Article Text
PDF
Summary
A patient presented with left upper eyelid swelling and ptosis. The MRI reported a cyst with proteinaceous content. On surgical excision of the cyst, a rigid gas permeable (RGP) contact lens was found. The RGP lens was encapsulated within the upper eyelid soft tissue. It was later revealed that the patient experienced childhood trauma while wearing RGP contact lenses 28 years previously. The patient assumed that the RGP lens fell out and was lost; however, it can be inferred that the lens migrated into the eyelid and resided there asymptomatically for 28 years.
- ophthalmology
- accidents, injuries
Statistics from Altmetric.com
Background
The migration of a rigid gas permeable (RGP) lens into the eyelid is a rare cause of eyelid swelling. Spontaneous migration of a hard contact lens into the eyelid is a relatively known occurrence, but we were only able to find four reported cases of lens migration secondary to significant trauma.1–4
This case report exhibits the longest time between traumatic RGP lens migration into the eyelid and presentation of eyelid swelling. We concluded that the lens migrated into the eyelid following trauma and was dormant for 28 years.
Case presentation
A 42-year-old Caucasian woman was referred to ophthalmology by her general practitioner (GP) with a 6-month history of left upper eyelid swelling and ptosis. The swelling started as a non-tender, pea-sized lump which grew larger and became painful on palpation. The upper eyelid swelling comprised a tender lump not attached to the orbital rim. It was located just nasal to the left upper eyelid and below the eyebrow within the soft tissue. There was mild left ptosis which the patient reported was long-standing and had never caused her concern (figure 1). There was no conjunctival scarring or inflammation on eversion of the upper lid.
Mild left ptosis.
Vision was unaffected at 6/4, and there was no discharge from the eye. The patient had a medical history of asthma, sinusitis and polycystic ovary syndrome.
Investigations
An MRI of the orbit showed a well-defined ovoid nodule measuring 8 mm × 4 mm × 6 mm (figure 2). The features on the MRI were in keeping with a cyst with proteinaceous content. There were no radiological features of a foreign body seen within the cyst.
T2-weighted MRI of the head: transverse and sagittal views. Red arrow: high-intensity signal nodular lesion in the left upper eyelid. The lesion edges are well defined and give a cystic appearance. There is associated surrounding soft tissue swelling.
During excisional surgery, an encapsulated cyst was found within the soft tissue superior to the superior fornix. There were no signs to suggest previous injury to the eyelid or tarsus. On removal, the cyst ruptured and a hard contact lens was extracted (figure 3). The foreign body was extremely fragile on removal and handling. It was later confirmed that this was an RGP lens.
The retrieved rigid gas permeable lens within the cyst. The lens was grossly intact in the eyelid but was cracked and damaged on removal.
Histology of the cystic lesion reported a multiloculated cystic structure lined focally by conjunctival-type epithelium merging with the epithelium which had a very oncolytic appearance but lacking in decapitation secretion. The surrounding tissue had the appearance of inflamed granulation tissue with fibrosis. The histological features were in keeping with reaction to the presence of a foreign body.
Outcome and follow-up
On further questioning, the patient’s mother recalled that the patient had a history of blunt trauma to the upper left eyelid as a child. The patient was hit in the left eye with a shuttle cock while playing badminton at the age of 14. The patient was wearing an RGP contact lens at the time, which was never found. It was assumed that the contact lens dislodged out of the eye and was lost. At the time she did had eyelid swelling which eventually resolved with conservative management from the GP. The patient never wore RGP lenses following this incident. We can infer that the RGP lens migrated into the patient’s left upper eyelid at the time of trauma and had been in situ for the last 28 years.
Discussion
Benger and Frueh5 report a similar case whereby a migrated lens had a similar protracted period of retention within the eyelid. They suggest that there was a minimal inflammatory and secretory response due to the lens being surrounded by the conjunctival epithelium. Similarly, the histology in our case reports a conjunctival-type epithelium-lined cyst. There is still an element of mystery as to what activated the eyelid swelling at the time it presented. There were no elicited triggers which may have precipitated the inflammatory process.
The patient also had a long-standing left ptosis, which was seen as insignificant by the individual. We assume that the ptosis was caused by the RGP lens in situ which was overlooked for 28 years. Intrapalpebral migration of the RGP lens has been known to present with ptosis only and with no eyelid swelling.6
The MRI reported a proteinaceous cyst and did not elicit a foreign body or RGP lens. Previously, MRI has shown to be a useful modality for imaging RGP migration into the eyelid and was reported as a curvilinear signal in T1-weighted MRI sequencing.7 MRI using a radiofrequency surface coil is a newer technology known to provide a more accurate submillimetre resolution of structures.8 This alternative method of imaging may have provided better visualisation of the eyelid anatomy and possibly identified the foreign RGP lens in situ.
Learning points
The case illustrates the importance of considering the differential diagnosis of rigid gas permeable lens migration into the eyelid for presentations of eyelid swelling and presenile ptosis.
We can assume that there was a delay of 28 years from the time of the initial trauma to presentation.
Therefore, the importance of taking a thorough history of previous trauma has been highlighted for this case as it can serve as an important tool for diagnosis.
Footnotes
Contributors SP wrote the manuscript with support from L-LT and HM.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.