Bilateral orbital emphysema from compressed air injury

PURPOSE

To describe a patient who developed bilateral subconjunctival and orbital emphysema after an automobile tire explosion.

METHOD

Case report.

RESULTS

A 60-year-old man sustained bilateral ocular injury after a tire explosion. Ophthalmic examination disclosed bilateral subconjunctival air, with no visible conjunctival laceration. Computed tomography showed orbital emphysema, with no evidence of orbital fracture. Follow-up examination 2 weeks after the injury disclosed resolution of the subconjunctival air. Best-corrected visual acuity in the right eye was decreased after the explosion but improved to the baseline level of 20/40 2 weeks after the injury.

CONCLUSION

Subconjunctival and orbital emphysema can occur from high-pressure air injury in the absence of an obvious entry site.

Kimura disease of the orbit and ocular adnexa

Kimura disease (KD) is a distinct clinicopathologic entity that has been the subject of considerable confusion and debate. Although common in Asia, KD rarely occurs in non-Asian patients. Kimura disease shares both clinical and histopathologic features with angiolymphoid hyperplasia with eosinophilia (ALHE). Because of this overlap and the rarity of KD in Europe and the United States, KD and ALHE have been used synonymously in the Western medical literature, as they were thought to represent variations of the same disease. Some pathologic reports have called for distinguishing KD and ALHE as two separate entities, based on their histologic features. Kimura disease occurs most commonly in the head and neck region and has been described in the orbit, eyelids, and lacrimal gland more frequently than ALHE. Because both diseases can cause proptosis, lid swelling, ocular dysmotility, or a palpable mass, they should be considered in the differential diagnosis of orbital lesions occurring in adults. We report two cases of KD involving the orbit and ocular adnexa, and review additional cases reported in the literature. The ophthalmic literature does not clearly reflect the current understanding that KD and ALHE are best considered two separate clinicopathologic entities.

[To evaluate the examinations both colour Doppler flow image and CT for orbital pseudotumors]

PURPOSE

To explore the values of colour doppler flow image(CDFI) technique and computer tomographic(CT) scan in diagnosising orbital pseudotumors.

METHODS

CDFI and CT were used for examining 67 cases of orbital pseudotumors demonstrated with surgery and pathaology. The results were treated with self-match design Chi-square test.

RESULTS

The diagnosis validities for 29 mass-type cases with CDFI and CT were 44.8% and 82.8%, respectively, with significant difference (chi 2 = 5.88, P < 0.05). The validities for 25 diffuse-type cases were 84.0% and 56.0%, respectively, with significant difference. (chi 2 = 4.0, P < 0.05). The validities for 19 mixture-type cases were 63.2% and 78.9%, respectively, with no significant difference (chi 2 = 1.63, P > 0.05). The diagnosis validities for all 67 cases were 63.0% and 72.7%, respectively, with no significant difference (chi 2 = 1.16, P > 0.05).

CONCLUSION

The diagnosis validities with both imaging methods were not different for diagnosis of orbital pseudotumors. But the values for diagnosing various pseudotumors were different. The validity with CDFI was superior to CT in diffuse type; CT was superior to CDFI in mass type; while the validity with CDFI and CT were not significant different in mixture type.

Eosinophilic granuloma (Kimura's disease) of the orbit: a case report

BACKGROUND

Eosinophilic granuloma of the soft tissue, Kimura's disease, is a benign slow-growing tumor that is manifested clinically by one or more inflammatory nodules involving mainly the face and scalp, but rarely the eye.

CASE REPORT

The patient was a 32-year-old male with swelling of the left lower eyelid, marked peripheral blood eosinophilia and increased serum immunogloblin E. MRI revealed swelling of all rectus muscles of the left eye, but no tumor mass. Corticosteroid treatment reduced the swelling of the eyelid, but it recurred after corticosteroid was discontinued. Eight years later the patient returned with a complaint of increased swelling of the left lower eyelid. An elastic, nontender, soft tumor mass was palpable subcutaneously in the left lower eyelid extending into the orbit. MRI revealed a tumor mass in the left orbital space. The parotid gland was also swollen and palpable. Both tumors were resected surgically, and histopathological study revealed prominent proliferation of lymphoid follicles with germinal centers showing interfollicular infiltration by eosinophils. The pathological findings in the parotid gland were similar. The diagnosis was Kimura's disease.

CONCLUSION

This patient is unique in that he had no tumor at the first examination, only swelling of the rectus muscles, and a tumor mass appeared many years later. Unilateral swelling of the rectus muscles may be one of the first signs of Kimura's disease. Not only tumor but also swelling of the rectus muscles limited ocular movement.

Phakomatous choristoma may be located in the eyelid or orbit or both

PURPOSE

Phakomatous choristoma is a rare congenital tumour of lenticular origin. The exact location at clinical presentation is controversial, but herein we provide evidence that phakomatous choristoma may be located in the lower eyelid or orbit or both.

METHODS

Case report of an infant presenting with a mass in the lower eyelid at birth, a systematic review of previous cases of phakomatous choristoma and an outline of the histopathological features in normal mid-facial embryonic development at different gestational ages.

RESULTS

The histopathological features of the present case were consistent with those of a phakomatous choristoma. The preoperative imaging studies and clinical findings at surgery suggested that the tumour occupied parts of both the lower eyelid and anterior orbit. Histopathological sections of a normal human embryo showed that at the 26-mm stage of development the embryonic lens is formed but the bony walls defining the orbit are not yet present.

CONCLUSION

Phakomatous choristoma arises in a setting of undifferentiated mesenchymal tissue which later may develop into the lower eyelid or orbit depending on the choristomatous elements being deposited superficial or deep to the embryonic surface.

[Noso-orbital related disease: an analysis of 39 cases]

OBJECTIVE

To enhance the Diagnostic and therapeutic levels of naso-orbital diseases.

METHOD

Thirty-nine cases of naso-orbital diseases were analyzed retrospectively.

RESULT

Among the 39 cases, 7 had no nasal symptoms. 9 had their symptoms mainly confined to eyes and were initially consulted with ophtalmologists. 1 case was consulted with neurologist at first. The main pathologies were as following: bony absorption of orbit wall in inflammatory disorders; compression, displacement and bony absorption of orbit wall in benign tumors and mucoceles; bony destruction in malignant tumors. Tranmatic fractures might involve multiple bony structures.

CONCLUSION

Nosal and orbital organs are closely related anatomically. Imaging investigations are important in diagnosis of naso-orbital related diseases. CT is helpful for early diagnosis. Treatment for benign tumors is mainly by operation, while malignant tumors should be treated by operation and radiotherapy together.

Aspergillus mycetoma in a secondary hydroxyapatite orbital implant: a case report and literature review

OBJECTIVE

The authors describe the first case report of a fungal abscess within a hydroxyapatite orbital implant in a patient who had undergone straightforward secondary hydroxyapatite implant surgery.

DESIGN

Case report and literature review.

INTERVENTION

Four months postoperatively after pegging and 17 months after original implant placement, chronic discharge and socket irritation became evident. Recurrent pyogenic granulomas were a problem, but no obvious area of dehiscence was present over the implant. The peg and sleeve were removed 31 months after pegging (44 months after original placement of the implant). The pain and discharge did not resolve, and the entire hydroxyapatite orbital implant was removed 45 months after sleeve placement and 58 months after initial implant placement. The pain and discharge settled rapidly.

MAIN OUTCOME MEASURES

Cultures and histopathology.

RESULTS

Results of bacterial cultures were negative. Results of histopathologic examination of the implant disclosed intertrabecular spaces with multiple clusters of organisms consistent with Aspergillus.

CONCLUSIONS

Persistent orbital discomfort, discharge, and pyogenic granulomas after hydroxyapatite implantation should cause concern regarding potential implant infection. The authors have now shown that this implant infection could be bacterial or fungal in nature. This is essentially a new form of orbital Aspergillus, that of a chronic infection limited to a hydroxyapatite implant.

[Dermoid cysts. Epidemiology, clinical and anatomo-pathologic aspects, therapeutic management]

We retrospectively analyzed a series of 17 tumors suggestive of dermoid cysts operated on from January 1, 1991, through November 30, 1997. Mean patient age was 3.68 years. The periorbital localization predominated. Two cases of intraorbital localizations required lateral and medial orbitotomy. Surgical treatment was given in all other cases. We observed no complication nor recurrence.

Ectopic brain tissue in the orbit

PURPOSE

The authors report findings in a 9-month-old male infant with heterotopic brain tissue in the orbit, and compare and contrast the characteristics in this patient with the few other descriptions of such lesions in the literature.

METHODS

Excisional biopsy of the growth was undertaken by means of an anterior orbitotomy.

RESULTS

A 9-month-old male infant had a history of congenital left 'anophthalmia' and a slowly growing mass in the left orbit. An MRI scan revealed an orbital mass with solid and cystic components. Histological study of the excised tissue was performed and revealed a choristomatous arrangement of dysplastic brain tissue with intermixed primitive retina including pigmented epithelium. There was no connection between the orbit and cranial cavity.

CONCLUSIONS

The mass must be considered a rare example of heterotopic brain tissue in the orbit and is the only instance we could find in the literature in which a formed eye was absent but in which a scattered primitive ocular structure could be identified.

Severe ocular and orbital toxicity after intracarotid etoposide phosphate and carboplatin therapy

PURPOSE

To report severe ocular and orbital toxicity after administration of intracarotid etoposide phosphate and carboplatin.

METHOD

Case report.

RESULTS

A 52-year-old man with glioblastoma multiforme underwent left intracarotid administration of eto poside phosphate and carboplatin inferior to the ophthalmic artery. Within 7 hours, a nonpupillary block angle-closure glaucoma developed secondary to uveal effusion in the ipsilateral eye, which was relieved by cycloplegia. Four days later, severe orbital inflammation resulted in a visual acuity of counting fingers, proptosis, optic neuropathy, and total external ophthalmoplegia in the eye. The patient's condition improved after a lateral cantholysis and administration of high-dose intravenous corticosteroids. Two weeks later, an anterior uveitis occurred in the left eye, which responded to topical corticosteroids. During a 2-month period, the patient recovered to a visual acuity of 20/70, near normal motility, and normal intraocular pressure, and the ocular and orbital inflammation resolved. Preexisting ipsilateral chemotherapy-induced maculopathy became more pronounced.

CONCLUSION

Ocular and orbital toxicity after intracarotid etoposide phosphate and carboplatin therapy is infrequently reported.

Panorama of orbital space-occupying lesions. The 24-year experience of a referral centre

PURPOSE

The aim of this survey was to study the frequency and management of orbital lesions requiring incisional or excisional biopsy for diagnostic or therapeutic purposes.

METHODS

A histopathological review of specimens from 300 consecutive patients with space-occupying orbital lesions managed over a period of 24 years at a tertiary referral centre.

RESULTS

The lesions could be attributed to 73 different entities with low-grade, non-Hodgkin lymphoma being the most common. More than half (54.3%) of lesions were neoplastic and malignant disease was present in 29.0% of patients. The majority of lesions were biopsied using the anterior transseptal or transconjunctival approach.

CONCLUSION

Most orbital space-occupying lesions requiring biopsy are benign and easily accessible. However, the diversity of these rare lesions and complexity of management suggest that patient care is best provided by a team of experienced subspecialists at a designated orbital centre.

Conjunctival cysts of the orbit

OBJECTIVE

This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts.

DESIGN

A case series review from four oculoplastic practices over 6 years.

PARTICIPANTS

Eleven patients with simple conjunctival cysts of the orbit were identified.

INTERVENTION

All cysts were excised and evaluated histopathologically.

MAIN OUTCOME MEASURES

Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling.

RESULTS

Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone.

CONCLUSIONS

Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.

Langerhans' cell histiocytosis and juvenile xanthogranuloma of the orbit. Clinicopathologic, CT, and MR imaging features

The clinical, radiologic, and histopathologic features of two main disorders of the orbit are discussed. Group I, Langerhans cell histiocytosis (histiocytosis X, Class I), is caused by proliferation of X histiocytic Langerhans' cells. Group II is juvenile xanthogranuloma, and Class II is related to the proliferation of non-X histiocytic (monocyte-macrophage) cells. The two diseases are of unknown cause and differ in their clinical, radiologic, and histopathologic features.

Fibro-osseous, osseous, and cartilaginous lesions of the orbit and paraorbital region. Correlative clinicopathologic and radiographic features, including the diagnostic role of CT and MR imaging

Fibro-osseous and cartilaginous lesions of the orbit and facial region share overlapping clinical, radiologic, and pathologic features that may lead to diagnostic confusion and possible misdiagnosis. The value of imaging studies in the histopathologic diagnosis of these lesions cannot be overemphasized. The histopathologic diagnosis of such lesions should not be rendered in the absence of radiographic correlation.

Parry-Romberg syndrome associated with intracranial vascular malformations

We describe a 23-year-old woman with iridocyclitis, enophthalmos, facial hemiatrophy, and transient numbness of her contralateral upper and lower extremities. The patient was found to have white matter densities in the right hemisphere in magnetic resonance T2-weighted images and vascular malformations involving right vertebral, right carotid, and right anterior cerebral arteries. Histopathologic evaluation of a biopsy specimen of anterior orbital fat and lacrimal gland revealed fibrosis and chronic inflammation. These findings were consistent with the diagnosis of progressive facial hemiatrophy (Parry-Romberg syndrome) in association with iridocyclitis and intracranial vascular malformations.

Ocular infections with dematiaceous fungi in two cats and a dog

Pigmented fungi were identified in ocular tissues from 2 cats and 1 dog. The first cat was euthanatized because of acute anterior uveitis that was unresponsive to treatment. On histologic examination, intraocular structures had been obliterated and replaced by a gray coagulum of inflammatory infiltrates and fungal elements. The second cat was treated for unilateral glaucoma that was unresponsive to treatment. A large retrobulbar mass, discovered and removed during an enucleation procedure, contained plant-origin foreign material. Keratitis, episcleritis, and orbital cellulitis with fungal elements were found on examination of the enucleated globe. The dog, examined because of a presumed corneal scratch of 2 weeks' duration that was unresponsive to treatment, had a corneal lesion subsequently removed by lamellar keratectomy that contained fungi on histologic examination. Infections caused by dematiaceous fungi are not common in domestic animals, and, to our knowledge, such infections in the eye have not been described.

Unilateral Blastomyces dermatitidis endophthalmitis and orbital cellulitis. A case report and literature review

PURPOSE

The authors report the clinical, cytologic, and histopathologic findings of a unique presentation of concomitant unilateral endophthalmitis and orbital cellulitis secondary to Blastomyces dermatitidis.

DESIGN

Case report.

METHODS

A 29-year-old healthy woman with a history of pulmonary tuberculosis presented with a painful right eye and rapidly decreasing vision. Fundus examination showed a diffuse elevated choroidal lesion at the posterior pole. With an otherwise unremarkable systemic work-up, the patient was treated with systemic antibiotics and corticosteroids for a presumed diagnosis of choroidal tuberculous granuloma. After an initial response to the treatment, the patient's condition deteriorated rapidly with visual acuity decreasing from 20/25 to no light perception in 3 months. Ipsilateral proptosis developed with magnetic resonance imaging showing a poorly defined orbital mass. Surgical enucleation and an orbital biopsy were performed.

RESULTS

Histopathologic examination of the orbital specimen and an intact enucleated globe showed a diffuse necrotizing granulomatous process with the presence of numerous yeasts consistent with B. dermatitidis. This subsequently was confirmed by positive culture of B. dermatitidis from the orbital specimen.

CONCLUSIONS

This is a unique case of concurrent unilateral endophthalmitis and orbital cellulitis secondary to B. dermatitidis. Intraocular dissemination of blastomycosis should be suspected in the differential diagnosis of endophthalmitis in patients with previous or active pulmonary lesions of equivocal nature. Early diagnosis and prompt treatment with antifungal medications are essential.

[Conjunctival cysts of the orbits: clinical aspects and histology in 4 patients]

BACKGROUND

Only a few reports concerning congenital conjunctival cysts of the orbit (primary nonkeratinized epithelial cysts) have been published.

PATIENTS

We describe four further cases of conjunctival cysts of the orbit, which were observed between 1995 and 1997 in Tübingen and Vienna. Histologically, all cysts were lined by nonkeratinizing epithelium with goblet cells. Epidermal appendages were found in the wall of one cyst. The patients' age was between 1 and 32 years. Clinically, the prominent symptom was swelling of the upper eyelid, persisting in three patients for more than several years. In one patients diplopia and restriction of eye movements developed within several weeks.

CONCLUSIONS

The cases we described are in accordance with the cases reported in the literature. Often a swelling of the upper eyelid persisted for several years, before the cyst has become symptomatic predominantly in an adult patient. In contrast to dermoid or epidermoid cysts, there is no bony erosion and the cysts are located in the superior to nasal orbit. These cysts are probably more common as it is represented in the literature.

Subarachnoid hemorrhage caused by Aspergillus aneurysm as a complication of transcranial biopsy of an orbital apex lesion--case report

A 62-year-old male complaining of unilateral visual disturbance and pain in the involved eye had a small mass at the right orbital apex which was identified as an Aspergillus granuloma by transcranial biopsy. One month later, the patient became comatose because of fatal subarachnoid hemorrhage due to a newly developed aneurysm. Autopsy showed a ruptured aneurysm on the right internal carotid-posterior communicating artery. Histological examination demonstrated prominent Aspergillus invasion of the arterial wall. Aspergillus infection must be taken into consideration in patients with orbital apex syndrome, which may lead to serious cerebrovascular consequences. If sino-orbital lesions are detected by neuroimaging techniques, biopsy using an extradural approach should be performed to obtain a definitive diagnosis.