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We report a case of a lacrimal gland adenoid cystic carcinoma (ACC) masquerading as a preseptal/orbital cellulitis, leading to delayed diagnosis.

A retrospective case report with radiological and histopathological correlation.

A 48 year old man attended the eye casualty on four separate occasions, over five months, with varying presentations that always included right upper lid swelling, and at each of these presentations a different diagnosis was made: (in chronological order) “lid swelling secondary to viral infection”; severe blepharitis; preseptal cellulitis; and orbital cellulitis.

While the patient was felt to have responded at least partially to intravenous antibiotics, computed tomography, and subsequent magnetic resonance imaging, of the orbits identified a mass in the superotemporal extra-conal space of the right orbit. Incisional orbital biopsy was performed, confirming that this mass was an ACC of the lacrimal gland, with prominent cribriform areas and evidence of vascular invasion. Excisional biopsy of the tumour was performed (American Joint Committee on Cancer [AJCC] category = T2aN0M0), followed by orbital radiotherapy (65 Gy in 30 fractions).

Lacrimal gland ACC may masquerade as a preseptal or orbital cellulitis. Given the high metastatic potential and poor prognosis of these tumours, early diagnosis is essential. While imaging is commonplace in cases of suspected orbital cellulitis, a low threshold for imaging is advisable in recurrent cases of suspected preseptal cellulitis.