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Primary orbital lymphoma is an unusual cause of epiphora in the elderly population. Lymphomas that give rise to nasolacrimal duct obstruction usually arise from within the lacrimal sac. Epiphora is a common presenting complaint that may be easily disregarded as a minor debilitating symptom. This case describes a 58-year-old Caucasian man presenting with epiphora due to primary extrasac orbital lymphoma, causing external mechanical compression on the nasolacrimal duct system. Although a rare presentation, it highlights the need for a thorough examination in patients presenting with epiphora. Nasolacrimal duct obstruction could well be the initial manifestation that leads to the diagnosis of a more serious underlying systemic disease, and lymphoma needs to be included in the differential diagnosis of secondary nasolacrimal duct obstruction.

Hyphema occurring after ocular paracentesis has been described as a classic feature of Fuchs' heterochromic uveitis (FHU) (Amsler's sign). We describe a case of hyphema occurring after peribulbar anesthesia in a patient with FHU. The bleeding occurred before the surgery began. Although the occurrence of this phenomenon does not preclude successful surgical outcomes, topical anesthesia may lower the risk preoperatively.

A 58-year-old woman presented to the emergency department after a minor fall, complaining of lower abdominal pain. A large, tender mass arising from the pelvis was palpable, in association with abdominal wall bruising. The patient believed that she may have had a "lump" there for several years. She had had a total abdominal hysterectomy and bilateral salpingo-oopherectomy for benign fibroids three years previously. She denied any gastrointestinal (GI) or genitourinary symptoms. She had no night sweats or weight loss. Routine blood investigations were normal. A CT scan of her abdomen and pelvis with oral and IV contrast contrast was performed to investigate what was thought to be a rectus sheath haematoma. This has revealed abnormal retroperitoneal lymphadenopathy in the mid and lower Abdomen (Fig. A). Most of her bladder was replaced by a 16 x 12 x 10 cm soft-tissue density mass (Fig. B). There was mild dilatation of both ureters with mild left hydronephrosis. Appearances suggested a malignant process, given the retroperitoneal adenopathy. Ultrasound-guided biopsy of a right-sided 13 x 8 mm solid inguinal lymph node was performed; histology of this was inconclusive. Following this, a rigid cystoscopy confirmed a grossly abnormal bladder with a diffuse, thick mass and a non-friable, pale-looking mucosa which was intact. Multiple resection biopsies were taken. MRI of pelvis the next day showed almost complete absence of a bladder lumen. The bladder wall was diffusely thickened, measuring 10 cms in places (Fig. C). Pathologically-enlarged iliac and retroperitoneal nodes were seen. Abnormal stranding of perivesical fat suggested transmural malignant infiltration. The histology of her bladder biopsies showed dense, diffuse infiltration by small lymphocytes, covered in part by intact urothelium. Microscopy and immunohistochemistry supported the diagnosis of low grade, diffuse, B-cell Non Hodgkin's Lymphoma (NHL). A diagnosis of primary malignant lymphoma arising in the urinary bladder was made. She was referred on to the Haematology service for further investigation and treatment. Given that her International Prognostic Index is 2-3/5, six cycles of RCHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) chemotherapy were planned. After completing her treatment, she will be re-staged with appropriate scans.