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CASE REPORT
Year : 2007  |  Volume : 40  |  Issue : 1  |  Page : 54-56
 

An arteriovenous fistula following chalazion excision


1 Plastic Surgery {Reconstructive and Aesthetic} Unit, Department of Surgery, Goa Medical College and Hospital, Bambolim - Goa, India
2 Department of Plastic Surgery and Burns Research Unit, Bai Jerbai Wadia Hospital for Children, Mumbai, India
3 Department of Plastic Surgery, Dr. RN Cooper Hospital, Mumbai, India
4 Department of Plastic Surgery, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, India

Correspondence Address:
Yuri AR Dias-Amborcar
S-6, Bemvinda Apartments, Pajifond, Margao, Goa - 403601
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-0358.32665

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 » Abstract 

An arteriovenous fistula secondary to a chalazion is a rare occurrence. It may follow spontaneous necrosis or surgical trauma. Digital subtraction angiography and identification of the arterial feeders combined with direct puncture of the nidus and embolization is recommended, as surgical excision becomes much easier and results in a complete excision of the lesion. Conchal cartilage graft is a useful lining material for reconstruction of the tarsal plate due to its natural curvature. It restores lid integrity and ensures a stable and functional eyelid.


Keywords: Arteriovenous fistula, chalazion, glue embolization


How to cite this article:
Dias-Amborcar YA, Mokal NJ, Abhyankar SV, Bhat UB. An arteriovenous fistula following chalazion excision. Indian J Plast Surg 2007;40:54-6

How to cite this URL:
Dias-Amborcar YA, Mokal NJ, Abhyankar SV, Bhat UB. An arteriovenous fistula following chalazion excision. Indian J Plast Surg [serial online] 2007 [cited 2019 Aug 19];40:54-6. Available from: http://www.ijps.org/text.asp?2007/40/1/54/32665



 » Introduction Top


Arteriovenous (AV) fistulas are uncommon lesions around the eye and may be congenital or following trauma or surgery. [1] When present, they are usually located deep in the orbit, posterior to the septum orbitalis [2] and the tarsal plate is rarely involved. [3] They cause a cosmetic deformity, may result in a deprivation ambylopia or astigmatism [4] and may get worse with time necessitating prompt treatment. We report a case of AV fistula, which presented secondary to drainage of a recurrent chalazion. It was managed by percutaneous glue embolization followed by surgical excision, the tarsal plate being reconstructed with conchal cartilage graft.


 » Case Report Top


A 17-year-old female presented in April 1998 with a swelling in the medial aspect of the left upper eyelid and restriction in upward gaze movement since one year [Figure - 1]. It was small to begin with and had gradually increased to the present size. Examination revealed a 1.5 x 1.0 cm pulsatile mass with tortuous engorged vessels. The overlying skin was erythematous with the presence of a previous surgical scar. There was hyperemia on the conjunctival side. Mechanical ptosis was present. The soft swelling was compressible and had a thrill. Vision was normal. The patient gave history of a swelling in the same location three years previously which was then diagnosed as a chalazion by an ophthalmologist. She underwent curettage for the same on three occasions. The post procedure period was uneventful until she noticed the present swelling one year prior.

With a clinical diagnosis of an AV fistula, a contrast enhanced computerized tomographic scan and digital subtraction angiography (DSA) were performed. The former revealed an ill-defined vascular lesion. On DSA there was evidence of a high-flow AV fistula with the main feeder coming from the ophthalmic artery. The feeder had communications with the palpebral and lacrimal branches. The venous drainage was into superior orbital, angular and facial veins.

Surgical excision of the tumor was planned with preoperative glue injection (with the help of the interventional radiologist). The tumor was directly punctured at two sites and 28% N-butyl cyanoacrylate (Histocryl) injected into the nidus under fluoroscopic guidance. The central portion was obliterated but there was still 20% residual flow found in the periphery of the tumor.

Ten days post embolization, the inflammatory edema subsided and the patient was operated under general anesthesia. Through a bicoronal approach, the scalp was raised in the subgaleal plane and the periosteum incised at the supraorbital margin. The periorbita was elevated and then opened to identify the feeder vessel, (from the ophthalmic artery) which was underrun at two sites and ligated with 4'0 chromic catgut. The communications to the palpebral and lacrimal branches and the venous drainage channels were also ligated. A separate anterior lid incision was taken to excise the tumor. It was found to be originating from the tarsal plate and this area of attachment to the tarsal plate was excised leaving behind a defect of approximately 10 x 8 mm in the tarsal plate. The defect in the tarsal plate was reconstructed using a conchal cartilage graft. The levator palpebrae superioris was reattached into the reconstructed superior tarsal plate. The overlying orbicularis oculi and skin was mobilized and sutured. The post-operative period was uneventful. Histopathological examination confirmed the clinical diagnosis of AV fistula. At the end of two years of follow-up, there was no recurrence of the swelling and the patient has an excellent functional and cosmetic result [Figure - 2].


 » Discussion Top


A chalazion is a chronic inflammatory granuloma caused by the retention of secretions of a tarsal gland whose opening is obstructed. The gland undergoes pressure necrosis and inflammation because of the inspissated lipid material. [4] Wolter [5] reported an AV fistula occurring in the region of a chalazion and opined that necrosis within the latter was the probable cause of the vascular malformation. He adds that pyogenous granulation tissue may result in a lesion that resembles cavernous hemangioma or AV fistula. [5]

Preoperative embolization with N-butyl cyanoacrylate is an effective and safe technique, which causes shrinkage of the lesion and reduction in its vascularity thereby facilitating easier surgical excision. [6] Hypertrophy and enlargement of the tarsal plate requires partial resection. [3] An intact tarsal plate is necessary for stability of the eyelid margin and hence various tissues including conchal cartilage, chondromucosal septal grafts, preserved sclera etc. have been used for reconstruction. Tarsal reconstruction with conchal cartilage graft is a simple and well described technique. [7] It is the preferred material because its contour ensures good contact of the lid margin with the eyeball and it is thin and soft, with a supple consistency similar to that of the tarsal plate. [8]


 » Acknowledgement Top


We acknowledge the support of Dr. Nimmi R. Lalwani, Professor and Head, Department of Plastic Surgery, B. Y. L. Nair Charitable Hospital, Mumbai.

 
 » References Top

1.Wolter JR. Arteriovenous fistulas involving the eye region. J Ped Ophth 1975;12:22-39.  Back to cited text no. 1    
2.Busin M, Graefe C, Koch J. Arteriovenous fistula presenting as a tumor of the upper eyelid. Ophthalmic Surg 1994;25:471-3.  Back to cited text no. 2  [PUBMED]  
3.Wang KH, Macomber WB. Tumors of the eyelids and orbit. In : Converse JM editor. Reconstructive Plastic Surgery. Vol. 2, 2 nd ed. WB Saunders Co: Philadelphia;1977. p. 874.  Back to cited text no. 3    
4.Illif CE, Illif WJ, Illif NT. Oculoplastic surgery. WB Saunders Co: Philadelphia; 1979.   Back to cited text no. 4    
5.Wolter JR. Arteriovenous fistula of the eyelid secondary to a chalazion. J Ped Ophth 1977;14:225-7.   Back to cited text no. 5    
6.Han MH, Seong SO, Kim HD, Chang KH, Yeon KM, Han MH. Craniofacial arteriovenous malformation: Preoperative embolization with direct puncture and injection of n-butyl cyanoacrylate. Radiology 1999;211:661-6.  Back to cited text no. 6    
7.Matsuo K, Hirose T. The use of conchal cartilage graft in involutional ectropion. Plast Reconstr Surg 1990;86:968-70.  Back to cited text no. 7  [PUBMED]  
8.Matsuo K, Hirose T, Takahashi N, Iwasawa M, Satoh R. Lower eyelid reconstruction with a conchal cartilage graft. Plast Reconstr Surg 1987;80:547-52.  Back to cited text no. 8  [PUBMED]  


    Figures

  [Figure - 1], [Figure - 2]


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