Cover

• Thank you moderator, dr. Fairooz for the warm introduction and the
organizers for this wonderful platform and opportunity. How do you
do everyone. I’d like to present our case with the title of
Unprecedented Tumor of the Lacrimal Sac that we encountered in our
hospital in Jakarta, Indonesia
Financial disclosure and credits
• First I’d like to give credits to dr. Mutmainah mahyuddin as my
supervisor and to dr. Nuryati Siregar as our Pathologist for providing
the excellent histopathology slides.
Case illustration
• A 30 years old male patient came to our clinic with chief complaint of watery of both eyes since
10 years before.
• Over the last year, this condition was accompanied with slowly growing mass in the medial
corner of both eyes.
• By this time, the watery condition became more prominent.
• Patient never experienced any purulent or blood discharge.

• There was no history of trauma, surgery, nor family history with similar condition.
• There was no complaints regarding sinonasal related condition.
• This is the picture of the patient at initial visit
Case illustration 2
• Other than the clinical features in the face and eyes, the patient was otherwise healthy.
• From examination we found epiphora of both eyes with intact punctae superior and inferior.
• Pseudo-telecanthus appearance was observed
• Mass was palpable at the lower medial canthal area, which is painless, soft, smooth surfaced,
with distinct edge.
• No discharged was observed and the irrigation showed very little passage to the nasal cavity.
• No signs of infection or inflammation whatsoever. And other part was within normal limit.
CT scan
• This is the axial and coronal ct scan.
• It showed disctinct homogenous masses filling bilateral lacrimal sac, similarly, expanding to
canaliculi and nasolacrimal ducts.
• Note that the ducts were dilated along the way, as shown in the pictures by the arrows and little
triangles, to the size of around 1 cm diameter.
• There were no signs of malignancy as in bone destruction or sinonasal extenstion
Case: surgery result
• Based on the imaging, we decided to do excisional biopsy in 1 side first and then
followed by the other side.
• In toto tumor excisions through subcilliary approach were done in 2 separate
surgeries for both eyes within 1 month interval.
• These are the gross appearance of the tumor.
• Intra-operatively the tumor was easily separated from the surrounding tissues
although trying to pull it along the nasolacrimal duct was quite a challenging part.
After the removal we can see the wide-dilated bony structure of the nasolacrimal
duct.
Pathology
• To our surprise, the pathology result showed a type of benign tumor that we’ve
never heard of.
•
• It showed fibrohyaline mass within adipose tissue in lower magnification and in
higher magnification there were elastic fibers in collagenous matrix.
• This shows resemblance with elastofibroma that usually found in subscapular
area.
• Further examination with Weigert elastic stain were positive, confirming the
diagnosis of elastofibroma.
Follow up
• This is the picture of the patient at about 6 months after the surgery.
• There was no sign of mass recurrency.
• The position and alignment of both eyes appear normal, the previous pseudo-telecanthus
appearance was no longer seen.
• A mild degree of epiphora was still found but did not bothered by the patient. The patient was
satisfied with the condition and no further procedure was done.
Discussion
• Elastofibroma is considered benign connective tissue neoplasm that is characterized by abnormal
elastic fiber which represent a degenerative and reactive change in elastic fibrous tissue.

• It’s more commonly found unilateral in elderly patient due to microtrauma in periscapular region

• It was firstly described by jarvi and saxen in 1961

• Other reported areas are in deltoid muscle, ischial tuberosity, greater trochanter, mediastinum,
hip, neck and oral mucosa
Discussion 2
• How about in the orbit or the ocular surface?

• We did not find any published report on elastofibroma in the orbit or the lacrimal drainage
system

• There were 2 reports from 1983 and 1997 of elastofibroma in the ocular surface. Both reported
the same clinical appearance of elastofibroma resembling pterygium.

• The pathologic finding, however, showed the similarity with elastofibroma commonly found in
the periscapular area, which shows acellular collagenous and adipose tissue containing numerous
elastic fibers.
Discussion 3
• The pathogenesis of elastofibroma is still in debate, there are 2 theories :
1.The elastic material is derived from activated fibrocytes

• 2. It Is resulted due to elastoid degeneration of collagen

Discussion 4
• Neoplastic causes of acquired obstruction of the lacrimal drainage system may be classified into
primary lacrimal drainage system tumors, tumos from surrounding tissues such as eyelid
carcinoma, and secondary tumor from nasolacrimal origin.

• Primary tumors are 45% caused by benign lesion, most commonly papiloma, and 55% caused by
malignant lesion, mostly squamous cell carcinoma.

• However, bilateral lacrimal sac swelling is a rare presentation of a patient

• In bilateral condition, sinonasal tumor extension, sarcoidosis, lymphoma or leukemia
involvement, and bilateral infections in a immunocompromised patients were the thought of
differential diagnosis.

• In our case, signs of malignancy or inflammation were not found, based on the clinical features
and imaging.
Conclusion
• In conclusion :

• 1. To our knowledge this is the first reported case of elastofibroma in

lacrimal drainage system

• 2. Elastofibroma should be considered as differential diagnoses for

bilateral lacrimal sac mass with chronic ephipora
References
• These are my references
Thank you
• Thank you very much for your kind attention