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The oil droplet sign
  1. P HEYWORTH,
  2. J R O COLLIN
  1. Moorfields Eye Hospital, London
  2. Institute of Ophthalmology, London
  1. P LUTHERT
  1. Moorfields Eye Hospital, London
  2. Institute of Ophthalmology, London
  1. Mr P Heyworth, Moorfields Eye Hospital, City Road, London EC1V 2PD susan.heyworth{at}virgin.net

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Editor,—Over the past 22 months we have collected a series of five patients with basal cell carcinomas of the lid who exhibit the oil droplet sign. The following case report is a representative example.

CASE REPORT

A 27 year old Zimbabwean male presented with a 14 month history of a progressively enlarging mass in the right lower lid.

Clinically there appeared to be a nodular basal cell carcinoma involving the lateral part of the right lower lid measuring 3.5 × 3.5 mm and involving the lid margin (Fig 1). There was no regional node involvement. On everting the lid there were multiple transparent droplets beneath the tarsal conjunctiva measuring between 0.25 and 0.50 mm in diameter (Fig 2, see arrow). The droplets lay directly over the area of tumour involvement and extended beneath the forniceal conjunctiva. The droplets contained a clear or straw coloured fluid which had an oily appearance.

Figure 1

Photograph showing a 3.5 × 3.5 mm nodular basal cell carcinoma involving the right lower lid margin.

Figure 2

Photograph showing multiple lipid droplets (arrow) beneath the tarsal conjunctiva.

A full thickness wedge resection with 4 mm margins was performed. The lid was closed directly.

A light photomicrograph (Fig 3) of the full thickness lid resection shows a basal cell carcinoma at the lid margin (superiorly) and along the tarsal conjunctiva (left). Lipid droplets are associated with an intense chronic inflammatory cell infiltrate. Note one large droplet very close to the surface.

Figure 3

Photomicrograph of full thickness lid resection shows a basal cell carcinoma at the lid margin (superiorly) and along the conjunctiva (left). Lipid droplets are associated with an intense chronic inflammatory cell infiltrate (haematoxylin and eosin; original magnification ×27). The insert (from an adjacent section) shows the lipid droplets at higher magnification (×110).

COMMENT

We have noted this sign over many years and have collected five cases over the past 22 months. To our knowledge this sign does not appear in the literature. The sign has only been noted among cases of basal cell carcinoma and has not been associated with other tumours such as squamous cell carcinomas or meibomian gland carcinomas.

We propose that the lipid droplets represent trapped meibomian gland secretions which cannot drain through obstructed or infiltrated meibomian gland ducts. It is interesting to note that the droplets appear beneath the conjunctiva rather than forming collections within the tarsus as is seen with chalazion formation. The invasion and destruction of the tarsus by tumour (as opposed to benign obstruction) may offer a route of least resistance whereby the droplets appear beneath the conjunctiva.

There are insufficient numbers of cases to state whether this is exclusively a sign associated with basal cell carcinomas or whether it may appear among the rarer tumour types. The sign is however a good indicator of an infiltrative process and may assist the clinician in the diagnostic process.

Manuscripts from all countries except the UK and the Republic of Ireland should be sent to Professor C Hoyt, Editor, British Journal of Ophthalmology, University of California, Department of Ophthalmology, 10 Kirkham Street, K 301, San Francisco, CA 94143-0730, USA (tel: 001 415 502-6871; fax: 001 415 514-1512).

Manuscripts from the UK and the Republic of Ireland should be sent to Professor Andrew Dick, UK Editor,British Journal of Ophthalmology, Division of Ophthalmology, University of Bristol, Lower Maudlin Street, Bristol BS1 2LX (tel: 0117 928-4827; fax: 0117 925-1421).

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