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.

Sarcoidosis with orbital tumor outside the lacrimal gland: initial manifestation in 2 elderly white women

Two elderly white women (aged 72 and 87 years) were first seen with painless, unilateral orbital swelling. Orbital scanning revealed masses infiltrating the soft tissue around the eye. Biopsy results showed nodular, noncaseating granulomas consistent with sarcoidosis. One patient's workup revealed systemic manifestations of sarcoidosis at the time of examination with hilar lymphadenopathy noted on gallium scan; the other refused a complete systemic workup. The orbital tumors resolved with systemic prednisone therapy. To our knowledge, our 87-year-old patient is the oldest to be seen with orbital sarcoidosis. These 2 patients demonstrate that this diagnosis must be considered with orbital tumors in the elderly and in unusual locations, such as these which occurred outside the lacrimal gland.

Orbital masses

The "space approach" will be introduced as a means of analyzing orbital masses on imaging studies. Determination in which space an orbital mass resides, the character of its margin, the presence or absence of bony changes, and evidence of extension of the mass beyond the orbit often allows the radiologist to narrow the differential diagnosis and provides essential information to the ophthalmologist for definitive diagnosis and treatment planning.

[Rhino-orbito-cerebral mucormycosis: clinical presentation]

BACKGROUND

Rhino-orbito-cerebral mucormycosis is an opportunistic rapidly progressive infection affecting almost exclusively diabetic or immunocompromised patients.

CASE REPORTS

Three cases are reported. For one patient mucormycosis was the first manifestation of juvenile diabetes and the evolution was favorable. In the second case the infection affected a known diabetic patient and the clinical course was fatal. The third patient was immunocompromised, showed mild clinical features and a rapidly fatal evolution, the diagnosis being made only postmortem.

CONCLUSION

These three cases illustrate the wide clinical spectrum of rhino-orbito-cerebral mucormycosis, its serious nature and difficult diagnosis.

Pseudotumor of the orbit in early childhood

Orbital pseudotumor, also known as idiopathic orbital inflammation, is defined as a nonspecific, nonneoplastic inflammatory process of the orbit without identifiable local or systemic causes. The disorder, first described by Birch-Hirschfield in 1905, is more prevalent in the adult population than in the pediatric population. In our study we discuss two cases of pseudotumor of the orbit in children less than 18 months old. This report will highlight the evaluation and management of pediatric orbital pseudotumor and the importance of its inclusion in the differential diagnosis of orbital disorders in young children.

Diffuse pancreatic fibrosis: an uncommon feature of multifocal idiopathic fibrosclerosis

Multifocal idiopathic fibrosclerosis (MIF) is a rare syndrome characterized by exuberant fibrosis involving diverse organ systems. MIF is manifest by varying combinations of the following conditions: mediastinal fibrosis, retroperitoneal fibrosis, orbital pseudotumor, Riedel's thyroiditis, and sclerosing cholangitis. Less common features of MIF include Dupuytren's contractures, lymphoid hyperplasia, Peyronie's disease, vasculitis, testicular fibrosis, and pachymeningitis. Fibrosis arising from the pancreas has been previously described in two patients with MIF. We report a 58-yr-old white man with MIF manifest as orbital pseudotumor, sclerosing cholangitis, lymph node hyperplasia, and diffuse pancreatic fibrosis.

Clinical practice guidelines for the management of orbital cellulitis

PURPOSE

A retrospective study was performed to review the management of periorbital and orbital cellulitis at Miami Children's Hospital, between January 1, 1993 and February 15, 1996.

RESULTS

One hundred and one patients were included in this study. The variables analyzed in this study included age, sex, length of hospital stay, imaging studies, laboratory tests, and microbiology specimens collected. Patients were classified according to the modified Chandler classification. Average length of stay for our patient population was 4.5 days. Data regarding the radiologic studies, laboratory tests, and microbiology yield of specimens were analyzed.

CONCLUSIONS

The incidence of orbital infection, manifested by lid swelling alone is much more common (stages I and II) than orbital infection involving postseptal findings (stages III, IV, and V); 84.16% compared with 15.84%, respectively. An updated approach and a general guideline for the management of periorbital and orbital cellulitis according to the clinical staging of the process is presented.

[Orbital sarcoidosis--a case with an unusual course]

BACKGROUND

Most cases of orbital sarcoidosis are associated with a systemic sarcoidosis.

PATIENTS AND METHODS

A 67-year-old woman suffered from an orbital mass on the right side, which led to disturbance of the ocular motility. Slight improvement was achieved by the administration of systemic steroids.

RESULTS

Histologically a chronic granulomatous inflammation was revealed in the biopsy of the orbital mass. The suspected diagnosis was sarcoidosis, but three conventional chest X-rays within 10 months and the serum angiotensin-converting-enzyme were normal. Suprisingly a computertomography of the chest showed mediastinal lymphomas.

CONCLUSION

Granulomatous orbital inflammation without any local cause or other systemic granulomatous disease strongly suggests a systemic sarcoidosis. In case of missing lymph node enlargement in conventional chest X-ray computertomography should be performed.

[Epithelial giant inclusion cyst 50 years after enucleation without orbital implant]

BACKGROUND

Conjunctival cyst formation following enucleation may occur in 3% to 7% of patients receiving orbital implants, especially secondary implants. We present a patient with a giant epithelial inclusion cyst of the anophthalmic orbit 50 years after enucleation without orbital implant.

PATIENT

A 54-year-old male presented with increasing proptosis of the ocular prosthesis, shallowing of the inferior fornix, a palpable orbital mass, and difficulty in retaining the ocular prosthesis. At the age of 1 year enucleation of the right eye without orbital implant was performed following perforating ocular trauma. Results of examination of the other eye were unremarkable. Transillumination of the orbital mass was possible. The clinical diagnosis of an epithelial inclusion cyst was confirmed using ultrasonography and CT scan. An incision of conjunctiva and cyst wall and subsequent marsupialization were performed. Nine months postoperatively there was no evidence of recurrence of the cyst. The ocular prosthesis was well in place.

CONCLUSION

Conjunctival cyst formation following enucleation may rarely occur in patients receiving orbital implants, especially secondary implants. The presentation of a conjunctival cyst formation following enucleation without orbital implant 50 years after surgery is noteworthy in comparison to implantation cysts which are known to occur more commonly within the first two years following secondary orbital implants.

Orbital pathology associated with diabetes mellitus

Diabetes mellitus may be associated with or result in diverse orbital and adnexal problems. It may include mild manifestations, such as blepharoptosis, blepharitis, xanthomas, increased tear-film glucose levels, and calcification of the trochlear apparatus. More severe findings involve third, fourth, and sixth cranial neuropathies. Finally, the physician always should be alert for the possibility of orbital infections in the diabetic population, especially the life-threatening rhinocerebral mucormycosis.

Orbital cysticercosis

BACKGROUND

Human cysticercosis is secondary to an infestation by cysticercus cellulosae, the larval form of Taenia solium. Cysticercosis is endemic to regions with poor sanitation. The purpose of this report is to present a large series of patients with orbital cysticercosis and to discuss the current treatment.

METHODS

A retrospective chart analysis of all patients with orbital cysticercosis from an urban practice in southern India was performed. The clinical features, the results of investigations, the therapies instituted, and the outcomes realized were recorded.

RESULTS

Twenty patients diagnosed with orbital cysticercosis were identified (11 female and 9 male). Their ages ranged from 5 to 25 years with a mean age of 12.5 years. Nine patients manifested subconjunctival cysts. Eight were excised and 5 of these were densely adherent to the adjacent extraocular muscle (EOM). The remaining 11 patients had a cyst in a single EOM. The EOM cysts had proptosis, restricted motility, recurrent inflammation, and blepharoptosis. Two of the EOM cysts were excised surgically and four extruded spontaneously. Six patients with EOM cysts were treated medically: they all received oral corticosteroids and, additionally, five were given oral albendazole and one was given oral praziquantel.

CONCLUSIONS

Excisional biopsy is recommended for subconjunctival cysticercosis. Idiopathic cystic myositis can present like EOM cysticercosis, but is differentiated by resolution with corticosteroid treatment. Medical therapy in orbital cysticercosis with oral albendazole and corticosteroids can arrest recurrent inflammation and improve ocular motility.

Prenatal diagnosis of orbital heterotopic brain tissue

Biopsy of fetal tissues is a relatively new procedure for the diagnosis of congenital malformations. The authors report the first case in which this technique has been applied to an orbital mass, in which heterotopic brain tissue was diagnosed by prenatal biopsy and excised in infancy. The wider implications of such intrauterine procedures are discussed.

[Reparative giant cell granuloma with orbital involvement]

A 54-year-old woman was evaluated for a left orbital mass that had been present for one year. Examination showed mild superolateral displacement of the normal left eye and a firm medical orbital mass. A complete resection of the lesion was accomplished via a combined neurosurgical, otolaryngologic and ophthalmologic superior orbital approach. Histologic features of the mass were consistent with giant-cell (reparative) granuloma. However, it has to be pointed out that fibroosseous lesions with giant-cells display similar histologic features and require clinicopathologic correlation including radiographic studies for final diagnosis.

Frozen section--guided surgical debridement for management of rhino-orbital mucormycosis

PURPOSE

To present a new method of surgical treatment for rhino-orbital mucormycosis.

METHOD

We treated a patient with extensive surgical debridement of mucormycosis with intraoperative frozen section guidance. The patient did not require exenteration.

RESULT

Our patient survived with normal vision and no diplopia.

CONCLUSIONS

Frozen section-guided surgical debridement in rhino-orbital mucormycosis may provide an alternative to traditional radical surgical excision. In selected cases, this new method of treatment may cause less morbidity than do traditional treatments.

Intraorbital subperiosteal hematoma due to paranasal mucocele--case report

A 68-year-old female was admitted with a rare intraorbital subperiosteal hematoma manifesting as sudden orbital pain, progressive blepharoptosis, and diplopia. Computed tomography showed a biconvex high density mass in the superomedial part of the left orbit, which was recognized to be a subperiosteal hematoma intraoperatively. The eroded orbital roof between the frontal sinus and orbit was a result of mechanical compression by the mucocele. Infection extending into the orbit was important in causing the hemorrhage.