 118-121 |
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Unusual presentation of lacrimal gland tumours
J Singh1, MS Boparai2, KA Ahmed3
1 Eye Specialist, Army Hospital Delhi Cantt-10, India
2 DDMS Northern Command C/O 56 APO, India
3 Consultant Ophthalmology, Army Hospital Delhi Cantt-10, India
Correspondence Address:
J Singh
Eye Specialist, Army Hospital, Delhi Cantt-10
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1338630 
The diagnosis of orbital tumour is a challenge to the ophthalmologist. The aim of this paper is to highlight the unusual presentation of lacrimal gland tumours.
How to cite this article:
Singh J, Boparai M S, Ahmed K A. Unusual presentation of lacrimal gland tumours. Indian J Ophthalmol 1992;40:118-21 |
| Introduction | |  |
Orbital lesions form a very heterogenous group. Being partially closed anteriorly by the orbital septum, the bony orbit acts, like the cranial cavity, as a closed space. Any increase in the orbital contents would tend to push the eye ball forward. Proptosis, pressure on the optic nerve and limitation of ocular motility are thus clinical features common to many orbital lesions.
While different lesions may therefore produce some common clinical features, the same lesion may have different clinical presentation, as is illustrated in the cases reported below.
| Case 1 | | |
HBL a 63 year old Hindu male reported in Feb 86 with complaints of gradual progressive protrusion of left eye of 12 years duration and a decrease in vision in left eye since last 2 years. There was no ENT or systemic complaint. Examination: General and systemic examination were normal. Ocular examination revealed that the right eye was normal with a vision of 6/6. Vision in the left eye was reduced to hand movements close to face. Left direct pupillary reaction was sluggish (afferent pupillary defect) and fundus examination showed a slight pallor of the left disc in comparison to the right. The left palpebral fissure was widened. Hertels exophthalmometry showed a relative proptosis of the left eye by 7 mm. The left eye was also displaced down by 10 mm and out by 5 mm [Figure - 1] a. Ocular motility of the left eye was restricted in upgaze. A mass 1 cm x 3.5 cm size was palpable in the upper part of the orbit. The overlying lid skin was free. The surface was nodular and it was firm to hard in consistency. It was non reducible and was tender on deep palpation. A provisional diagnosis of lacrimal gland tumour was considered at this stage. However, in this case the eye was displaced down and out while in lacrimal gland tumours one expects the eye to be displaced down and in.
Investigations: Routine blood, urine and X-ray chest were normal.
Plain X-ray orbit, showed an erosion of the upper outer orbital rim on the left side [Figure - 1] b.
B mode ultrasound left orbit showed a large tumour mass with mixed echogenic pattern extending posteriorly into the orbit and involving the posterior part of the optic nerve [Figure - 1] c. CT scan, coronal view done in April 1984, showed a well defined tumour mass in the upper and temporal part of orbit, pushing the eyeball down and in [Figure - 1] d.
A repeat CT scan done 2 years later (May 1986) showed that the tumour had not only increased in size but had also extended medially towards the medial wall of the orbit. At this stage, the eye was displaced down and out [Figure - 1] e.
FNAB was done in Feb 86 and the histological picture was suggestive of a pleomorphic adenoma of the lacrimal gland. However, in a portion of the slide a small globule of secretion was seen, giving the suspicion of adenoid cystic carcinoma.
Surgery: The patient was operated in May 86 and the tumour mass was removed by lateral orbitotomy. In the post operative period, the proptosis subsided and vision improved to 4/60. The patient developed a complete ptosis for which a crutch spectacle was given [Figure - 1] f and [Figure - 1] g.
1 year later the patient had an orbital recurrence which was treated by exenteration and local radiation. 5 years later, the patient was symptom free with no evidence of secondaries.
| Case 2 | | |
BL a 20 year old Hindu male reported in Dec 90 with complaints of swelling and drooping of the right upper lid since the last 4 months and a decrease in vision right eye since the last 2 months. There was no history of pain, trauma or any systemic complaint.
Examination: General and systemic examination were normal. Ocular examination showed that the Ieft eye was normal with a 6/6 vision. Right eye vision was 3/60, improving with a pin hole to 6/60. There was marked swelling of the right upper lid along with a complete ptosis [Figure - 2] a. A tumour mass 4 cm x 2.5 cm was present occupying most of the right upper lid. It had a lobulated surface and the overlying skin was free. It was soft to firm in consistency and non-tender. There was a localized enlargement (notching) of the lateral part of the right upper orbital rim. The right eye was displaced down in comparison to the left [Figure - 2] b.
During the patients 3 week stay in the hospital pre-operatively, the lid swelling showed a significant increase and the tumour increased in size by almost 1 cm. Owing to this rapid growth, the possibility of malignancy was thought of at this stage.
Investigations: Plain X-ray orbit showed a localized enlargement of right orbit in the region of the lacrimal fossa [Figure - 2] c.
FNAB was done, which showed a picture of mixed tumour.
Surgery: The patient was operated in Feb 91. An anterior orbitotomy was done. The tumour, which was well encapsulated, was removed in-toto.
Histopathology done confirmed the diagnosis of a mixed lacrimal gland tumour.
Post-operative recovery was uneventful [Figure - 2] d & c.
| Discussion | | |
Lacrimal gland tumours constitute about .6%-18% of orbital tumours, as reported in different series [1],[2],[3].
Pleomorphic adenoma (benign mixed tumour) is the commonest epithelial tumour of the lacrimal gland [4].
It occurs most commonly in the 3rd to 4th decade, the mean age at diagnosis being 39 years [5].
The tumour usually arises from the orbital lobe of the lacrimal gland [6]sub and being confined by the bony orbital walls, growth tends to be slow. Patients with this painless, slow growing tumour usually report late, sometimes years after the onset [4].
Owing to the site of the lacrimal gland, tumours arising from it, tend to displace the eye down and in. A palpable mass is almost invariably present in cases of lacrimal gland tumour and usually has a lobulated surface.
An older age group, a more rapid growth, presence of pain or tenderness and bony erosion seen radiologically are features suggestive of malignancy [4].
While these are the usual features of lacrimal gland tumours, unusual presentations may occur.
The tumours may occur in younger patients and even an adenocarcinoma of lacrimal gland has been reported in children [4],[5]. Our second case was only 20 years old. The absence of a palpable mass is rare in cases of lacrimal gland tumour. Boparai et al reported one such case in which the tumour arose from ectopic lacrimal gland tissue. The ectopic tissue was situated deep inside the orbit, giving rise to axial proptosis with no mass palpable externalIy [7].
While they usually displace the eye down and in, occasionally lacrimal gland tumours may displace the eye down and out. This occurs when the tumour has been allowed to grow for a long time and it extends medially towards the nasal wall of the orbit, as was seen in our first case.
Lid extension of lacrimal gland tumour is an extreme rarity, and to our knowledge, has not been reported earlier. This possibly occurs due to defect in the orbital septum. Once the tumour escapes from the bony confines of the orbit, into the loose sub-cutaneous tissues of the lid, growth may be quite rapid. In fact it may be so rapid so as to suggest a malignancy. This is what was seen in our second case.
| References | | |
| 1. | Boparai, M.S., and Vijayalakshmy: A review of 300 cases of proptosis. Paper read at the Xth Congress of Asia Pacific Academy of Ophthalmology, 1985, New Delhi.  |
| 2. | Hoshino. M., and Ichikawa H.: 109 cases of orbital tumours II, Histopathological classification. Fold Ophthalmol, JPN 1980, 31/4. 648-656. |
| 3. | Gogi, R., Nath, K., Ahuja, L., Shuka, M.: Ocular and adnexal tumours. Ind. J. Ophthalmol., 1979, 1;25. |
| 4. | Duke Elder: The ocular adnexa Vol XIII Part II. Henry Kimpton, London, 1974. |
| 5. | Steven G Silverberg: Principles and Practice of Surgical Pathology Vol. II. 2056-2057. Churchill Livingstone, 1990. |
| 6. | Ackerman's Surgical Pathology Vol 11 1799-1800. The C V Mosby Company, 1989. |
| 7. | Boparai, M.S., Chakraborty, M., and Sharma R.C.: Mixed tumour of the lacrimal gland presenting with proptosis and retinal striations. Ind. J. Ophthalmol, 1979, II, 49-51. |
[Figure - 1], [Figure - 2]
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