
==== Front
Ophthalmic Plast Reconstr Surg
Ophthalmic Plast Reconstr Surg
IOP
Ophthalmic Plastic and Reconstructive Surgery
0740-9303
1537-2677
Lippincott Williams & Wilkins Hagerstown, MD

38776159
OPRS-D-24-00107
00028
10.1097/IOP.0000000000002658
3
Case Reports
Enlarging Orbital Rim Mass Due to Old Pencil Injury
Schumaier Nahrain Putris M.D. *†
Mileo Lauren DeMaria M.D. ldemaria825@gmail.com
†‡
Folberg Robert M.D. robert.folberg@corewellhealth.org
*†§
Schlachter Dianne M. M.D. dschlachter@facialworks.com
*†‡
* Oakland University William Beaumont School of Medicine, Auburn Hills
† Corewell Health William Beaumont University Eye Institute, Royal Oak
‡ Consultants in Ophthalmic and Facial Plastic Surgery, Southfield
§ Department of Pathology, Corewell Health, Royal Oak, Michigan, U.S.A.
Address correspondence and reprint requests to Nahrain Putris Schumaier, M.D., Corewell Health William Beaumont University Hospital Eye Institute, 3535 West 13 Mile Road Suit #555, Royal Oak, MI 48073. E-mail: nahrain.putris@corewellhealth.org
22 5 2024
Sep-Oct 2024
40 5 e154e156
12 2 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

A 54-year-old female noticed a 2-month history of an enlarging left inferomedial orbital rim mass. The patient remembered a pencil injury at approximately 7 years of age. Her complete ophthalmic examination was otherwise unremarkable. She underwent CT orbital imaging, demonstrating a centrally hyperdense lesion along the left inferomedial orbital rim. There was no involvement of the nasolacrimal duct system. The patient underwent an excisional biopsy. The pathology disclosed noncaseating granulomatous inflammation to particulate black material consistent with graphite.

A female patient developed an enlarging inferomedial orbital rim mass after a pencil injury more than 4 decades ago, with an excisional biopsy revealing noncaseating granulomatous inflammation to particulate black material consistent with graphite.

STATUSONLINE-ONLY
OPEN-ACCESSTRUE
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pmcA few cases in the literature indicate that pencil injuries to the globe and ocular adnexa have varied presentations.1–9 Lead pencils are a misnomer as they are primarily made of graphite, clay, and wax. Although the toxicity of these individual elements is low, they are associated with granulomatous inflammation as the composites break down over time. Therefore, penetrating trauma with a pencil core can delay the presentation of granulomatous inflammation.5 Most patients do not even recall the initial injury.1,6–8

Nevertheless, an enlarging mass with or without a history of trauma raises concern for a neoplastic process. Preoperative orbital imaging is often utilized to characterize the lesion better and guide surgical management for biopsy when the diagnosis is uncertain.9 The authors herein present a case of a growing amelanotic orbital rim lesion in a patient with unique CT imaging and pathology findings approximately 47 years after a known childhood pencil injury. This case was reported in compliance with the Health Insurance Portability and Accountability Act and adhered to the Declaration of Helsinki.

CASE PRESENTATION

A 54-year-old female presented with a 2-month history of a rapidly enlarging left inferomedial orbital rim mass. The patient denied periorbital pain, diplopia, discharge, or vision changes. The patient recalled a pencil injury to that area around the age of 7 that left her with a small residual bump. She also stated that she underwent orbital imaging immediately after the injury, which revealed a minor orbital fracture without the need for surgical intervention. Upon presentation, a complete ophthalmic examination revealed a firm nodular mass inferior to the medial canthal tendon extending along the inferomedial orbital rim. It was without overlying skin discoloration and was adherent to the orbital rim (Fig. 1A,B). On probing and irrigation, there was no nasolacrimal duct obstruction. There were also no pupillary abnormalities, extraocular muscle limitations, and proptosis.

FIG. 1. A and B, Clinical image of a nodular mass inferior to the left medial canthal tendon. C, Coronal CT image illustrating a superficial inferomedial left orbital lesion with central hyperdensity corresponding to the location of remote pencil injury. D, Sagittal CT image demonstrates the mass extending along the inferomedial orbital rim.

Given her trauma history and the need for better lesion characterization, the patient underwent CT orbital imaging, which showed a left-sided soft tissue lesion with calcification along the inferomedial orbital rim (Fig. 1C,D). The decision was made to explore and excise the lesion due to its location, rapid progression, orbital imaging findings, cosmetic appearance, and need for confirmatory diagnosis. Excisional biopsy revealed a nodular, rubbery, purple-gray lesion directly over the left inferior orbital rim adherent to the periosteum and bone without apparent bony destruction or extension to other ocular adnexal structures. The periosteum and bone immediately adjacent to the lesion demonstrated grayish discoloration. The specimen was sent for histopathological analysis, illustrating noncaseating granulomatous inflammation to particulate black material. The material was graphite in the setting of her old pencil injury (Fig. 2A–C). It should also be noted that gross dissection revealed a central cylindrical, gray-tan, hard foreign body surrounded by white fibrous tissue consistent with the old pencil core. The patient’s postoperative course was complicated by significant inflammation and scarring that improved following a short course of oral corticosteroids, firm massage, and combined intralesional triamcinolone and 5-fluorouracil injections.

FIG. 2. A, Photomicrograph illustrating a concentration of inert black pigment (i.e., graphite) surrounded by fibrous connective tissue. Graphite is also outside the fibrous capsule with a surrounding granulomatous reaction (hematoxylin-eosin, ×10). B, Photomicrograph demonstrating numerous giant cells containing graphite and lymphocytic infiltrate consistent with a granulomatous inflammatory reaction (hematoxylin-eosin, ×20). C, Photomicrograph of multinucleated giant cells and epithelioid histiocytes containing graphite (hematoxylin-eosin, ×40).

DISCUSSION

A history of pencil trauma is often revealed after biopsy due to its ability to remain inert for decades.8 Moreover, a granulomatous foreign body reaction is often delayed because pencil “lead” is an amalgam of graphite, clay, and sealed waxes.1–4,6,7 These materials do not usually elicit an immediate inflammatory response. However, the innate and adaptive immune responses activate once the composites degrade and particles disperse in the surrounding tissue.5 In the presented patient, pathology revealed a high concentration of inert black pigment (i.e., graphite) surrounded by fibrous connective tissue. It appeared that the degraded graphite escaped its fibrous encapsulation, inciting a surrounding granulomatous reaction.

The patient’s CT imaging demonstrated a centrally “calcified” lesion along the area of concern. Soft tissue calcification in orbital rim masses can either be metastatic from systemic causes of hypercalcemia or dystrophic from cellular injury after trauma, tissue hypoxia, or vascular stasis. Notably, orbital calcification within the lacrimal gland fossa is usually associated with malignant disease. Calcification outside the lacrimal gland fossa is generally related to vascular lesions.10 Benign, malignant, and vascular lesions were therefore considered in the differential diagnosis of the patient’s orbital mass despite a high clinical suspicion for a foreign body granuloma in the setting of her previous pencil injury. Furthermore, differences in CT signal intensity help distinguish between various substances, such as graphite, which often appears hyperdense.9 Upon further review of the patient’s CT imaging, the authors clarified the calcification as a focal cylindrical hyperdensity more representative of foreign body material. This suspicion was confirmed on pathology, which revealed no calcium deposits. Therefore, clinical correlation remains integral in a patient’s diagnosis. We recommend that radiologists be provided with detailed clinical background, if available, to characterize CT findings better.

The authors highlight a unique presentation of an orbital rim foreign body granuloma and inflammation with graphite particles in a patient with a previous pencil injury. Clinicians should consider a foreign body granuloma in their differential diagnosis of orbital rim masses and inquire about old trauma on initial evaluation.

ACKNOWLEDGMENT

None.

D.M.S. is a consultant and speaker for Amgen. The remaining authors have no conflicts of interest to disclose.
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