 We're going to move ahead with our next resident presentation, Aslan Bernheisel, one of our first-year residents, is going to speak about subepidermal calcinosis in the ocular adnexa. Are you ready to roll? You're up. Thank you, Dr. Dahliawell, for that last lecture. I was really nice change and to talk about life and advice, so I appreciate that. I think it might be nice to take a break and have her show us some acupuncture, maybe on Dr. Mifflin, to get some experience with that. And I'd like to borrow Dr. Warner's fanny pack sometime. So thanks for all you being here at the end. So I'm going to talk about subepidermal calcinosis. So I'm going to be talking about subepidermal calcinosis. And first of all, to start out, has anyone ever heard of this before? If I raise the hands. I don't think so. So it's extremely rare and not really well understood, which is why we decided to do a major review and a case report to kind of illustrating this. So to start out, calcinosis cutis is characterized by abnormal calcium deposits in the skin, and it's divided into five subtypes. The first one is dystrophic calcinosis, and that is basically when there's some kind of damage to the connective tissues, most classically crest syndrome, and the same kind of calcium deposits that occur with a tumor growth or with trauma. And there's also metastatic calcinosis, and that's kind of any kind of calcium deposition in the skin that is secondary to calcium or phosphorus abnormalities. And then you have iatrogenic calcinosis, and this is most classically with giving IV calcium gluconate or calcium chloride, which is used back in our medicine days, and I don't know if any of you guys remember this, using it to stabilize the cardiac conduction system in situations where there's hypermagnesemia or hyperkelemia. And then calcifilaxis is almost exclusively occurs with end-stage renal disease and dialysis, and that's when you have deposition in the small vessels in the skin and end up with necrosis. The last one is subepidermal calcinosis, which is idiopathic in what I'm going to be spending most of the time talking about today. So there's basically five synonyms for this, which makes it also hard to look into cases. So other names for this is subepidermal calcified nodule, idiopathic calcinosis cutis, cutaneous calculi, localized cutaneous calcinosis, and solitary nodular calcification. So what do we know about subepidermal calcinosis? A lot of this is based off of what dermatology has done and looking at lesions all over the body. We know that there's a low incidence, as I've already mentioned, and that these lesions are typically, at least in prior publications, shown to be hard, freely mobile, and painless. Usually in children, and it seems to be a pre-election for males, and predominantly in non-caucasians. And again, this can be ruled out by the presence of abnormal labs. So some lesions that these have been misidentified as, and again, this is talking about not just the eyelids, but the skin throughout the body, and that includes papilloma, santhogranuloma, syringoma, milia, pylometriczoma, epithelial cysts, cutaneous horns, chalazion, moluscombe, and santholasma. So I wanted to go through some of these photographs of these that they have been misidentified as to kind of give you an idea as why they were misidentified as that. And there's going to be a quiz at the end, which I was told you have to get 90% on in order to get CMA credits, so pay attention. So here we've got moluscombe, and I chose to put it with santhogranuloma because they both have that very round appearance. It's hard to tell from this picture, but if you were to look under the slant lamp as you all know, you would hopefully see that unbellicated center. And the santhogranuloma are usually a little bit darker pigmented, or it can be like an orange or red color. And then pylometriczoma, this is another rare benign disease, and it's usually a genetic disorder of the hair cells. And here you can actually see that there's also calcium here. This kind of makes sense why this could be misidentified as adiapathic hallucinosis. But you can see that there's variable presentation with even this islet lesion. So here these are just various papillomas or epithelial hyperplasia. There's a lot of different other, there's different lesions that fit in this category. Here are varuka and a severic keratosis. Here's a seringoma and amelia. You can see kind of how those might be confused. These look like a little bit more superficial. And then we have xanthalasma and then epidermal inclusion cysts. So these are all things, again, that people have assumed to be adiapathic hallucinosis at times. So our questions for this review and looking just specifically at the eyelids were are the assumptions about demographics correct specifically looking at eyelid lesions? Where are these occurring around the eye? What do they look like? Do we know anything about the pathophysiology or does anybody know? And what about the histopathology? So we did a search in PubMed, Scopias and Google Scholar and looked for the key words subepidermal calcinosis, subepidermal calcified nodule, calcinosis, cutis, adiapathic eye, and eyelid. We looked from 1952, which was when I was first described to 2016. We found 57 citations and we had these independently reviewed by two readers. We excluded 36 because of non-aphthalmic presentations and one was excluded because the histopathology was indeed an epithelial inclusion cyst. And so we ended up with 10, excuse me, 20 case reports in case series and a total of 47 patients. And within those patients, some of them had several lesions. So our results, we found that indeed this mostly occurs in males, 64%. The age of presentation almost 90% occur in individuals less than 21 years old. As far as race, we found that there was a good distribution across races. As far as location, upper eyelid was the most common with the medial canthus being the second most common. 80% showed with a single nodule and very few had bilateral or multiple. The size was typically very small at less than 5 millimeters and none of them were larger than 10. And interestingly, the time to presentation was 75% of them took over six months to be seen. So looking through these, we found that almost all of the cases show calcium deposits in the upper layer of the dermis and the calcium deposits were these amorphous mesophilic spherules that were seen on H&E stain and can be confirmed with von Kassa. Occasionally there were giant cells and inflammatory cells in the specimens, but that was not very common. And that the overlying epidermis could be hyperplastic, hyperkeratotic, or ecanthotic. So here's a classic example. You can see the epithelium here, and this is low magnification, but here are those H&E spherules that show the calcium here on von Kassa. You can see the calcium more clearly. And this was from one of the cases that we included. So, okay, just look at these really quick. These are the ones that it could potentially be for this next quiz. I'll just give you a few seconds to look these over. So you can notice they're quite different, but these are actually all idiopathic calcinosis. So I actually didn't really realize how significantly different they all appeared until I was putting this presentation together. And we haven't published this information yet, so it's something that I actually did kind of a post-talk analysis just in the last couple days looking at this. So, and even in one page, this is the same patient. This one's on the left upper lid, and this is the lower lid on the left side. You can see how different the appearance is externally, but they both ended up being idiopathic calcinosis. So, looking at the ones that did just kind of, some of them don't describe very well what they look like, but the ones that do, I found that nine out of 27, so exactly a third of them ended up having papillomidus features. So quite different from what was published and what was understood to be throughout the rest of the body. And then the other most common were nodules and cysts, but there was again a large variety in how they presented. And actually one interesting thing was that this publication that had nine of the cases contained all five of the descriptions as cysts. So this is kind of what they thought they were. And there's no other publication, there's no other case reports that anyone thought that they looked like cysts except for five out of these nine. So I thought that was kind of interesting. So as far as what causes this, we really don't know. It continues to be poorly understood. Some of the proposed mechanisms within these case reports and case series were that this is possibly secondary to mast cell activation, proceeding nevi, stromal degeneration, calcification of sweat ducts, or proceeding lesions. But pretty much everything has been debunked other than mast cell activation, which still doesn't really have a strong case because only a handful of them end up having mast cells in the histopathology. And the thought is that if it was due to mast cell activation that they would have some predilection to allergies or some atopic dermatitis. So treatment is complete surgical excision. Pretty much everyone, all of the reports show that that was what was needed to be done. A few of them had recurrence after incomplete resection. A few other things were attempted including topical steroids, CO2 laser, saucerization, followed by electro desiccation and systemic corticosteroids. So other than electro desiccation, all of these failed and eventually had to be followed by complete excision. So the case that I'm going to talk about real quick, it just kind of, it's unusual in that, first of all, looking right at the beginning, it's a 61-year-old female, so kind of out of our usual demographic. But she, it's not impossible that, you know, there is a variety in presentation. She had, came in with complaints of right eyelid ptosis and she did say that she noticed five years prior to coming in that she noticed some eyelid thickening. She had no history of trauma. She did feel like it was tender to palpation and she was otherwise healthy, had no other past medical history. She did take some vitamins and occasional ibuprofen. So her best corrected visual acuity was 20-20 in both eyes. Her pupils were normal, she had full motility and visual fields and her slit lamp examination was unremarkable. She did have some overlying vascularity on the upper lid, some erythema and there was concerns that this could be sebaceous cell carcinoma due to the thickened eyelid and kind of the yellow and inflamed appearance of that lid. So here's her appearance. Again, you can appreciate the ptosis on the right and kind of just the really thickened eyelid potentially losing some lashes here, some erythema. So just to compare, you know, this is a pretty angry sebaceous carcinoma but this is kind of what we were worried that it could become. So it was surgically excised. We found that it was, Dr. Patel found it was connected to the upper margin of the tarsus and histopathology. So at 40X you can see the tarsus right here and then kind of in the centre some of these calcium granules and at 200X you can actually appreciate that these are spherules and calcium. We did not do vancosis staining but it didn't feel like we needed to. It was pretty straightforward. So the ptosis was repaired at the time of surgery and she has not had any recurrence. She's about three years post op now and she's doing great and luckily could give her the good news that she did not have sebaceous cell carcinoma. So in conclusion, sub epidermal calcinosis should be on the differential when you're looking at lesions of the eyelid. It might be something that you don't think about but can present in many, many different ways as you've seen but it particularly should be considered in young males with no history of systemic disease or laboratory abnormalities because people are going to want to know an answer when there's a bump on their kid's eyelids. So most typically on the upper lid it's usually solitary. It's less than five millimetres in size and typically chronic. Like I said, the presentation and appearance can be variable and you have to confirm diagnosis with biopsy and histopathology. Like I said, treatment is always excision and the pathophysiology remains elusive. So this was done as a collaboration between us here at the Moran Eye Center and with Dr. Dutton and Dr. Kain at UNC. I don't know. Dr. Dutton, if you look at our BCSC has illustrated a lot of our pictures. So it's fun to work with them and any questions? I agree. No comment. Dibi, I have a paper just submitted to me for review from Sweden, Acupuncture for Facelifts. Here's the interesting thing. Four and a half pictures look exactly the same. 92% of the raw women thought they looked better. I'm so excited about it for exactly four and a half pictures. I think that's more important honestly with subjective. You had objective testing of the vision. It wasn't just subjective. No, I'm not sure. I would like to see that lady could see so clearly with a clear distance, no glasses. It's also refractive. It was awesome.