Exploring the unseen: Medial eyelid cystic swelling

A 55-year-old female presented with non-progressive swelling in the right eye for 8 months. It had initially been diagnosed and treated as chalazion by a general ophthalmologist with no response to treatment. No history of trauma, surgical intervention, or prior infection was present. No history of watering or discharge, no canaliculoliths, and no signs of inflammation or tenderness were noted. On examination, a well-defined, round, non-tender, fluctuant, cystic swelling was present medially in the upper lid involving the pars lacrimalis portion just short of the medial canthus [Fig. 1a and b]. The overlying skin was normal, and an opaque bulge was noted on the conjunctival side with a faint bluish hue.Figure 1: Medial upper eyelid cystic swelling around the canaliculus with stenosis of the upper punctum (a, b). Histopathology of the lining epithelium showing stacked-on, multi-laminated, stratified squamous epithelium without any inflammatory infiltration or goblet cells (c). Postoperative photograph showing a healed and healthy wound (d)What will you do next? Punctum examination Transillumination test Lacrimal syringing All of the above Findings Medial eyelid cystic swelling can have various differential diagnoses, including apocrine hidrocystoma, sebaceous cyst, gland of Moll cyst, infectious or secondary canaliculitis, and canaliculus diverticulum. In this case, the cyst affected the upper canalicular segment with a stenosed puncta and showed positive transillumination. On syringing, lacrimal patency was achieved from the lower punctum with no change in the size of the swelling during or after irrigation. Marsupialization of the cyst was done along with an incision biopsy of the cyst lining, and a good cosmetic outcome was achieved with no postoperative epiphora. Histopathology showed stacked-on, multi-laminated, stratified squamous epithelium without any inflammatory infiltration or goblet cells, confirming the diagnosis of canaliculops [Fig. 1c and d]. Diagnosis Canaliculops (or canaliculocele). Correct answer All of the above Discussion Canaliculops, that is, ectasia of the canalicular wall, is a distinct entity and results from the ball-valve mechanism or/and redundancy of hyperplastic epithelium. Etiology includes diverticula or secondary to lacrimal plugs and can present with punctal agenesis or stenosis, mimicking eyelid adnexal cystic swelling.[1] It lacks typical inflammatory signs such as redness, tenderness, canaliculoliths, or discharge, distinguishing it from other cysts. No fluid/mucus/pus on regurgitation is observed upon pressing, unlike canaliculitis or canaliculi diverticulum. Transillumination reveals clear fluid content, which is not seen in sebaceous cysts. UBM shows a dilated canaliculus with an internal well-defined cyst with a distal non-echoic normal canaliculus. AS-OCT shows a smooth anterior cyst wall with an underlying non-reflective cavity.[2] Preoperative suspicion is crucial to avoid iatrogenic damage to the canalicular segment. Marsupialization with or without a mini-Monoka stent can be done.[3] Histopathology remains the gold standard for diagnosis in such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.