Sir,
Blepharoplasty is a common cosmetic procedure carried out throughout the world. The skin that is removed during the procedure is usually discarded. We present a case of a routine blepharoplasty performed for bilateral dermatochalasis, in which a high suspicion of index on the part of the surgeon, resulted in the detection of serious histopathological changes in the redundant eyelid skin that would otherwise have been discarded.
Case report
A 68-year-old woman was referred to the oculoplastic surgeons with dermatochalasis with vision obstruction. In clinic the visual acuities were 6/9 OD and 6/9 OS aided and the lids showed bilateral upper lid dermatochalasis worse on the right, with a mechanical ptosis (Figure 1a). The facial and lid skin was generally red and thickened. Thinning of both eyebrows was noted. The patient underwent bilateral blepharoplasties and in view of the clinical observations above, the right upper eyelid specimen (that would have otherwise been discarded) was sent for histopathological diagnosis.
The haematoxylin and eosin sections revealed a striking folliculotropic, lymphocytic infiltrate. (Figure 1b). The lymphocytes were rather irregular and cerebriform in shape at higher power (Figure 1c). No follicular mucin was identified. Immunohistochemistry showed that the atypical lymphocytes expressed CD3 (Figure 1d), indicating a T-cell phenotype and CD4 with some loss of CD7.
CD30 or CD56 was not expressed. DNA extracted from the paraffin tissue showed the presence of a T-cell clone (Figure 1e). The morphological, immunohistochemical and molecular features were those of folliculotropic mycosis fungoides (MF) (WHO classification). Dermatological review subsequently discovered reddish patches on her anterior chest, with biopsy showing an identical histological diagnosis.
Comment
To the best of our knowledge, this is the first report of folliculotropic MF to affect the peri-ocular skin. Ophthalmic manifestations of mycosis fungoides have shown that late plaque or tumour phase MF affected the eyelids in a significant number of patients.1 MF can present clinically with lower eyelash and eyebrow loss2 as in our case. The significance of folliculotropic MF is that it carries a worse prognosis compared to conventional plaque stage MF and therefore important to distinguish histologically.3 From a practical perspective, oculoplastic surgeons carry out a large number of cosmetic blepharoplasty procedures. Sending every blepharoplasty specimen for routine histological analysis would not constitute wise use of the histopathology service. However, this case serves to illustrate the point that any eyelid skin that is deemed to be even faintly abnormal during examination or during the surgical procedure should be sent for histopathological examination to exclude serious pathology, of the kind identified in this case.
The study was performed in accordance with the declaration of Helsinki. The patient consented to an identifiable photograph of the eyes to be used for publication. The signed consent is in the medical notes.
References
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Gül U, Soylu S, Aslan E, Yazar Z, Demiriz M . Uncommon presentation of mycosis fungoides: eyelid margin involvement. J Dermatol 2008; 35 (9): 581–584.
van Doorn R, Scheffer E, Willemze R . Follicular mycosis fungoides, a distinct disease entity with or without associated follicular mucinosis: a clinicopathologic and follow up study of 51 patients. Arch Dermatol 2002; 138 (2): 191–198.
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Mudhar, H., Tiffin, N., Currie, Z. et al. Incidental folliculotropic mycosis fungoides in a blepharoplasty specimen performed for dermatochalasis. Eye 28, 359–361 (2014). https://doi.org/10.1038/eye.2013.297
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DOI: https://doi.org/10.1038/eye.2013.297