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Dhabarde et al. UJMDS 2015, 03 (02): Page 44-46
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Unique Journal of Medical and Dental Sciences
Available online: www.ujconline.net
Case Report
RARE CASE OF LARGE ORBITAL SEBACEOUS CYST WITH
FISTULOUS TRACT NEAR LACRIMAL SAC AREA
Dhabarde Kavita A1*, Deshmukh MR2 , Bodalkar VP3
1
2
Assistant Professor, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India
Associate Professor, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India
3
Post Graduate, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India
Received: 26-04-2015; Revised: 24-05-2015; Accepted: 22-06-2015
*Corresponding Author: Dhabarde Kavita A
Assistant Professor, Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India, Mobile No. 09423105181
ABSTRACT
A 55 year old male presented with a large gradually increasing swelling over left lacrimal sac area with thick cheesy toothpaste like
material coming out from skin over sac area on pressure since 2 years. On examination obvious roughly 3cm x 3 cm swelling with
external fistula was present on sac area which was raised above the surface, slightly tender with no redness or increased temperature
on it and attached to overlying skin. Material on culture and sensitivity showed no growth. On histopathological examination , cheesy
material with few leucocytes and red blood cells were seen, malignant cells were absent. ELISA for HIV was nonreactive. Patient was
given systemic and local antibiotics and anti-inflammatory drugs with daily expression of material from cyst. Removal of cyst with
fistulectomy was done and sebaceous cyst was confirmed on histopathological examination.
Keywords: Large Orbital Sebaceous Cyst, Fistula Near Lacrimal Sac Area, Cheesy Discharge
INTRODUCTION
Diseases of the orbit create some of the most complex and
perplexing problems in ophthalmology1. Sebaceous cyst are
small lumps just under the skin that contain keratin. (Keratin –
a pasty or cheesy looking protein that often has a foul
odour).They are usually painless, slowly growing occurring
often as a result of swollen hair follicles or skin trauma,
diagnosed easily by appearance2. Most common areas are
armpits, groin, bikini line, inner legs and anywhere that sweats
and rubs against clothing. Stress is a big inducer.2 Sebaceous
cyst in lacrimal sac area is very rare. Reported prevalence of
sebaceous cyst is 5 per 1000 ie approx.1 in 200 or 1.4 million
people in USA. Present case is a very rare case of large orbital
sebaceous cyst with fistulous tract near lacrimal sac area.
CASE REPORT
A 55 years old male, slum dweller, rickshaw-puller by
occupation presented with gradually increasing swelling over
left lacrimal sac area with thick cheesy toothpaste like material
coming out from skin over sac area on pressure since 2 years.
The thick discharge material was slightly blood tinged with no
foul smell. Patient had no complaint of pain, redness over the
swelling or watering from the eye. He was non-diabetic and
chronic alcoholic since 20 years. There was no history of
contact. On examination, his visual acuity was 20/20 in right
eye and 20/60 with no improvement with pinhole in left eye.
Right eye was normal except a small 1 cm x 1cm nontender
swelling n sac area. In left eye, lids were edematous with
mechanical ptosis. Eyelashes were matted with discharge. Rest
of anterior segment was normal in right eye .The left eyeball
was displaced laterally by 4 mm. A large round obvious
roughly 3cm x 3 cm swellng with external fistula was present
on sac area .The swelling was raised above the surface for
about ½ cm with punctum over it and was attached to
overlying skin. Continuous discharge of thick pultacious
cheesy looking initially white and then blood stained material
was present on pressure over sac area .The swelling was
slightly tender with no redness or increased temperature of the
skin over selling .
Culture and sensitivity of thick discharge material showed no
growth of organisms. Plain X-ray left orbit (lateral view)
showed soft tissue density lesion anterior to ethmoidal sinus.
CT scan of left orbit demonstrated an irregular lesion
involving left lacrimal fossa . ENT examination did not reveal
any nasal pathology. Skin specialists opinion was suggestive
of long standing sebaceous cyst with fistula over sac area.
Syringing of right eye was patent and of left eye could not be
done. Blood sugar levels were within normal limits. Elisa for
HIV was non- reactive. Histopathological examination of
Unique Journal of Medical and Dental Sciences 03 (02), April-June 2015
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Dhabarde et al. UJMDS 2015, 03 (02): Page 44-46
discharge revealed cheesy keratin material with few
leucocytes and red blood cells. Malignant cells we
were absent.
Patient was administered systemic (Cefotaxime, Gentamycin,
Metronidazole) and local antibiotics and anti
anti-inflammatory
drugs with daily expression of thick discharge from the cyst.
Removal of cyst with fistulectomy was done with the help of
oculoplasty
oplasty surgeon and cyst was sent for histopathological
examination. The cyst was lined by stratified squamous
epithelium and was filled with keratinous material.
CLINICAL PHOTOGRAPHS OF THE PATIENT
Sebacious Cyst with cheesy thick pultaceous, slightly blood stained discharge
Cyst showing umblication, with gross lid oedema and thick cheesy discharge with fistula in sac area
DISCUSSION
A sebaceous cyst is a type of cyst that forms in the epidermis,
the outermost layer of the skin. Sebaceous cysts are common,
noncancerous, and are generally not a serious condition3. It
also sometimes called an epidermal cyst, forms when keratin,
a protein that makes of the epidermis, blocks a sebaceous
gland2. This creates a contained sac that fills with a fatty white
substance secreted by the sebaceous gland called sebum. The
contents of the sebaceous cyst are often referred tto as
resembling cottage cheese. Sebaceous cysts can be caused by
skin trauma, swollen hair follicles, high levels of testosterone,
and some hereditary syndromes4. Sometimes they grow large
enough that may interfere with everyday life. Sometimes even
lasting
ng for weeks or months, they can tunnel under skin and
spread. They can become infected and can form painful
abscesses. Often a sebaceous cyst requires no treatment, and it
may disappear by itself. If the cyst is small injection of
steroids with antibiotics
ics can be tried. In cases of large cyst,
surgical removal is indicated. If incompletely removed, can
recur2.
CONCLUSION
Sebaceous cyst in lacrimal sac area is very rare. The above
reported case of large orbital sebaceous retention cyst with
fistula near lacrimal sac area of long duration is a very rare
case. It can very well mimic chronic dacryocystitis (large
mucocele), adenocarcinoma of lacrimal sac, pseudo tumor of
orbit and orbital cellulitis. We recommend considering it in
the differential diagnosis of swelling over lacrimal sac area5.
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4.
REFERENCES
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Levine RA, Putterman AM, Macrae DW.Orbital and
Adnexal Tumors.In:Peyman GA,editor. Principles
and Practice of Ophthalmology,1st Indian ed. New
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Tracee Cornforth. Sebaceous cyst. Sebaceous cysts
are pasty filled bumps and lumps below the skin.
http://www.nlm.nih.gov/medlineplus/ency/article/000
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.Available from 2014About.com
PubMed Health A.D.A.M Medical Encyclopedia.
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Epidermal
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Lydia Krause. What’s causing this sebaceous cyst ?
Healthline medically reviewed by George Krucik
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Ophthalmology 103;10:1601-05
Source of support: Nil, Conflict of interest: None Declared
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