Incidental Hamartoma in an elderly patient: a case report
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A 70-year-old man presented to the emergency department with sudden-onset chest discomfort and dizziness. Computed tomography (CT) scan revealed encephalomalacia in the right ventral frontal lobe with a mass in the superomedial aspect of the right orbit. However, he had no ophthalmologic symptoms, and no specific treatment was administered for the mass. Five years later, the patient presented to the neurology clinic complaining of headache. Magnetic resonance image (MRI) showed a solid mass (2.4?×?1.5?×?2.0?cm) at the superomedial aspect of the right orbit with T1 and T2 iso-signal intensity. A comparison with a previous CT showed no change in the mass.

One month later, the patient presented to the ophthalmology clinic with right eye proptosis. On ophthalmologic examination, the degree of proptosis was 3?mm, but external ocular movement (EOM) was normal. A conservative management approach was decided based on the assumption of a benign mass. However, 2 years later, proptosis of the right eye had increased to 5?mm, and signs of subconjunctival hemorrhage, chemosis, and downward ocular deviation of the right eye were noted in the 9-cardinal photograph, but the EOM was normal. One month later, an excisional biopsy was performed through a medial canthal incision to almost completely excise the brown-colored tissue. After incision, the thin capsulated mass was easily found and there was no adhesion with the surrounding tissue or rectus muscle, although it was difficult to remove completely due to bleeding. Histopathological evaluation of the tissue revealed a neuromuscular hamartoma with mature muscular tissue and proliferation of nerve tissue; the specimen was Desmin positive in muscle and S-100 positive in nerve tissue.

Postoperative steroid tapering was administered. At a follow-up visit on postoperative day five, the patient complained of vertical diplopia. Conservative management was applied because it was thought to be caused by conjunctival swelling over the inferior rectus muscle-side conjunctiva. Although exophthalmos and conjunctival swelling decreased, diplopia has worsened with EOM increased to 15 prism RHT and downward gaze limitation. Therefore, inferior rectus (IR) muscle resection (2?mm) & superior rectus (SR) muscle recession (3.5?mm) were performed based on the diagnosis of inferior rectus muscle palsy.Diplopia persisted after strabismus surgery, for which a prism glasses prescription was administered to relieve the symptom. Nearly, one year after strabismus surgery, The condition improved to around 4 to 6 prism RHT.