ABSTRACT Purpose: To present a patient with bilateral severe and symmetric lower lid lymphedema in the setting of previous neck surgery and chronic psoriasis, and to review the potential relationships of neck surgery, irradiation, psoriasis, and rosacea to chronic lymphedema. Design: Single case report with literature review. Methods: A 60-year-old female with long-standing psoriasis presented with a 2-year history of severe, symmetric bilateral lower eyelid edema that developed after total laryngectomy and selective right neck dissection for recurrent Squamous Cell Carcinoma (SCC). 10 years prior she underwent radiation and radical left neck dissection for metastatic disease. Surgical management entailed transcutaneous debulking of the masses combined with ectropion repair and suture tarsorrhaphy. A comprehensive literature review was performed using Pubmed and Medline. Results: Surgical debulking of the soft tissue masses via a transcutaneous incision resulted in significant improvement in the patient’s lymphedema without recurrence at 5 months follow-up. Histopathologic findings were consistent with chronic eyelid lymphedema. Conclusions: Isolated eyelid lymphedema is rare, with many etiologies, and poses a diagnostic challenge. While ophthalmologists are familiar with the ocular manifestations of rosacea such as conjunctivitis or blepharitis, it is important to consider rosacea as an etiology of eyelid lymphedema. Reviewing the history for previous surgery or radiation to the head and neck, or other dermatologic inflammatory disorders is also warranted. Rosaceous lymphedema is typically less severe than in post-surgical/radiation patients, and does not respond well to medical treatment; however, it often shows a favorable response to debulking blepharoplasty surgery, with or without skin grafting. This patient with a history of severe psoriasis and bilateral neck dissections with radiation for SCC also responded well to surgery without recurrence of lymphedema. Therefore, surgical debulking can be considered in these patients with severe eyelid lymphedema as an option to markedly improve visual function and overall cosmetic appearance.
Cite this paper
M. Possin and C. Burkat, "Severe Symmetric and Chronic Lower Eyelid Lymphedema in the Setting of Neck Surgery and Psoriasis," Open Journal of Ophthalmology, Vol. 2 No. 4, 2012, pp. 103-109. doi: 10.4236/ojoph.2012.24022.
 S. Lu, T. Tran, D. Jones, et al., “Localized Lymphedema (Elephantiasis): A Case Series and Review of the Literature,” Journal of Cutaneous Pathology, Vol. 36, No. 1, 2008, pp. 1-20. doi:10.1111/j.1600-0560.2008.00990.x
 F. P. Bernardini, R. C. Kersten, L. M. Khouri, et al., “Chronic Eyelid Lymphoedema and Acne Rosacea. Report of Two Cases,” Ophthalmology, Vol. 107, No. 12, 2000, pp. 2220-2223.
 R. Chalasani and A. McNab, “Chronic Lymphedema of the Eyelid: Case Series,” Orbit, Vol. 29, No. 4, 2010, pp. 222-226. doi:10.3109/01676831003695735
 D. R. Jordan, “Eyelid Lymphedema,” Arch Opthalmology, Vol. 109, No. 2, 1991, pp. 178-179.
 A. T. Silverman, R. Hoffman, M. Cohen and R. Garza, “Severe Cheek and Lower Eyelid Lymphedema after Resection of Oropharyngeal Tumor and Radiation,” Journal of Craniofacial Surgery, Vol. 21 No. 2, 2010, pp. 598-601. doi:10.1097/SCS.0b013e3181d08c90
 A. V. Marzano, P. Vezzoli and E. Alessi, “Elephantoid Oedema of the Eyelids,” Journal of the European Academy of Dermatology and Venereology, Vol. 18, No. 4, 2004, pp. 459-462.
 D. M. Chen and D. L. Crosby, “Periorbital Edema as an Initial Presentation of Rosacea,” Journal of the American Academy of Dermatology, Vol. 37, No. 2, 1997, pp. 346- 348. doi:10.1016/S0190-9622(97)80389-1
 A. Morales-Burgos, G. Alvarez Del Manzano, J. L. Sánchez and C. L. Cruz, “Persistent Eyelid Swelling in a Patient with Rosacea,” Puerto Rico Health Sciences Journal, Vol. 28, No. 1, 2009, pp. 80-82.
 H. Uhara, S. Kawachi and T. Saida, “Solid Facial Oedema in a Patient with Rosacea,” The Journal of Dermatology, Vol. 27, 2000, pp. 214-216.
 B. F. O’Donnell, “Visual Impairment Secondary to Rosacea,” British Journal of Dermatology, Vol. 127, No. 3, 1992, pp. 300-301.
 T. Jansen and G. Plewig, “The Treatment of Rosaceous Lymphoedema,” Clinical and Experimental Dermatology, Vol. 22, 1997, pp. 54-64.
 D. Harvey, N. A. Fenske and L. F .Glass, “Rosaceous Lymphedema: A Rare Variant of a Common Disorder,” Cutis, Vol. 61, 1998, pp. 321-324.
 T. F. Lai, I. Leibovitch, C. James, et al., “Rosacea Lymphoedema of the Eyelid,” Acta Ophthalmologica Scandinavica, Vol. 82, No. 6, 2004, pp. 765-767.
 D. O. Maisels and A. O. A. Korachi, “Lymphoedema of the Eyelids in the Yellow Nail Syndrome,” British Journal of Plastic Surgery, Vol. 38, No. 1, 1985, pp. 93-96.
 J. H. James, “Lymphedema of the Eyelids,” Plastic and Reconstructive Surgery, Vol. 61, No. 2, 1978, pp. 703-706. doi:10.1097/00006534-197805000-00007
 S. M. Kabir, A. Raurell and V. Ramakrishnan, “Lymphoedema of the eyelids,” British Journal of Plastic Surgery, Vol. 55, No. 2, 2002, pp. 153-154.
 K. W. Dewey, “A Contribution to the Study of the Lymphatic System of the Eye,” The Anatomical Record, Vol. 19, No. 2, 1920, pp. 125-140. doi:10.1002/ar.1090190205
 W. R. Pan, C. M. Le Roux and C. A. Briggs, “Variations in the Lymphatic Drainage Pattern of the Head and Neck: Further Anatomic Studies and Clinical Implications,” Plastic and Reconstructive Surgery, Vol. 127, No. 2, 2011, pp. 611-620. doi:10.1097/PRS.0b013e3181fed511
 B. E. Cook, M. J. Lucarelli, B. N. Lemke, et al., “Eyelid Lymphatics. I. Histochemical Comparisons between the Monkey and Human,” Ophthalmic Plastic & Reconstructive Surgery, Vol. 18, No. 1, 2002, pp. 18-23.
 J. Deng, S. H. Ridner, M. S. Dietrich, et al., “Prevalence of Secondary Lymphedema in Patients with Head and Neck Cancer,” Journal of Pain and Symptom Management, In press.
 J. Buntzel, M. Glatzel, R. Mucke, et al., “Influence of Amifostine on Late Radiation-Toxicity in Head and Neck Cancer—A Follow-Up Study,” Anticancer Research, Vol. 27, No. 4A, 2007, pp. 953-956.
 H. A. Wolff, T. Overbeck, R. M. Roedel, et al., “Toxicity of Daily Low Dose Cisplatin in Radiochemotherapy for locally Advanced Head and Neck Cancer,” Journal of Cancer Research and Clinical Oncology, Vol. 135, 2009, pp. 961-967.
 F. Schiefke, M. Akdemir, A. Weber, et al., “Function, Postoperative Morbidity, and Quality of Life after Cervical Sentinel Node Biopsy and after Selective Neck Dissection,” Head and Neck, Vol. 31, No. 4, 2009, pp. 503-512. doi:10.1002/hed.21001
 S. Ensari, E. Kaptanoglu, K. Tun, et al., “Venous Outflow of the Brain after Bilateral Complete Jugular Ligation,” Turkish Neurosurgery, Vol. 18, No. 1, 2008; pp. 56-60.
 D. J. Browning and A. D. Proia, “Ocular Rosacea,” Survey of Ophthalmology, Vol. 31, 1986, pp. 145-158.
 J. Daroczy, “Pathology of lymphedema,” Clinics in Dermatology, Vol. 13, 1995, pp. 433-444.
 J. K. Wilkin, “Rosacea. Pathophysiology and Treatment,” Archives of Dermatology, Vol. 130, No. 3, 1994, pp. 359-362. doi:10.1001/archderm.1994.01690030091015
 I. M. Braverman and A. Yen, “Microcirculation in Psoriatic Skin,” Journal of Investigative Dermatology, Vol. 62, 1974, pp. 493-502.
 T. Yamamoto and K. Nishioka, “Psoriasis Arthropathy and Lymphedema,” The Journal of Dermatology, Vol. 29, 2002, pp. 812-814.
 M. Bohm, B. Riemann, T. A. Luger and G. Bosmann, “Bilateral Upper Limb Lymphoedema Associated with Psoriatic Arthritis: A Case Report and Review of the Literature,” British Journal of Dermatology, Vol. 143, 2000, pp. 1297-1301.
 P. D. W. Kiely, A. E. A. Joseph, P. S. Mortimer and B.E. Bourke, “Upper Limb Lymphedema Associated with Polyarthritis of Rheumatoid Type,” The Journal of Rheumatology, Vol. 21, 1994, pp. 1043-1045.
 L. Quarta, A. Corrado, F. d’Onofrio, et al., “Two Cases of Distalextremityswelling with Pittingoedema in Psoriatic Arthritis: The Different Pathological Mechanisms,” Rheumatology International, Vol. 30, No. 10, 2010, pp. 1367-1370. doi:10.1007/s00296-009-1060-y
 J. M. Gelfand, D. D. Gladman, P. J. Mease, et al., “Epidemiology of Psoriatic Arthritis in the Population of the United States,” Journal of the American Academy of Dermatology, Vol. 53, No. 4, 2005, p. 573.