Periocular and orbital amyloidosis: clinical characteristics, management, and outcome

OBJECTIVE

To present the clinical features and management outcome in a large series of patients with periocular and orbital amyloidosis.

DESIGN

Retrospective, noncomparative, interventional case series.

PATIENTS

All patients diagnosed with periocular and orbital amyloidosis in 6 oculoplastic and orbital units.

METHODS

Clinical records of all patients were reviewed.

MAIN OUTCOME MEASURES

Clinical presentation, radiological and histological findings, treatment modalities, and outcome.

RESULTS

The study included 24 patients (15 female, 9 male) with a mean age of 57+/-17 years. Nineteen cases were unilateral, and 5 were bilateral. Clinical signs and symptoms included a visible or palpable periocular mass or tissue infiltration (95.8%), ptosis (54.2%), periocular discomfort or pain (25%), proptosis or globe displacement (21%), limitations in ocular motility (16.7%), recurrent periocular subcutaneous hemorrhages (12.5%), and diplopia (8.3%). Seven cases had orbital involvement, and 17 were periocular. Immunohistochemistry in 7 patients showed B cells or plasma cells producing monoclonal immunoglobulin chains that were deposited as amyloid light chains. Only 1 patient was diagnosed with systemic amyloid light chain amyloidosis. Treatment modalities were mainly observation and surgical debulking. During a mean follow-up period of 39 months, 21% showed significant progression after treatment, whereas 79% were stable or showed no recurrence after treatment.

CONCLUSION

Periocular and orbital amyloidosis may present with a wide spectrum of clinical findings and result in significant ocular morbidity. Complete surgical excision is not feasible in many cases, and the goal of treatment is to preserve function and to prevent sight-threatening complications.

Proptosis: etiology and demographic patterns

OBJECTIVE

To determine the demographic pattern of patients presenting with proptosis and its etiology.

DESIGN

A cross-sectional descriptive study.

PLACE AND DURATION OF STUDY

Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Hayatabad Medical Complex, Peshawar from July 2001- December 2002.

PATIENTS AND METHODS

Sixty cases of proptosis presenting at KIOMS were included. Thirtysix patients were male while 24 were female. They were divided into two age groups; 0-15 years (paediatric group) and above 15 years (adult group). An elaborate work up plan was formulated for all patients, which included detailed history, clinical examination (ocular, orbital and systemic), radiological and histopathological investigations.

RESULTS

Neoplasms (33%) were the most common causes of proptosis in all the patients followed by orbital inflammations (23%), orbital infections (20%), structural abnormalities (12%), vascular abnormalities (7%) and trauma (5%).

CONCLUSION

Neoplasms were the most common cause of proptosis in both paediatric and adult group. Proptosis was the cardinal feature and visual deterioration was present in more than half of the patients. Timely referral, early diagnosis and appropriate management can result in reduction of visual morbidity.

Orbital hydatid cyst manifested as expanding exophthalmos following blunt orbital trauma

A 14-year-old boy suffered right blunt orbital trauma. X-ray revealed a compressed fracture of the right ethmoidal sinuses. Three months after the trauma, progressive, painless right proptosis developed. Ocular examination revealed a severe proptosis and pronounced down displacement of the right globe without signs of orbital inflammation. A well-demarcated, extraconal right orbital cystic mass was seen on computerized tomography scan. The cyst contents were aspirated and found to contain echinococcal scolices and "hydatid sand." Hypertonic saline was injected and the cyst was excised. Progressive proptosis after blunt orbital trauma in patients from endemic areas should be suspected of being an orbital hydatid cyst.

Compressive optic neuropathy due to orbital metastasis of a sacral chordoma: case report

A 44-year-old man presented with unilateral proptosis and progressively deteriorating vision of his left eye over a 2-week period. He had a history of recurrent sacral chordoma for 1 year that had previously been treated with combined surgical excision, chemotherapy, and radiation therapy. MRI showed compression of the optic nerve by an orbital mass that proved to be an orbital metastasis of his sacral chordoma. The tumor mass was excised subtotally, and adjuvant orbital radiation therapy was administered.

Ophthalmic manifestations of multiple myeloma

PURPOSE

To describe ophthalmic manifestations in a series of patients with multiple myeloma (MM) and review the literature.

DESIGN

Retrospective case series.

METHODS

Review of all cases with ophthalmic manifestations of MM seen at the Department of Ophthalmology, Royal Adelaide Hospital, between 1987 and 2002.

RESULTS

Of all patients with MM who were managed at the Royal Adelaide Hospital in the study period, only 8 were referred to the Ophthalmology Department with ophthalmic manifestations. Five males and 3 females with a mean age of 61.25 years (range 42-78) who exhibited ophthalmic manifestations were studied. Six patients (75%) had known MM at the time of their ophthalmic evaluation. Four patients (50%) had neuro-ophthalmic symptoms resulting in diplopia or visual disturbances. Three patients (37.5%) presented with orbital involvement and 1 (12.5%) with hyperviscosity retinopathy. Five patients (62.5%) died within 2 months of their ophthalmic presentation.

CONCLUSION

Ophthalmic manifestations of MM are uncommon and diverse. They may appear at the initial presentation of the disease or occur late in the disease process. Awareness of the possible manifestations may lead to an earlier diagnosis and have a positive influence on the disease course.

[Exophthalmos--case report]

Exophthalmos is one of the most common clinical manifestations of an orbital abnormality. It usually results from a mass, a vascular abnormality, or an inflammatory process. We discuss the difficulty to obtain a correct diagnosis and the applied treatment in a clinical case, and at the same time we remark the importance of the close collaboration between the ophthalmologist and other specialists.

[Therapy for Graves' ophthalmopathy]

Graves' ophthalmopathy (GO) is also called thyroid-related eye disease, infiltrative ophthalmopathy, which is related with the autoimmunity of thyroid, especially hyperthyroidism. Its morbidity ragnes from five percent to ten percent of hyperthyroidism, and the morbidity of male patients is higher than that of the female patients. The treatment of severe GO is a difficult task for doctors. The therapeutic effect is not always satisfactory. In order to solve this knotty problem, researchers have been devoting themselves to the development of new therapeutic methods. Here, the development of the therapies for GO is introduced, and the trends of treatments are prospected.

[Clinical analysis of 339 cases of thyroid-associated ophthalmopathy]

OBJECTIVE

To summarize the clinical manifestation of thyroid-associated ophthalmopathy (TAO), to analyze the thyroid function and to monitor the therapeutic effect of anti-hyperthyroidism on the progression of TAO.

METHODS

Three hundred and thirty nine TAO cases (597 eyes) were collected from 1994 to 2001 and their clinical manifestations were summarize and analyzed.

RESULTS

TAO occurred mostly in individuals over 40 years with no gender preference. Exophthalmos and diplopia were the major manifestations and main reasons for ophthalmic examination. Retraction of eyelids and involvement of extraocular muscle were present in over 70% cases. In 339 TAO cases, euthyroidism was found in 93 cases and abnormal thyroid function (hyperthyroidism or hypothyroidism) was present in 246 cases. The V and VI grade of TAO occurred more frequently in patients with abnormal thyroid function than those with euthyroidism. (131)I, oral anti-hyperthyroidism drug, or thyroidectomy was used for all patients with abnormal thyroid function. TAO occurred in 39.3% cases treated with (131)I, in 15.6% cases with oral anti-hyperthyroidism drug, and in 14% cases with thyroidectomy. All ocular pathologic changes occurred after hyperthyroidism had been controlled and hypothyroidism was found in most of these cases.

CONCLUSIONS

The condition of thyroid function has a certain relationship to the severity of TAO. Over-fast and undue anti-hyperthyroidism therapy may impact an untoward effect on TAO; immediate and appropriate treatment can improve the effect of therapy on TAO.

Orbital xanthogranuloma: clinical and morphologic features in eight patients

PURPOSE

To describe the clinical and morphologic features of patients with orbital xanthogranuloma (XG) with or without Erdheim-Chester disease (E-Cd).

METHODS

Retrospective, noncomparative case series. A review of 8 consecutive histopathologically proven cases of orbital XG from 3 medical centers. Four male and four female patients with ages ranging from 23 to 79 years presented with 4 bilateral and 4 unilateral orbital XGs.

RESULTS

Age at diagnosis, ocular and systemic manifestations, histopathologic and radiologic features, type of treatment, and prognosis were evaluated for each patient. Six of 8 patients had proptosis and 2 presented with afferent pupillary defect and severe extraocular motility limitations. Other signs and symptoms included eyelid retraction, mechanical ptosis, and chemosis. Planar xanthomas of eyelids were present in 3 individuals. CT and MRI showed infiltrating soft tissue masses within the orbit in 7 and 2 patients, respectively. Histopathology revealed proliferation of foamy histiocytes intermingled with Touton and multinucleated giant cells and lymphocytes. The absence of Birbeck granules within the histiocytic elements of the tumor, indicating that the cell of origin is a non-Langerhans histiocyte, was documented with electron microscopy in 3 cases. The most common treatment was surgical excision combined with oral corticosteroids. Two patients with E-Cd with involvement of the long bones of the upper and lower extremities and retroperitoneal region died of kidney failure within approximately 1 year of diagnosis.

CONCLUSIONS

Orbital XG is a proliferative lesion of the non-Langerhans histiocytes, which may present as a solitary orbital lesion or may be associated with a systemic condition known as E-Cd with very poor prognosis.

[Thyroid orbitopathy (pathogenesis, diagnosis and treatment)]

PURPOSE

To review and to update the current diagnostic and therapeutic approaches and the pathogenesis of thyroid orbitopathy. To propose a practical, basic and precocious approach based in the knowledge of the disorder.

METHODS

Literature review and exposition of our experience in the management of thyroid orbitopathy.

RESULTS

Thyroid orbitopathy is an inflammatory orbital disease that probably has an autoimmune origin and most of the time is related to systemic disorders of the thyroid gland. The disease has a variable clinical presentation and it may cause severe damage in vision and orbital architecture, therefore, producing a decrease in the patient's quality of life and may also alter significantly the personal behavior. Pathogenesis of the disease is not yet fully understood, but it is widely held that there is a common autoantigen shared between the thyroid gland and the orbital adipogenic fibroblasts. Women are more likely to develop thyroid orbitopathy, and the disease is clearly affected by several factors such as smoking, age, sex and race.

CONCLUSIONS

Clinical knowledge is essential for the early diagnosis of this disorder, and it is the most important factor for the proper management of the disease. The medical treatment must be initiated promptly and should be aggressive and based in the current phase of the disease, in order to avoid the severe damage that follows thyroid orbitopathy. The surgical approach must be logical and sequential, but, on the other hand, must be rapid and aggressive in order to return the patient to his/her labour, social and familiar environment.

[Diagnosis and therapy of Graves' ophthalmopathy--consensus guidelines]

On 22-09-2001 the VIth Grazer Hormonsymposion took place. Diagnosis and therapy of Graves' Ophthalmopathy was discussed in an interdisciplinary way by endocrinologists, surgeons and ophthalmologists. The results of the round-table discussion and the consensus talk are presented.

[Complications of rhinosinusitis]

Rhinogenous complications may manifest in the region of the orbits, bone or soft parts of the wall of the frontal sinus, or endocranially. With regard to orbital complications, a differentiation is made between edema, periostitis, subperiosteal abscess and phlegmon--depending on severity and extent. A possible sequela of frontal sinusitis may be osteomyelitis. If the frontal bone is involved, there is a danger that the infection may spread to the endocranium via medullary spaces and blood vessels. The diagnostic basis for deciding appropriate treatment is CT or MRI. While orbital edema and periostitis usually respond to conservative treatment, subperiosteal abscess, orbital phlegmon and abscess of the brain require immediate operative treatment under antibiotic cover. The treatment of choice for osteomyelitis of the frontal bone is the liberal removal of affected bone, also under antibiotic cover.

Castleman's disease in the orbit. A 20-year follow-up

PURPOSE

To report a case of localized orbital Castleman's disease of mixed cell type with a follow-up of 20 years.

METHODS

A female patient presented at the age of 12 years with constitutional symptoms and left-sided proptosis. Laboratory tests revealed marked hypergammaglobulinaemia and high erythrocyte sedimentation rate (ESR), suggesting an immunological disturbance. A CT scan and MRI showed an infiltrating orbital mass lateral to and behind the eye.

RESULTS

Histological examination of orbital biopsies showed a lymphoid lesion consistent with Castleman's disease of the mixed cell type. The patient was treated with systemic steroids, immunosuppressives and irradiation. She is now 33 years old and has been without relapse for the last 7 years.

CONCLUSION

Orbital involvement in Castleman's disease is very rare. The clinical course, good prognosis and histological picture of the present case favour the diagnosis of localized Castleman's disease of mixed cell type. The successful medical treatment suggests that such a regime may substitute for surgery when the latter proves difficult.

[How to investigate a patient with exophthalmos?]

Exophthalmos is the main symptom revealing orbital masses. This sign needs to be imaged mainly by MRI and/or CT. As Graves disease is the main etiology of exophthalmos, CT scan should be performed as the initial imaging modality. Indications for US and Doppler are mostly limited to the study of ocular masses, and eventually may help the characterization of extra-ocular lesions. In all cases, imaging is useful to characterize: the precise location of the lesion which can be the intra-conal space (including muscles), the extra-conal space (associated or not to an extra-orbital lesion), or the eyeball; the features of the lesion (density, signal, enhancement.). These findings are used to generate a differential diagnosis. Imaging is also useful to precise the extension of the mass, and in some cases to select the appropriate surgical approach, and for follow-up.

[Post-traumatic pulsating exophthalmus coexisting with congenital carotid-cavernous fistula]

Pulsating exophthalmus develops most frequently in the course of penetrating or bitemporal head trauma. Idiopathic form is even more rare. Orbit venous system over-loading with pathological arterial blood infiltration is the cause of pulsating exophthalmus. A patient with congenital carotid-cavernous fistula (right eyeball enlargement and noise), suffering from head trauma after road accident has been presented. Carotid-cavernous fistula was diagnosed and than treated casually by endovascular closure of the infiltration between internal carotid artery and cavernous sinus. After 5-month treatment regression of the noise and exophthalmus was observed.

[Treatment results in 25 patients with Graves' ophthalmopathy between 1998 and 2001]

In our outpatient clinic 25 patients with Graves' ophthalmopathy were treated, 21 women, mean age 58.8 years (range 19-74 years) and 4 men, mean age 47.5 years (range 38-56 years). In the female group two showed euthyroid Graves' ophthalmopathy and one Hashimoto's disease; in the male group one showed euthyroid ophthalmopathy. Treatment was done depending on the findings of the NOSPECS-classification in identical way for each group. Final results were obtained three and six months after therapy, at that time all patients were euthyroid. In five patients (two men and three women) sicca-treatment was sufficient because the ophthalmopathy improved by therapy of the thyroid disease only. Three women were treated by oral steroids over three months and had a complete remission. Nine women were treated by oral steroids and external radiation, six of them showed major improvement but in one case orbital decompression had to be done. Somatostatin therapy was done over six months in six women who showed no change after oral steroids plus radiation. Out of them five showed major improvement but in spite of a positive octreoscan in one case orbital surgery had to be performed. Two men were treated by oral steroids and external radiation without change of disease, somatostatin therapy was not done because of a negative octreoscan. With the exception of one nonsmoking woman in whom orbital surgery had to be done, the treatment results were worse in smokers.

[Exophthalmia]

The authors present the association of signs and symptoms in exophthalmos syndrome, which occurs in many diseases. Although exophthalmos was considered to be of ophthalmological interest, according as researches were made on its pathogeny and according as investigation methods were developed, exophthalmos is no more considered a symptom, but a syndrome. After defining the syndrome, the present study shows its classifications, clinical and complementary investigations, and its treatments.

Two Cases of Refractory Endocrine Ophthalmopathy Successfully Treated with Extracorporeal Immunoadsorption

Endocrine ophthalmopathy (EO) is a severe disease entity that is characterized by retrobulbar swelling due to accumulation of glycosaminoglycans on an autoimmune basis. This disorder can lead to the loss of vision and often is resistant to conventional therapy. There is a relation to Graves' hyperthyroidism, but probably no close association. Two patients with severe EO that was resistant to usual therapeutic approaches including steroids and radiological and surgical measures underwent a 20 session course of intensive immunoadsorption therapy (Plasmaselect/Therasorb Anti-IgG) with a mean 2- to 3-fold plasma volume treated. After the first sessions, both patients voiced an impressive relief of their major symptoms, which was confirmed by ophthalmological investigation. Throughout the time of therapy until present, these patients have remained at their respective levels of improvement. We consider immunoadsorption an effective therapeutic opportunity in severe EO resistant to conventional treatment.

[Means syndrome. 8 cases]

BACKGROUND

Euthyroid Graves' disease is defined as an ophthalmopathy without dysthyroidism. We report 8 cases in 6 women and 2 men with an average follow-up of 16 months after diagnosis.

CASE REPORTS

Unilateral ex-opythalmos was the first and most frequent sign. Ultrasonographic and immunological thyroid abnormalities were frequent but of questionable significance. Thyroid hormone levels continued to remain normal. The orbital CT-scan, used to screen for infra-clinical exophthalmos, evidenced focal or diffuse hypertrophy of the extraocular muscles and normal tendon insertions. More than 3 years after diagnosis, only one patient developed overt Graves' disease and clinical signs resolved spontaneously in one other.

DISCUSSION

In mild to moderate forms of euthyroid Grave's disease, therapeutic abstention is advisable. Corticosteroids and orbital radiotherapy are interesting options in functionally disabling forms. Decompressive surgery is rarely needed.

Long-term follow-Up of an infant with thyrotoxicosis due to germline mutation of the TSH receptor gene (Met453Thr)

A 18-year clinical follow-up period in a male patient with a germline TSH-R gene mutation (Met453Thr) is described. Nonautoimmune thyrotoxicosis was diagnosed at the age of 7 months. The patient had exophthalmus, failure to thrive, advanced bone age and no goiter. Long-term antithyroid drug treatment (ATD) was necessary during childhood. At the age of 7 years he developed a goiter. Subtotal thyroidectomy was performed at the age of 9 years, followed by repeated ablative radiotherapy at the age of 9.5-13 years due to a toxic multinodular goiter. After 13 years ATD could be discontinued and the patient was euthyroid until 16 years of age, where L-thyroxine substitution had to be started. The exophthalmus diminished, and had disappeared at the age of 18 years, when CT scan of the orbit was performed.

CONCLUSION

TSH-R mutation must be considered in early nonautoimmune thyrotoxicosis. A very aggressive treatment strategy is necessary.

Sarcomatous transformation of the orbit in a patient with Paget's disease

OBJECTIVE

To report the clinical and pathologic features of sarcomatous transformation of the skull with involvement of the orbit, in Paget's disease.

DESIGN

Interventional case report.

PARTICIPANT

An 83-year-old woman with Paget's disease who experienced progressive proptosis of the left eye.

INTERVENTION

Fine-needle aspiration biopsy of the orbital mass.

RESULTS

Cytologic examination revealed round to oval malignant cells with wispy cytoplasm, consistent with the diagnosis of sarcoma. The patient died shortly after institution of orbital radiation therapy and systemic steroid therapy.

CONCLUSIONS

Proptosis related to Paget's disease is uncommon, and only rarely is it a result of sarcomatous transformation. Sarcomatous transformation of the skull involving the orbit should be included in the differential diagnosis of progressive proptosis in patients with Paget's disease.