Orbital Lesions Research Articles

Treatment of orbital penetrating lesion by retained wooden foreign body. Case report

Treatment of orbital penetrating lesion by retained wooden foreign body. Case report

Endoscopic Endonasal Resection of Orbital Apex Cavernous Hemangioma: 2-Dimensional Operative Video.

A 52-yr-old woman was referred to a tertiary medical center for evaluation of 2 yr of progressive visual symptoms and 1 yr of retro-orbital pressure. Her ophthalmologic exam was unrevealing except for mild asymmetrical impairment in color perception. A gadolinium contrast-enhanced magnetic resonance image of the head showed a left extraconal orbital apex lesion consistent with cavernous hemangioma. Computed tomography reveled bony remodeling of the medial-inferior orbital walls with superior orbital fissure expansion. The lesion was endoscopically resected and confirmed by pathological analysis. The endoscopic approach is demonstrated in detail, including correlation with cadaveric anatomic specimens‡. During the approach, a rescue nasoseptal flap was raised in case the orbit required further support after tumor resection, but was replaced as this was not needed. This patient had a brief period of postoperative diplopia, which resolved 1 wk after surgery. Her subjective visual deficits and pressure have also resolved. Advantages of the endoscopic approach include improved direct visualization of the lesion, lack of external skin incisions, avoidance of significant neurovascular retraction, and shorter hospital stays than alternative orbitotomy or craniotomy approaches. This 4-handed approach demands endoscopic expertise of 2 surgeons, and is often performed by rhinology-neurosurgery or rhinology-ophthalmology surgical teams. The risk of postoperative diplopia should be discussed with the patient during informed consent. ‡ Anatomic specimen photography courtesy Dr Peris-Celda.

Quality-based pharmacokinetic model selection on DCE-MRI for characterizing orbital lesions.

Although several studies have evaluated dynamic contrast-enhanced (DCE) MRI in the orbit, showing its utility when detecting and diagnosing orbital lesions, none have evaluated the pharmacokinetic models. To provide a quality-based pharmacokinetic model selection for characterizing orbital lesions using DCE-MRI at 3.0T. Prospective. From December 2015 to April 2017, 151 patients with an orbital lesion underwent MRI prior to surgery, including a high temporal resolution DCE sequence, divided into one training and one test dataset with 100 and 51 patients, respectively. 3T/DCE. Six different pharmacokinetic models were tested. Univariate and multivariate analyses were performed using Wilcoxon-2-sample tests and a logistic regression to compare parameters between malignant and benign tumors for each pharmacokinetic model for the whole cohort. Receiver operating characteristic (ROC) curve analyses were performed on the training dataset to determine area under curve (AUC) and optimal cutoff values for each pharmacokinetic model, then validated on the test dataset to calculate sensitivity, specificity, and accuracy. Regardless of the model, tissue blood flow and tissue blood volume values were significantly higher in malignant vs. benign lesions: 103.8-195.1 vs. 65-113.8, P [<10-4 -2.10-4 ] and 21.3-36.9 vs. 15.6-33.6, P [<10-4 -0.03] respectively. Extracellular volume fraction and permeability-surface area product or transfer constant appeared to be less relevant: 17.3-27.5 vs. 22.8-28.2, P [0.01-0.7], 1.7-4.9, P [0.2-0.9] and 9.5-38.8 vs. 8.1-22.8, P [<10-4 -0.6], respectively. ROC curves showed no significant differences in AUC between the different models. The two-compartment exchange (2CX) model ranked first for quality. DCE MRI pharmacokinetic model-derived parameters appeared to be useful for discriminating benign from malignant orbital lesions. The 2CX model provided the best quality of modeling and should be recommended. Perfusion-related DCE parameters appeared to be significantly more relevant to the diagnostic process. Level of Evidence 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1514-1525.

Clinical and tomographic features of acute inflammatory disorders of the orbit

Acute inflammatory disorders of the orbit can cause not only blindness but also intracranial complications that directly threaten the patient’s life. Accurate and timely diagnosis of the type of orbital lesion is necessary for determining the treatment tactics. The clinical and tomographical data of 57 patients with acute inflammatory disorders of the orbit were analyzed prospectively (2008–2017) along with the data of 37 patients analyzed retrospectively (1999–2007). Morphometric and functional parameters of the patients’ orbits on the healthy side were used as a control group (94 orbits). All patients underwent visometry, biomicroscopy, ophthalmoscopy, measuring the width of the palpebral fissure in the central part, and exophthalmometry, measuring the lateral displacement of the eyeball. All patients underwent computed tomography examination. The scanning was performed in axial, coronary, and orbitomeatal projections with a step size of 1 mm. Osteoperiostitis and subperiostal abscess were characterized by moderate pathological changes of the eyelids and orbital soft tissues and normal visual functions. Retrobulbar infiltrate and edema of orbital cellular tissue were characterized by pathological changes of the eyelids and orbital soft tissues and a decrease in visual acuity in 42.9% of cases of edema of the orbital tissue.. Orbital abscess and phlegmon of the orbit were characterized by heavily expressed pathological changes of the eyelids and orbital soft tissues and a marked decrease in visual acuity in all patients with phlegmon of the orbital. Clarification of the type of orbital inflammatory disease via the clinical and tomographic criteria determined in this study led to a decrease in the number of unjustified transcutaneous orbitotomy procedures.

Transorbital Endoscopic Surgery

Endoscopic surgery of the orbit and the creation of transorbital portals to access lesions involving the orbit, sinuses and skull base is now being performed in multiple centres across the world since being popularised by Kris Moe in 2010. This review focuses on the current knowledge base with regard to transorbital endoscopic surgery. Numerous publications show favourable outcomes in the management of orbital, skull base and intracranial lesions using endoscopic transorbital surgery when compared to traditional surgical approaches. Previously inaccessible or difficult-to-access lesions can now be reached using surgery which often offers superior visualisation with minimal collateral tissue trauma. Endoscopic transorbital surgery has proven to be a safe and effective alternative to traditional and often destructive surgical approaches for lesions of the orbit and skull base. Orbital and transorbital anatomy has been freshly described looking at anatomical structures from an endoscopic anterior approach, and techniques and instrumentation refined to a degree where the surgery is now reproducible.

Primitive neuroectodermal tumors: a clinical and radiological analysis of six cases.

Primitive neuroectodermal tumor (PNET) is extremely rare and highly aggressive with poor prognosis. Few studies concerning PNET's the imaging features have been published. Six cases of PNET, all confirmed by pathology and immunohistochemical (IHC) examinations, were treated during January 2012 to December 2016. These cases' clinical course and imaging findings were retrospectively analyzed. Among six PNET cases, one located in left superior abdomen, one case at posterior abdominal wall, one case in right orbit, one case in left frontal temporal lobe, one case in pelvic cavity, and one case located in left supraclavicular fossa. The tumor's density was uniform for small tumor and heterogeneous for large tumors on CT images, while the size of tumors differed during presentation depending on the location of the tumor. Marked enhancement was visualized after injection of contrast media. The demarcation between the lesion and adjacent tissues or organs tended to be unclear. On magnetic resonance imaging (MRI) images, the mass mainly showed heterogeneously long T1 and long T2 signal intensity, mixed high signal intensity on fluid-attenuated inversion recovery (FLAIR) image. In two cases maximum intensity projection image reconstruction demonstrates tortuous blood vessels within the tumor on enhanced CT images. Five cases were treated by surgical resection with two cases received adjuvant radiotherapy and three cases received adjuvant chemotherapy. Six patients were followed up with a mean period of 34.5 months (ranging from 6 to 55 months). Five patients survived and one died. Among the five patients undergoing surgeries, one patient presented pelvic and abdominal recurrence/metastasis 2 months after abdominal PNET resection. One patient had a recurrent lesion in the right orbit involving the right ethmoid sinus 6 months after right orbital PNET resection. One patient's pelvic tumor recurred 7 months after PNET operation, and this patient died after 1 year and 10 months of follow-up. During the follow-up period, the remaining three cases did not show obvious recurrence and/or metastasis. Overall, the imaging appearances of PNET lack characteristics. PNETs generally do not have clear boundary, or partially so, with its adjacent organs or tissues suggesting their invasive nature. Upon further validation, maximum intensity projection image reconstruction demonstrates tortuous blood vessels within the tumor on enhanced CT images may be valuable information for the diagnosis of PNET.

Giant cell tumour of frontal bone in a patient with bilateral retinoblastoma

Abstract A case is presented of a 5 year-old patient with bilateral hereditary retinoblastoma treated with radiotherapy in the right eye and enucleation of the left eye. After three years without evidence of progression, the patient presented with a right orbital mass that compromised the frontal bone. After surgical excision, the histology analysis was consistent with a diagnosis of giant cell tumour. Primary orbital bone neoplasms, such as giant cell tumours, are extremely rare. Both radiological and histopathology studies are essential to establish the differential diagnosis of orbital mass lesions.

Orbital aspergillosis masquerading as lymphoma diagnosed by cytology – A case report

Orbital aspergillosis is rare, more so in immunocompetant individuals. Fine needle aspiration cytology plays an important role in diagnosis of mass lesions in orbit, in spite of the fright of hemorrhagic episodes. We herein report a rare case of aspergillosis presenting as a mass lesion in orbit in a young immunocompetent female. Clinical and radiological features favored a malignant process. Fine needle aspiration cytology (FNAC) followed by culture assisted in accurate diagnosis. Keywords: Aspergillosis, FNAC, Cytology, Orbit.

Demographics of Pediatric Orbital Lesions: A Tertiary Eye Center Experience in Saudi Arabia

Orbital lesions vary in their classification, incidence, and presentation depending on the age and geographic distribution. Such lesions in the pediatric age group have been studied extensively because of the possibility of faster progression of orbital involvement and the higher risk of morbidity in this age group in which vision is still developing. In Saudi Arabia, orbital lesions were studied over a 6-year period in the late 1980s, when retinoblastoma cases used to present late with orbital involvement. In this study, we revisited the same topic 20 years later aiming to find out the most recent prevalence of orbital lesions in a similar population of patients over a longer period (14 years) in the same eye center, and compare the current results to other reports worldwide. A total of 107 lesions from 106 patients were identified by tissue diagnosis, of which more than half of the lesions were benign cystic (being the most common), vasculogenic, and inflammatory in 63% [95% confidence interval (CI, 53.3–72.0)] of all biopsied lesions. Neoplasms accounted for 37% [95% CI (28.0–45.8)] with rhabdomyosarcoma being the most common, accounting for about one third of neoplasms, and no orbital cases of retinoblastoma were found. Our results demonstrated different distribution of orbital lesions in recent years reflecting the indirect effect of the improved health awareness and medical care in Saudi Arabia. This baseline demographic study is expected to be helpful for further clinical and prognostic studies with emphasis on pediatric orbital malignant lesions, their clinical presentation, management, and prognosis.

Pathological Features and Clinical Course in Patients With Recurrent or Malignant Orbital Solitary Fibrous Tumor/Hemangiopericytoma

A risk assessment score for metastasis based on age, tumor size, and mitotic figures has been suggested for nonorbital solitary fibrous tumor (SFT)/hemangiopericytoma. The authors herein examine the clinicopathological features of recurrent and metastatic orbital SFT and evaluate the existing risk assessment score for orbital SFT. The American Society of Ophthalmic Plastic and Reconstructive Surgery Oncology Database was queried for patients with recurrent or malignant orbital hemangiopericytoma/SFT. The medical records were reviewed for clinical and pathologic findings, treatments, and outcomes. Eight patients from 3 institutions were identified with recurrent orbital hemangiopericytoma/SFT. Median age at diagnosis was 59 years, and 4 patients were women. The mean size of tumor was 2.1 ± 1.1 cm. All patients were initially treated with surgery and experienced local recurrence after a median of 4 (range 0.5-10) years. Five patients were treated with orbital radiation. Two patients also developed distant metastases and eventually died of their disease. Median Ki-67 was 5% (range 1-65%) and 5 mitotic figures/10 high-power fields (range 2-30). The previously described risk stratification model for nonorbital SFT did not correlate with the propensity to develop metastases in this cohort; however, both patients with distant metastasis had > 4 mitotic figures /10 high-power fields. In this cohort of recurrent orbital hemangiopericytoma/SFT, median time to recurrence was 4 years underscoring the importance of careful continued follow-up. The current risk stratification models have limited use for orbital lesions, mostly due to the fact that orbital SFTs are smaller than even the smallest size criteria in this risk assessment model.

Myasthenia Gravis Associated With Orbital Marginal Zone Lymphoma

Myasthenia Gravis Associated With Orbital Marginal Zone Lymphoma

Mélange of orbital lesions – A histomorphologic study of 135 cases

Background: The orbit is an important site for primary and secondary diseases. Various tissue types such as osseous, vascular, neural, muscular, and glandular may be involved with specific pathologies. Tumors can secondarily invade the orbit from the periorbital regions including the paranasal sinuses, eyelids, and intracranial region. Objectives: (i) To assess the histomorphology of various orbital lesions. (ii) To determine the frequency, age, and sex distribution of various orbital lesions in our study population and compare them with the other studies. Materials and Methods: The study involved 135 patients of either sex presenting with orbital lesions reporting to a tertiary care hospital. Results: Among the 135 cases, we observed a slight female predominance, with a female-to-male ratio being 1.17:1. Most of the patients were in their fifth decade and presented with exophthalmos. Histopathologically, cystic lesions were most frequent followed by lymphoproliferative lesions. About 25% of lesions were malignant and included lymphomas, lacrimal gland malignancies, and rhabdomyosarcomas predominantly. We came across a rare case of intravenous papillary endothelial hyperplasia. Conclusion: Orbital lesions arise primarily from soft tissues and bones. The frequency of orbital lesions varies among different series depending on age group, source institution, medical specialty, and geographic areas. Histopathology remains the mainstay of diagnosis. In addition to determining the malignant potential of a lesion, it reveals its exact nature and structure, thereby influencing management and prognosis.

Long-term Outcome in 7 Patients With Idiopathic Orbital Myositis.

Purpose:Idiopathic orbital myositis, a rare disease of unknown cause, presents a diagnostic puzzle because the diagnosis is based on the exclusion of other diseases. This study aims at elucidating its long-term outcome to answer a clinical question whether idiopathic orbital myositis would be a distinct clinical entity.Methods:Retrospective review was made on 7 consecutive patients (6 men and 1 woman) with the age at the initial visit ranging from 33 to 69 years (mean, 45.8 years) who were diagnosed with idiopathic orbital myositis and followed for 5 years or more (mean, 9.2 years) at a referral-based hospital.Results:Chief complaint at the initial visit was diplopia in 4 patients, blurred vision in 2 patients, and proptosis in 1 patient. On magnetic resonance imaging, 4 patients showed enlargement of a single extraocular muscle on unilateral side while 3 patients showed enlargement of multiple extraocular muscles on unilateral side or bilateral sides. No patient developed systemic diseases or other orbital lesions in the long-term follow-up. All patients at the last visit were free from symptoms, including diplopia, after tapering of prednisolone at the initial dose of 20 to 60 mg daily.Conclusion:Idiopathic orbital myositis had a favorable long-term outcome with corticosteroid administration and appears to be a distinct clinical entity without systemic involvement.

Sensitivity and specificity of frozen section diagnosis in orbital and adnexal malignancies.

Purpose:To analyze the diagnostic accuracy of frozen section in orbital and adnexal malignancies.Methods:A total of 55 cases between January 2006 and December 2011 for which intraoperative frozen section was performed for various orbital and adnexal lesions were included in the study. The frozen section diagnosis was compared with the permanent section diagnosis. Margin clearance was also compared between the two. Data were analysed using SPSS version 14. Odds ratio and cross-tabulation was used to perform the analysis.Results:The mean age at presentation was 51.46 ± 20 years. Eyelid was the most common site of involvement. Out of 55 cases, diagnosis was deferred in four cases (7.27%) on frozen section. Among 51 cases, 44 (86%) cases were concordant, whereas 7 (13%) cases were discordant. The sensitivity and specificity of frozen section compared to permanent section for diagnosis of malignancy was found to be 87.2% and 87.5%, respectively. The sensitivity and specificity of frozen section for diagnoses of basal cell carcinoma was found to be 100%, while it was 83.3% and 100% respectively for sebaceous gland carcinoma and 87.5% and 94.9% respectively for squamous cell carcinoma.Conclusion:Frozen section had high sensitivity and specificity when compared with permanent section for all three parameters studied. It is an important intraoperative tool that is increasingly being used in histopathological examination of ophthalmic lesions. However, it should not be used as a substitute for the permanent section and critical decisions based on it are best avoided.

The eye of the beholder: orbital metastases from midgut neuroendocrine tumors, a two institution experience

BackgroundMetastases to the orbit occur rarely in midgut neuroendocrine tumor (NET) patients with only 20 cases reported to date. Patients typically present with bilateral involvement of the recti muscles and experience symptoms such as diplopia, proptosis, and decreased vision. Although orbital MRI remains the gold standard for imaging orbital disease, many orbital lesions are now detected on somatostatin-receptor (SSTR) based imaging such as 68Ga-DOTATATE PET-CT.Case presentationsPatient 1 is a 72 year-old female with a well-differentiated G3 ileal NET who was incidentally diagnosed with orbital metastases during a hospitalization for pre-septal cellulitis in 2018. Her disease has been controlled with capecitabine rather than local therapy.Patient 2 is a 68 year-old male with a G2 ileal NET who was diagnosed with orbital involvement after developing left peri-orbital swelling in 2017. He was found to have bilateral rectus muscle involvement and was treated with image-guided radiation therapy (IGRT) to both orbits and achieved disease control.Patient 3 is a 63 year-old female with a well-differentiated G3 ileal NET who was incidentally diagnosed with bilateral orbital masses in her recti after undergoing a 68Ga-DOTATATE PET-CT in 2015. She was asymptomatic initially however has now developed diplopia. She will be starting 177Lu-DOTATATE peptide radionuclide receptor therapy (PRRT) shortly.Patient 4 is a 72 year-old male with a grade 2 ileal NET who was incidentally diagnosed with a left lateral rectus metastasis in 2007. This was monitored via surveillance MRI until it began to grow and became symptomatic in 2015. The patient received stereotactic radiation to the site and has been asymptomatic since.Patient 5 is a 61 year-old female with a grade 2 ileal NET who developed progressive diplopia in 2016. Bilateral orbital metastases were noted on orbital MRI and she completed IGRT to the sites shortly thereafter. In the setting of continued growth of the masses she was switched to chemotherapy with capecitabine which has controlled her orbital disease.ConclusionsNETs can metastasize to the orbits. Orbital disease now often is detected on SSTR-based imaging rather than orbital MRI; when found, it changes treatment approach and surveillance for patients.

Application of image-guided system in endoscopic sinus and skull base surgery

Objective:To evaluate the applicative value of image-guided system in endoscopic sinus and skull base surgeries. Method:A total of 103 endoscopic surgical procedures were performed.All these procedures were conducted with the utilization of image-guided system, among which there were 92 cases of sinonasal-skull base surgery(including nasal sinuses resection of benign and malignant tumors involving skull base lesions, the cumulative orbital lesion resection of nasal sinus lesions, etc. ), 6 repair of cerebrospinal fluid leak, 3 pituitary adenoma resection, 2 traumatic neuropathy optic nerve decompression. Result:With the utilization of image-guided system, all patients had successful surgery without major and minor complications. The image-guided system provided high precision with short registration time. Conclusion:Image-guided system can help the surgeon to identify accurately the vital anatomic landmarks of sinus and skull base, improving surgical accuracy and safety as well as reducing or avoiding the intraoperative and postoperative complications.

Exophthalmos and Blindness Revealing a Non-Hodgkin’s Malignant Lymphoma Type B with High Grade of Malignancy

Background: Non-Hodgkin’s lymphomas represent a heterogeneous group of haematological disorders characterized by a malignant monoclonal proliferation of the lymphoid system (B or T cells). Orbicatory lolisation is rare, it is seen mainly in adults. Case Report: We report the case of a 79-year-old patient with a high-grade NHML, revealed by blindness and left exophthalmos evolving for 3 months. Ophthalmological examination revealed left blindness with axil exophthalmos grade 1. MRI cranio-orbital objectified a left orbital processe lesion intra and extra conical associated with a mucosal thickening of the cavum with left necrotic jugulocarotidian adenopathies. A biopsy of the cavum and ADP objectified a NHML of type B with high grade of malignancy. Result: The patient was put on induction chemotherapy first before being placed on radiotherapy. The evolution was marked by the regression of the left exophthalmia. Conclusion: The NHML is characterized by an extreme clinical polymorphism, especially in the cervicofacial localizations, make the diagnosis difficult and lead to a delay in management.

Clinical observation of orbital IgG4-related diseases.

The aim of the present study was to observe the histopathological changes of immunoglobulin G4-related orbital diseases (IgG4-RODs), summarize the clinical manifestations and imaging features of the IgG4-RODs of the eyelids and explore the early diagnosis of IgG4-RODs. Between June 2011 and May 2015, 23 patients with non-specific orbital inflammation in the Department of Ophthalmology at the First Central Hospital of Tianjin were recruited. The serum IgG4 titer in 9 patients ranged from 4.58 to 46.70 g/l (reference value, 0.03-2.01 g/l), with an average value of 21.93±2.18 g/l. Notably, the degree of increase in the 9 patients with IgG4-RODs was different, but all were >1.35 g/l. A total of 6 cases of infraorbital nerve thickening were observed. In addition, there were 3 cases of extraocular muscle thickening and 1 patient with IgG4-ROD had an orbital tissue lesion extending along the inferior temporal septum to the left pterygopalatine fossa, with left sacral fissure widening and involvement of the left maxillary sinus. The study revealed that the thickening of the inferior orbital nerve may be a characteristic of IgG4-ROD. Therefore, on the basis of biopsy and serological examination in the clinic, early diagnosis can be combined with imaging examination, clinical manifestation and laboratory examination, so as to reduce misdiagnosis and missed diagnosis.

Tumor óseo de células gigantes en techo orbitario de paciente con retinoblastoma bilateral

A case is presented of a 5 year-old patient with bilateral hereditary retinoblastoma treated with radiotherapy in the right eye and enucleation of the left eye. After three years without evidence of progression, the patient presented with a right orbital mass that compromised the frontal bone. After surgical excision, the histology analysis was consistent with a diagnosis of giant cell tumour.Primary orbital bone neoplasms, such as giant cell tumours, are extremely rare. Both radiological and histopathology studies are essential to establish the differential diagnosis of orbital mass lesions.

Ectopic orbital meningioma: a retrospective case series

BackgroundTo evaluate the ophthalmic manifestations and radiographic features of ectopic orbital meningioma to improve diagnostic accuracy.MethodsPatient data from patients admitted to our institution during a 217-month period from August 1999 to September 2017 were included. Patient ophthalmic manifestations, radiographic features (CT and MRI), diagnosis, pathology, therapeutic regimens, and prognosis were retrospectively reviewed.ResultsSix patients with ectopic orbital meningioma were identified. The mean age at the first visit was 33.2 years (range, 7–56 years). All six patients displayed manifestations of exophthalmos, upper eyelid oedema, and motility impairment with a mean history of illness of 20.3 months (range 3–72 months). Optical lesions were located in the superonasal extraconal compartment (3/6, 50%), bitemporal extraconal compartment (1/6, 16.7%) and orbital intraconal compartment (2/6, 33%). Radiographic features were ill-defined, heterogeneous, enhancing soft tissue masses with extraocular muscular adhesion (6/6, 100%) and calcification (1/6, 16.7%), not adjacent to the optic nerve and not extending along the dura. Six cases were treated intraoperatively with complete surgical resection, indicating that all lesions were independent of the optic nerve and sphenoid ridge. The histopathologic classification was mostly of meningothelial cells (5/6, 83%). Immunohistochemistry revealed EMA and vimentin to have positive expression in all six cases, while two cases were calponin-positive and strongly expressed in the olfactory bulb. Postoperatively, lesions caused no visual impairment, and there were no cases of recurrence.ConclusionsEctopic orbital meningiomas are rare tumours that are not easily diagnosed without postoperative histopathology. This report highlights some of the distinguishing features of isolated orbital lesions, especially around the location of frontoethmoidal suture. Accompanying upper eyelid oedema and eye mobility restriction were observed to be dissimilar to other orbital tumours. In these cases, a diagnosis of ectopic orbital meningioma should be considered.