Four years old patient attended the Ophthalmology Clinic in June 2008 from Pediatrics, with a diagnosis of congenital left eye ptosis, which according to the parents was evident since two years old.
Parents report that they tend to rub that eye a lot.
Normal pregnancy, term by cesarean section.
They only highlight coagulation problems in the mother during pregnancy, treated with subcutaneous heparin.
On physical examination discreet upper eyelids, internal third of the left upper eyelid slightly decreased were observed.
No masses in that area.
Visual acuity was 0.8 in both eyes with Snellen's E test.
Normal ocular motility, negative Cover test.
Eye fundus was unchanged.
He came for a new evaluation at five months, referring to a left eye itching.
In the new exploration, a slight bulging in the inner third of the upper eyelid of the left eye was observed.
There is no clear limitation of the motility of this eye, but it seems to be in slight hypotropia.
Rest of normal examination.
Differential diagnosis is proposed between motility alteration or orbital mass.
The diagnosis was made based on child image assessment.
1.
In the infantile constriction consultation a week later, visual acuity without correction, of 1 in right eye, and 0.7 in left eye, which with 1.25 to 40o reaches the unit.
Cover negative test in primary position with discrete limitation to adduction and elevation, normal stereopsis and eye fundus without alterations.
A mass in the internal third of the upper eyelid was intuitively fixed by palpation.
Astigmatism increased in the waiting time until nuclear magnetic resonance (NMR) was performed.
MRI showed a tumor in the superointern angle of the left orbit, compressing the eyeball, compatible with dermoid cyst, so surgical treatment was indicated.
Anterior orbiotomy was performed through the internal third of fold thickness.
Intraoperatively, a well-defined lesion was detected in the superointerno orbital quadrant, which was extracted in its entirety.
One week after surgery, symmetry between the upper eyelids and the position of the eye were recovered.
