Hidrocystoma: surgical management of cystic …

1 368 hidrocystoma : surgical management of cystic lesions of the eyelid Hidrocistoma: conduta cir rgica na les o palpebral c sticaAbelardo de Souza Couto J nior 1 Gabrielle Macieira Batista 2 caro Guilherme Donadi Ferreira Calafiori 3 Vin cius Crist fori Radael 4 Wilker Benedeti Mendes 5 Abstract:This report describes the case of a hidrocystoma of the eyelid and the surgical techniqueused in the therapeutical management of benign cystic lesions of the eyelids. Hidrocystomas are rela-tively common benign lesions of the eyelids, principally the lower eyelid. They are more common infemales over thirty years of age. Diagnosis is clinical and when there is a single lesion, surgery is thetreatment of choice. The surgical technique used should be described in greater detail, since it offersgood esthetic results and a low risk of : Eyelid neoplasms; hidrocystoma ; hidrocystoma /diagnostic; hidrocystoma /etiology; hidrocystoma /surge ry; Sweat glandsResumo:Relato de caso de hidrocistoma palpebral e apresenta o de t cnica cir rgica na conduta ter-ap utica dos tumores c sticos benignos da p lpebra.

2 Os hidrocistomas s o tumores benignos relativa-mente frequentes nas p lpebras, principalmente, na p lpebra inferior, com maior preval ncia no sexofeminino e a partir da quarta d cada de vida. O diagn stico cl nico e, em casos de les o nica, a con-duta cir rgica o tratamento de escolha. Deve-se descrever melhor a t cnica cir rgica utilizada, poistraz bons resultados est ticos e menor risco de : Gl ndulas sudor paras; Hidrocistoma/cirurgia; Hidrocistoma/diagn stico;Hidrocistoma/etiologia; Neoplasias palpebraisReceived on by the Advisory Board and accepted for publication on *Study conducted at the Valen a School of Medicine, Rio de Janeiro, of interest: None / Conflito de interesse: NenhumFinancial funding: None / Suporte financeiro: Nenhum1 PhD, Head of the Department of Ophthalmology, Valen a School of Medicine, Rio de Janeiro.

3 Coordinator of the Medical Residency Program in Ophthalmology of the Benjamin Constant Institute, Ministry of Education, Brazil. Professor in the Postgraduate Course in Ophthalmology of the Pontifical Catholic University of Rio de Janeiro. Brazilian Society of Ophthalmology, Rio de Janeiro, medical student, Valen a School of Medicine, Rio de Janeiro, medical student, Valen a School of Medicine, Rio de Janeiro, enrolled in the postgraduate course in Ophthalmology at the Hospital dos Servidores of the state of Rio de Janeiro, participating in the Residency Program in General Surgery at the Valen a School of Medicine, Rio de Janeiro, Brazil. 2010 by Anais Brasileiros de DermatologiaCASEREPORTINTRODUCTIONH ydrocystomas are a cystic form of sweat glandadenoma resulting from proliferation of the apocrineor eccrine secretory glands.

4 1,2 They consist of singleor multiple lesions of varying sizes, generally situatedon the head, predominantly on the face: the forehead,cheeks and eyelids (glands of Moll), the outer canthusof the lower eyelid being the most common site. 3 Their pathogenesis appears to result from anobstruction of the sweat gland ducts immediatelyabove the glandular coil within the deep dermal layerfollowing an inflammatory process or trauma. 4 Hydrocystomas are benign lesions of the eyelidthat are differentiated in two histological types: apoc-rine and eccrine. 5,6 The apocrine hydrocystoma or cyst of Mollaffects the eyelid border and generally appears follow-ing an obstruction of the apocrine secretory duct ofthe gland of Moll (apocrine and eccrine sweat glands).

5 2 They consist of small, painless, round, translucent,fluid-filled vesicles. 1,5,7 The eccrine hydrocystoma or cyst of the eccrinesweat glands originates from the eccrine sweat gland,also known as the gland of Moll, and is a rare disor-der. It generally presents as multiple cutaneous vesi-cles on the lower eyelid. 5 The most common site for cysts of Moll is closeto the eyelashes, the route of lacrimal drainage, whilethe most common site for eccrine hydrocystomas ison the skin of the eyelid. 8 According to the results of a study conducted atAn Bras Dermatol. 2010;85(3) : surgical management of cystic lesions of the eyelid369An Bras Dermatol. 2010;85(3) Botucatu School of Medicine in Brazil, hydrocys-tomas predominantly affect females from the fourthdecade of life onwards, usually in the form of a singlelesion, a finding that is in agreement with otherreports in the literature.

6 6,8,9 The most usual site is onthe lower eyelids. 10 The time between the first appearance of thelesion and reaching clinical diagnosis varies from oneto five years; however, it should be emphasized thatthis figure is imprecise since in many cases onset ofthe lesion s growth was not observed by the physician,given that the lesion is usually asymptomatic. 10 Consequently, the majority of patients seek treatmentfor esthetic reasons. 6 The initial diagnosis is clinical, followed byhistopathological confirmation. 6,8 Histologically, apocrine hydrocystomas presentwith various large cystic spaces and papillary projec-tions in the dermis, covered by two layers of secreto-ry cells. The innermost cells are columnar-shapedwith eosinophilic cytoplasm with typical apical projec-tions and decapitation secretion, periodic acid-Schiff(PAS)-positive and diastase-resistant granules.

7 11 Eccrine hydrocystomas are retention cysts his-tologically characterized by a single, partially col-lapsed cystic cavity in the dermis, with no papillaryprojections, surrounded by one or two layers of smallcuboid epithelial cells. Sometimes the content of thecysts has a brownish coloring due to the lipofuscinsecreted by the neighboring cell, giving it a clinicalappearance of blue nevus or melanoma. 11 Differential diagnoses include: contagious mol-lusk, nodular or cystic basal cell carcinoma, hidradeno-ma, nevocytic nevus, blue nevus, disseminated syringo-ma, hordeolum, chalazion and epidermal cyst. 12 The objective of presenting this case report is todescribe the surgical management of cases of cystictumors of the eyelid with the respective surgical tech-nique in each REPORTA 34-year-old, white female patient, SHO, a mar-ried housewife from Valen a, Rio de Janeiro, Brazil,presented at the clinic complaining of a lesion on hereye.

8 The patient reported that it had begun as a smallpustulous, painless lesion in the outer canthus of thelower eyelid of her right eye ten years previously. Fiveyears ago, she injured the lesion and from thenonwards it began to grow more rapidly and becameslightly painful. She then went to the ophthalmologyoutpatient department at the Teaching Hospital of theValen a School of Medicine in Rio de Janeiro with acomplaint that the lesion was hampering vision in herright eye. She reported no other symptoms. She hada past history of systemic arterial hypertension and nohistory of diabetes mellitus or of any other comorbid-ity. Her father died at 68 years of age of acute myocar-dial infarction. Her mother has systemic arterialhypertension and diabetes mellitus.

9 The patientsmokes sixteen packs of cigarettes per year and drinksalcohol socially. Ophthalmological examinationrevealed normal visual acuity in both eyes and noabnormalities in extrinsic ocular motility. Pupillaryreflexes were preserved. Biomicroscopy revealed thepresence of a translucent tumor in the outer canthusof the lower eyelid of the right eye (Figure 1).Diagnostic hypothesis was consisted of surgical removal andhistopathological evaluation. Histology revealed anapocrine hydrocystoma. surgical procedure/tech-nique: Anesthesia was achieved by perilesional infil-tration of 2% Xylocaine with adrenalin at a solution of1:200,000 after which an incision was made in theskin above the cystic lesion, taking care not to pene-trate too deeply with the scalpel in order not to per-forate the lesion, thereby allowing it to be completelydissected and removed intact.

10 Next, the edges of theskin were opened and the lesion was completely dis-sected up to its base, always by stretching (divulsion)with scissors rather than by cutting (Figure 2). Finally,the lesion was removed intact without perforating thecystic capsule. Next, the wound was cauterized, theexcess skin was excised and the wound was suturedusing nylon thread and separated stitches (Figure 3).In the surgical procedure, a single, round,translucent cystic lesion measuring approximately at its greatest diameter was removed intact with-out rupturing the capsule (Figure 4). Evaluation of the histological sections of thelesion revealed the structure of the cystic wall to belined with a cubic epithelium or with predominantlysimple pavement epithelium.