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Lacrimal Cystadenoma in a Chinese Box Turtle (Cuora flavomarginata)
Author(s): Jack KottwitzD.V.M., Ashley M. ZehnderD.V.M., Nicole WyreD.V.M., Dipl. A.B.V.P.
(Avian), and Susette AquinoD.V.M., Dipl. A.C.V.O.
Source: Journal of Zoo and Wildlife Medicine, 39(1):103-106.
Published By: American Association of Zoo Veterinarians
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Journal of Zoo and Wildlife Medicine 39(1): 103–106, 2008
Copyright 2008 by American Association of Zoo Veterinarians
LACRIMAL CYSTADENOMA IN A CHINESE BOX TURTLE
Jack Kottwitz, D.V.M., Ashley M. Zehnder, D.V.M., Nicole Wyre, D.V.M., Dipl. A.B.V.P. (Avian),
Susette Aquino, D.V.M., Dipl. A.C.V.O.
Abstract: An adult male Chinese box turtle (Cuora flavomarginata) presented to the Avian and Exotic Pet Service
of the Animal Medical Center for periorbital swelling of the right eye. The swelling had failed to respond to nutritional
supplementation and parenteral administration of vitamin A. What had initially presented as periorbital swelling de-
veloped into a growth ventral to the globe that impeded vision and was frequently traumatized by forelimb movements
of the turtle. Twenty-six months after initial presentation, the turtle was anesthetized and the bulk of the mass was
surgically removed. Histopathologic examination determined the mass to be a benign lacrimal cystadenoma.
Key words: Chinese box turtle, Cuora flavomarginata, lacrimal cystadenoma, periorbital mass, hypovitaminosis A,
An adult male, 486-g Chinese box turtle (Cuora
flavomarginata) presented to the Avian and Exotic
Pet service of the Animal Medical Center as an
emergency due to active bleeding of a mass ventral
to the right eye. This turtle had a 26-month history
of repeat visits for waxing and waning swelling of
the right nictitans and periorbital region. From the
history provided in the medical record, this turtle
had been treated for suspected hypovitaminosis A
with a combination of injectable vitamin A (Vita-
min A, D, E, 100 M/10 M/20 IU/ml, Creative Com-
pounding, Imlay City, MI 48444, USA: 0.01 ml
i.m.), oral vitamin A supplementation, in the form
of an unspecified brand of liquid, at a dose of 2,000
units once weekly, and recommendations to modify
the diet to include food sources high in vitamin A,
including dark green leafy and yellow- or orange-
colored vegetables. The turtle was also treated after
the initial visit with triple antibiotic ophthalmic
ointment (Vetropolycin, Pharmaderm: 1/8-inch strip
t.i.d. for 14 days) and 0.3% ciprofloxacin ophthal-
mic drops (Ciloxan, Alcon Laboratories, Inc., Fort
From the Department of Medicine, The Animal Medical
Center, Elmer and Mamdouha Bobst Hospital, 510 East
62nd Street, New York, New York 10021, USA. Present
addresses: (Kottwitz): The Montgomery Zoo, 2301 Coli-
seum Parkway, Montgomery, AL 36110, USA; (Zehnder):
Department of Medicine and Epidemiology, School of
Veterinary Medicine, University of California, One
Shields Avenue, Davis, California 95616, USA; (Wyre):
Department of Clinical Studies, School of Veterinary
Medicine, University of Pennsylvania, 3900 Delancey
Street, Philadelphia, Pennsylvania 19104, USA. Corre-
spondence should be directed
Worth, TX 76134, USA: one drop t.i.d. for 14 days)
for a suspected bacterial ocular infection.
During an examination 14 mo after initial pre-
sentation, a small proliferative, erythematous mass
was noted near the nictitans of the right eye. Mild
proliferation of the nictitans of the left eye was also
noted. Aspiration of the mass near the right eye
yielded no fluid. Cytology was submitted, which
identified minimal to mild chronic active inflam-
mation, possibly associated with a benign prolifer-
ative process. No infectious organisms were iden-
According to the owner, the swelling was in an
area of an old injury; however, duration or extent
of injury could not be determined from the history
available. There was no history of other medical
problems other than a minor beak malocclusion,
and the turtle was reported as having a good ap-
petite. The diet offered throughout this time con-
sisted of mango, papaya, pineapple, banana, cooked
shrimp, and fish, as the turtle had rejected all at-
tempts at dietary modification. The turtle was al-
lowed to roam freely within a room arranged with
a hiding area, a dedicated ‘‘hot spot’’ with heat
lamps, and a shallow water container for soaking.
The owner could not provide information on aver-
age humidity or temperature
During an emergency presentation one year later,
self-induced trauma of the mass was noted, with
ulceration of the caudal–ventral aspect of the mass
and a dry, hyperkerototic appearance to the rostral
border. The mass had enlarged to 9 mm in diameter,
causing obstruction of vision of the right eye. At
this time, due to the size of the mass with concur-
rent self-trauma and resultant hemorrhage, surgical
removal was recommended. Triple antibiotic oph-
thalmic ointment (Vetropolycin, Pharmaderm Ani-
mal Health: 1/4-inch strip, b.i.d.) was prescribed to
JOURNAL OF ZOO AND WILDLIFE MEDICINE
medial canthus of the right eye of a Chinese box turtle
prior to surgical debulking. Note the hyperkaratotic ap-
pearance of the rostral border of the mass and ventral
ulceration secondary to self-induced trauma.
Lateral view of lacrimal cystadenoma in the
prevent possible bacterial infection secondary to
contamination from fecal material on the foot and
for lubrication of the eye and mass.
The turtle returned to the hospital for surgical re-
moval of the mass 1 wk later (Fig. 1). The mass ap-
peared unchanged. The owner reported a good ap-
petite and activity level at home, but described two
instances of self-induced trauma causing bleeding
from the mass. This bleeding resolved spontaneously
and did not warrant returning to the hospital.
Propofol (Rapinovet, 10 mg/ml, Schering-
Plough, Kenilworth, NJ 07033, USA: 10 mg/kg, 4.8
mg total, i.v.) was administered for anesthesia in-
duction in the subcarapacial sinus. The turtle was
intubated with a No. 2.0 uncuffed Cole endotrache-
al tube and maintained on isoflurane gas at 1.5–
2.0% with intermittent positive pressure ventilation
and an oxygen flow rate of 0.75 L/min. A handheld
unipolar electrocautery unit was used to incise the
edges of the mass. The mass extended deep to the
ventrocaudal border of the nictitans rostral to the
globe in the approximate location of the nasolac-
rimal duct opening. The duct opening could not be
visualized. Complete excision was not possible
without significant dissection of surrounding tis-
sues, including removal of the nictitans and possi-
ble dissection ventral to the globe. Because of this,
the decision was made to debulk as much of the
mass as possible without causing damage to sur-
rounding tissues. A significant amount of serosan-
guinous fluid was noted leaking from the mass dur-
ing the surgery. The defect in the conjunctiva was
left open to heal by second intention. The portion
of the mass that was excised was submitted for his-
topathologic examination. A swab of the mass tis-
sue and conjunctiva was submitted for bacterial
culture and antimicrobial susceptibility.
Recovery from anesthesia was without compli-
cation. Trimethoprim-Sulfa Suspension (48 mg/ml,
Hi-Tech Pharmacal, Amityville, New York 11701,
USA: 0.2 ml p.o. s.i.d.) and triple antibiotic oph-
thalmic ointment (Vetropolycin, Pharmaderm Ani-
mal Health: 1/4-inch strip, b.i.d.) were prescribed
postoperatively pending culture results. Upon ad-
ministration of postoperative medications, the sur-
gical site began to leak serosanguinous fluid. Gentle
manual pressure was applied to the area along with
two drops of 2.5% phenylephrine (AK-Dilate,
Akorn, Inc., Decatur, IL 62522, USA) to provide
hemostasis. No further bleeding was noted. The
next day the turtle was discharged from the hospital
with instructions to return for a recheck examina-
tion in 2 wk. Perioperative cultures proved negative
for bacterial growth.
Histopathologic examination of the mass re-
vealed multiple interconnecting cystic spaces lined
by cuboidal to columnar epithelial cells (Fig. 2).
The cyst lumina contained a small amount of eo-
sinophilic amorphous to granular appearing mate-
rial. The lining of the cystic spaces resembled lac-
rimal duct epithelium microscopically with mono-
morphic round to focal hyperchromatic nuclei. No
evidence of vascular invasion was noted; however,
the mass extended to the cut margins. Histologi-
cally, the mass was interpreted as a benign cyst-
adenoma originating from lacrimal tissue. A cyst-
adenoma is a benign tumor derived from glandular
tissue, composed of structures lined with cuboidal
or columnar epithelial cells within which glandular
secretions are retained, forming cysts. Cystadeno-
mas are considered uncommon masses of the liver
and of the thyroid glands of domestic cats.9,13This
article represents the first description of a cystade-
noma of lacrimal tissue origin within a reptile;
however, this type of tumor has been described in
mice and humans.3,4,11Surgical excision of these
masses in other species could be extensive, how-
ever, was curative if excision was complete.
Reptiles possess lacrimal and Harderian glands,
which could have served as a possible tissue source
for initial growth of this tumor.10Other periocular or
ocular neoplastic masses reported in reptiles include
a squamous cell carcinoma in a veiled chameleon
(Chameleo calyptratus) and ocular fibropapillomas in
green sea turtles (Chelonia mydas).1,5The most com-
mon cause of eyelid and periocular swelling in che-
lonians is hypovitaminosis A.7Diets deficient in vi-
tamin A can lead to squamous metaplasia of epithelial
KOTTWITZ ET AL.—CYSTADENOMA IN A CHINESE BOX TURTLE
the mass. These interconnecting cystic spaces were lined by cuboidal to columnar epithelial cells with monomorphic
round to focal hyperchromatic nuclei, similar to lacrimal duct epithelium.
Histopathologic appearance of a lacrimal cystadenoma in a Chinese box turtle. Note cystic cavitation of
surfaces.7Shedding of excess epithelial cells may
block the lacrimal ducts, leading to accumulation of
fluid in the periocular space. Secondary bacterial in-
fections can also occur, leading to conjunctivitis.
Treatment involves dietary supplementation or par-
enteral vitamin A in severe cases.7
Infectious agents and parasites can cause ocular
disease in reptiles. Acid-fast bacteria were isolated
from an ocular granuloma in a female box turtle.8
Filarial nematodes (Foleyella sp.) have been asso-
ciated with periorbital swelling in an Oustalet’s
chameleon (Chemaeleo oustaleti).12There have also
been reports of functional abnormalities leading to
periocular masses in reptiles. A red-eared slider
(Chrysemys scripta elagans) was found to have a
lacrimal cyst that may have been secondary to an
inflammatory process.2Exophthalmia in a rhinoc-
eros viper (Bitis nasicornis) has been reported as a
result of a developmental abnormality that resulted
in cystic structures around the eye. These cysts had
a large number of eosinophils, but no identifiable
In the turtle reported in this article, the initial
periocular swelling may have been related to a di-
etary deficiency, but is unlikely, because it did not
resolve with parenteral vitamin A administration or
dietary vitamin A supplementation. The swelling
was more likely an early stage of tumor develop-
ment and not related to nutritional deficiency as
originally thought. It is also possible that the meta-
plasia induced by a diet low in vitamin A pro-
gressed into an adenoma of the lacrimal gland;
however, the absence of histopathologic evidence
of metaplasia does not support this hypothesis.
At the time of manuscript submission, more than
9 mo after surgical debulking of the mass, the re-
maining tissue does not appear to have increased sig-
nificantly in size. The owner has declined advanced
diagnostic imaging to evaluate the full extent of the
mass. Because surgical excision was not complete and
106 Download full-text
JOURNAL OF ZOO AND WILDLIFE MEDICINE
the mass extended deep into the periorbital tissues, it
is possible that regrowth will occur.
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Received for publication 30 September 2006