Orbital apex syndrome following inferior turbinate radiofrequency

INTRODUCTION

We report a case of orbital apex syndrome following turbinate radiofrequency.

METHODS

The clinical features, investigations (nasofibroscopy, supra-aortic and trans-cranial vessels ultrasounds, CT- and MRI-scans) are described.

RESULTS

A forty-year-old man underwent radiofrequency volumetric tissue reduction (RFVTR) for bilateral inferior turbinate hypertrophy. No particular problems were reported during the procedure under general anaesthesia. Immediately after the general anaesthesia, the patient complained of right eyelid ptosis with right monocular blindness. The patient also had ophthalmoplegia and suffered from right corneal anaesthesia and right hypoaesthesia of the cheek. The CT-scan showed right ethmoidal and maxillary sinusitis with no bone or tissue lesions. MRI-scan showed an enlarged aspect of the subarachnoid membrane of the right optic nerve. Corticosteroid treatment was prescribed but did not produce any satisfactory result. No improvement in visual acuity was observed.

CONCLUSION

Turbinate radiofrequency may result in a definitive orbital apex syndrome.

Use of fine needle cytology in the diagnosis of orbital and eyelid mass lesions

OBJECTIVE

To study the use offine needle cytology (FNC) in the diagnosis of orbital and eyelid lesions.

STUDY DESIGN

A total of 34 orbital and eyelid lesions were subjected to fine needle aspiration (FNA) and nonaspiration techniques, and the cytologic findings and diagnoses of 28 lesions were correlated histpathologically. Data were statistically analyzed, and the specificity, sensitivity, predictive values and rate of nondiagnostic aspirates were calculated.

RESULTS

Of 28 cases, 9 were orbital and 19 were eyelid lesions. There was 100% concordance in differentiating benign vs. malignant orbital and eyelid lesions; the concordance with respect to the precise histologic diagnosis was 100% for orbital and 77.7% for eyelid lesions. The overall percentage of malignant lesions was 53.1%; the rest were benign neoplastic, cystic or inflammatory lesions. The overall concordance rate in differentiating benign vs. malignant lesions and for precise histologic diagnosis was 100% and 80.8%, respectively. The rate of nondiagnostic aspirates was 5.9%. Sensitivity, specificity and positive and negative predictive values of FNA in detecting malignant lesions were 100%.

CONCLUSION

If done with adequate safety precautions to protect the eye, FNC is a simple, safe, reliable, minimally invasive and rapid test for diagnosis of orbital and eyelid lesions.

Multiple brain infarcts after orbital inflammation

A 75-year-old woman developed trigeminal varicella-zoster virus infection complicated by ophthalmoplegia, and visual loss followed by recurrent cerebral infarctions involving small and large intracranial arteries. Medical therapy improved her ophthalmoplegia, but she developed a right hemiparesis and aphasia.

[Case of inferonasal subconjunctival orbital fat herniation]

BACKGROUND

We report a case with orbital fat herniation beneath the inferonasal conjunctiva, which is very rare in the literature.

CASE

A 52-year-old non-obese female. The subconjunctival mass in the right eye that had formed spontaneously at a young age was yellow, soft, and easily retreated into the orbit with pressure. A magnetic resonance image showed that the intraconal orbital fat herniated through a space that was formed by the inferonasal sclera and the intermuscular septum between the medial rectus muscle and the inferior rectus muscle. Surgical resection obtained good results.

CONCLUSION

This route of fat herniation in this case is similar to that of superotemporal lesions in previous reports. One possible explanation of the mechanism of such a rare lesion is congenital weakness in the inferonasal Tenon's capsule.

Sclerosing Wegener's granulomatosis in the orbit

PURPOSE

To report three cases of sclerosing Wegener's granulomatosis in the orbit and to compare the histopathological morphology with those of other types of sclerosing orbital inflammation.

METHODS

We analysed the clinical data along with histopathological specimens from orbital biopsies and from two enucleated eyes.

RESULTS

All three patients had longstanding inflammation in the orbit and involvement of the paranasal sinuses. Proptosis, impaired ocular motility and reduced visual acuity dominated the clinical picture. All histopathological specimens featured granulomatous inflammation, tissue necrosis, vasculitis and widespread dense fibrosis. In certain areas of all specimens the fibrous tissue was arranged in characteristic concentric, onionskin-like whorls of collagen around obliterated small blood vessels.

CONCLUSIONS

Wegener's granulomatosis may lead to orbital fibrosis and sclerosis. The stromal changes and cellular infiltrate resemble the non-specific orbital inflammation previously termed orbital pseudotumour. We present the first 'onionskin' lesions in association with Wegener's granulomatosis in the orbit. This latter morphology may represent an abnormal fibrotic reaction in inflammatory tissue.

Long-term multidisciplinary follow-up of unilateral thyroid-associated orbitopathy

BACKGROUND

Thyroid-Associated Orbitopathy (TAO) is an autoimmune disease characterized by orbital inflammation involving both adipose tissue and extra-ocular muscles (EOM). Whereas bilateral and possibly asymmetric orbital involvement is commonly found at radiological work-up, mono-orbital involvement is poorly documented, and ascribed to an initial and/or transient stage of subsequent bilateral TAO.

METHODS

From a cohort of two hundred TAO patients, we selected retrospectively fourteen patients with initial clinical unilateral TAO. Five of them were excluded because of clinical bilateralization.

RESULTS

The sex ratio was 0.8 (4M, 5F), and mean age 44.6 years (range: 18-63). All patients were euthyroid when the initial magnetic resonance imaging (MRI) was performed. One patient was treated with Levothyroxine, because of subclinical hypothyroidism. Eight patients (six smokers) suffered from Graves' disease, of 1-4 years duration, for which they were treated with antithyroid drugs. A thyroidectomy was performed in two patients. None of the patients ever received radioiodine. Six patients remained euthyroid after stopping of the antithyroid regimen, and two became hypothyroid. Seven patients had active, and two severe TAO. Four of nine patients exhibited bilateralization of TAO on initial MRI. Clinical status ultimately improved or normalized in all. In two patients, MRI performed after 9 years demonstrated partial shrinkage of previously enlarged EOMs, together with fatty involution of involved muscles.

CONCLUSIONS

Unilateral TAO is not different and just as severe as bilateral TAO. At initial work-up MRI shows signs of bi-laterality in 45% (4/9), with mild involvement of 1 or 2 extra-ocular muscles. The radiological status of affected muscles does not normalize, even in the very long term.

[Acute blepharoptosis caused by fibrous dysplasia]

We report a case of fibrous dysplasia revealed by acute ptosis in a 38-year-old patient. Ophthalmologic examination disclosed a moderate right ptosis. The rest of the results were strictly normal except for a known facial asymmetry. Visual acuity was 20/20 in both eyes, there was no extrinsic or intrinsic oculomotor disorder, and funduscopy was normal. Given this acute presentation, emergency cerebral imagery was carried out, providing a diagnosis of fibrous dysplasia with orbital and cavernous repercussions, with no sign of cerebral disorder or obvious vascular lesion. Progression was marked by a regression of the ptosis. Fibrous dysplasia is a rare pathology but presents varied clinical presentations. The authors present the broad characteristics of this pathology and the management of an acquired ptosis. They discuss the possible mechanisms involved in the drop of the right upper eyelid of this patient and the therapeutic solutions.

Development of Langerhans cell histiocytosis associated with chronic active Epstein-Barr virus infection

Chronic active Epstein-Barr virus (CAEBV) infection is characterized by a status of lymphoproliferative disease of EBV-infected cells, resulting in chronic or recurrent infectious mononucleosis-like symptoms. CAEBV is always accompanied by life-threatening complications. We report the case of a 2-year-old female patient with CAEBV who subsequently developed Langerhans cell histiocytosis (LCH) presenting with bilateral exophthalmos, bone, and skin involvement. In situ hybridization for EBER revealed EBV-infected B-cells present in lesional tissue implying that interactions between EBV-infected B-cells and lesional Langerhans cells may be associated with the development of LCH.

Orbital fibrous dysplasia with soft tissue hamartoma--a variant of Mazabraud's syndrome

BACKGROUND

Mazabraud's syndrome was first described, by Mazabraud et al. as a rare disease, associated with single or multiple intramuscular myxomas with monostotic or polyostotic forms of fibrous dyplasia,

PURPOSE

Reports of this syndrome is rare and usually associated with myoxomatas. The authors would want to report the occurrence of this rare case associated with a hamartoma as basis for record and future studies.

METHOD

An adult male came to the institution 4 years ago complaining of a right unilateral proptosis that he had since childhood. However, proptosis progressed in a month's time accompanied by right eye redness. Right eye was congested with a palpable firm mass on the right lower lid. Best corrected visual acuity was 6/15-2. Pupillary examination revealed the presence of RAPD on the right eye. Exophthalmometry revealed a 10 mm proptosis. EOMS were restricted on the right eye and diplopia was noted in all gazes. Ishihara test showed 14/15 for the right eye. CT SCAN and MRI confirmed a mild inflammatory extraconal or intramuscular mass in the right obito-retrobulbar region. Bony changes seen in the right zygoma, sphenoid bone and squamous part of the temporal bone with extensive bone mineralization. The patient underwent a right lateral orbitotomy with biopsy and debulking of the inferior orbital mass. Histopathology revealed a hamartomatous lesion.

CONCLUSION

Due to the associated soft tissue lesion with multiple craniofacial bone changes, this case may be considered a variant of Mazabraud's Syndrome. The associated hamatomatous lesion may be a rare occurrence that should be noted.

Necrobiotic xanthogranuloma occurring in an eyelid scar

We present a case report of necrobiotic xanthogranuloma (NXG) in a 76-year-old Caucasian lady occurring as a nodule in a blepharoplasty scar. NXG is a rare histiocytic disease with progressive orbital and systemic features. Management options of excision biopsy or chemotherapy are discussed.

Orbital and adnexal Rosai-Dorfman disease

PURPOSE

To report the clinico-radiological findings, clinical course, and treatment outcomes in five patients with orbital and adnexal Rosai-Dorfman (R-D) disease.

METHODS

Analysis of case records of patients with Rosai-Dorfman disease seen at four orbital units between January 2000 and December 2006.

RESULTS

Five patients (3 Caucasian males, 1 Hispanic female, and 1 African female), mean age 41.1 years, (range 18 months to 75 years) with orbital or adnexal Rosai-Dorfman disease were seen during the study period. Four of the patients had orbital involvement and one had eyelid involvement. Presenting features were proptosis (4 patients), diplopia (1 patient), epiphora (1 patient), and eyelid thickening (1 patient). Three of the patients with orbital involvement also had adjacent paranasal sinus involvement, and the nasolacrimal duct was involved in one patient. The patient with eyelid involvement had evidence of cutaneous R-D disease elsewhere in the body. The follow-up period (since initial diagnosis of R-D disease) ranged from 1 month to 15 years, and 2 of the patients had a history of recurrent growth despite treatment. Surgical debulking was employed in 2 patients with good results.

CONCLUSIONS

Orbital and adnexal Rosai-Dorfman disease is a condition with protean manifestations that may show indolent but unremitting growth despite treatment. The disease may remain extranodal and localized for many years. Adjacent paranasal sinus involvement is commonly seen in conjunction with orbital disease, simulating midline destructive lesions. Surgical debulking gives good results in patients with functional or significant cosmetic problems.

[Langerhans cell histiocytosis located in the orbit]

Langerhan's cell Histiocytosis of the orbit. Langerhan's cell Histiocytosis is a rare condition that affects children and less frequently young adults. It is characterized by a proliferation of histiocytes derived from Langerhan's cells. Orbital involvement is described in 20% of cases where orbital eosinophilic granuloma located in the frontal bone is the most frequent. The malignant nature of this disease is not established. Its evolution is unpredictable and spontaneous regression after simple biopsy were described. The authors report four cases of Langerhan's cell Histiocytosis and will discuss on the clinical and radiological aspects as well as on the evolution of orbital histiocytoses X.

Floretlike Cells in In Situ and Prolapsed Orbital Fat

PURPOSE

Orbital pleomorphic lipoma has been rarely reported in the literature. Although floretlike cells are characteristic of pleomorphic lipoma, they are not pathognomonic. We reviewed cases of prolapsed orbital fat and exenteration specimens to determine the significance of presence of these cells in the diagnosis of orbital pleomorphic lipoma.

DESIGN

Retrospective interventional case series with clinicopathologic correlation.

PARTICIPANTS

Seventy-two specimens of 45 patients with prolapsed orbital fat and 74 exenteration specimens as controls.

INTERVENTION

Histologic review of the specimens including light microscopy, Masson trichrome staining, immunostaining for S100, CD34, CD68, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay, and transmission electron microscopy and review of clinical records and analysis of the data with generalized estimation equation.

MAIN OUTCOME MEASURE

Evidence of histologic abnormalities in histologic specimens and clinical and demographic data.

RESULTS

Floretlike cells were present in 31 of 72 (43%) specimens of prolapsed orbital fat and in 12 of 74 (16%) orbital exenterations. Fewer than 6 florets were present in twenty 40x high-power fields in 15 (48%), 6 to 10 in 9 (29%), and >10 in 7 (23%) specimens. The florets stained positive for CD34 but not for S100 or CD68. TUNEL assay revealed significant nuclear pyknosis, and transmission electron microscopy disclosed spindle-shaped cells with abundant rough endoplasmic reticulum and no basement membrane. The mean age of patients with prolapsed orbital fat with florets was 67 years (range, 52-86). Of 31 samples, 29 (94%) were from males. Of 30 samples, 29 (97%) were located in the superotemporal conjunctiva; only one was located in the lower lid. There was significant association between the presence of florets and location of the prolapsed orbital fat (P = 0.0013) and gender (P = 0.0015).

CONCLUSION

Floretlike cells may be present in in situ and prolapsed orbital fat as a degenerative process. What some have called "orbital pleomorphic lipoma" is in fact only age-related orbital fat prolapse.

A rare presentation of invasive rhino-orbital mucormycosis in an immunocompetent young girl: a case report

A 18 year young, healthy, immunocompetent girl presented with proptosis of left eye, referred to eye OPD, suspected clinico-radiologically as malignancy. This presentation with suspicion of malignancy resulted into extensive surgical debridement with removal of left eye, which was diagnosed as mucormycosis on histopathological examination. Her eye could have been saved if the mucormycosis was highly suspected initially, because of the good general health and immunocompetency led to misdirected thought.

Magnetic resonance imaging features of orbital inflammation with intracranial extension in four dogs

This retrospective study describes the clinical and magnetic resonance (MR) imaging features of chronic orbital inflammation with intracranial extension in four dogs (two Dachshunds, one Labrador, one Swiss Mountain). Intracranial extension was observed through the optic canal (n=1), the orbital fissure (n=4), and the alar canal (n=1). On T1-weighted images structures within the affected skull foramina could not be clearly differentiated, but were all collectively isointense to hypointense compared with the contralateral, unaffected side, or compared with gray matter. On T2-, short tau inversion recovery (STIR)-, or fluid-attenuated inversion recovery (FLAIR)-weighted images structures within the affected skull foramina appeared hyperintense compared with gray matter, and extended with increased signal into the rostral cranial fossa (n=1) and middle cranial fossa (n=4). Contrast enhancement at the level of the affected skul foramina as well as at the skull base in continuity with the orbital fissure was observed in all patients. Brain edema or definite meningeal enhancement could not be observed, but a close anatomic relationship of the abnormal tissue to the cavernous sinus was seen in two patients. Diagnosis was confirmed in three dogs (one cytology, two biopsy, one necropsy) and was presumptive in one based on clinical improvement after treatment. This study is limited by its small sample size, but provides evidence for a potential risk of intracranial extension of chronic orbital inflammation. This condition can be identified best by abnormal signal increase at the orbital fissure on transverse T2-weighted images, on dorsal STIR images, or on postcontrast transverse or dorsal images.

Congenital cystic eye: features on MRI

Congenital cystic eye is a rare cause of cystic orbital lesion. The condition is recognized at birth as a large orbital mass in place of a normal eye. Only 29 cases have been reported previously. We report a case of unilateral congenital cystic eye with multiple brain anomalies in the form of agenesis of corpus callosum and grey matter heterotopias. In this case report we highlight the MRI features of this entity, which have not been described previously in the literature.

Orbital syndromes

The orbit is a complex anatomical structure with unique properties not observed in other regions of the body. Composed of seven bones, the orbit is filled by the eye, optic nerve, lacrimal gland, extraocular muscles, peripheral motor and sensory nerves, fat, arteries, and veins. All these structures are intimately related to one another within an intricate framework of connective tissue. A variety of traumatic, vascular, inflammatory, infectious, and neoplastic processes can affect the orbit and its structures. Aside from the many primary orbital diseases, systemic disorders and pathological processes from neighboring structures (eye, ocular adnexa, oral cavity, paranasal sinuses, and intracranial cavity) can involve the orbit. A careful history and complete physical examination, with special attention to the orbit and ocular adnexa, are required to identify subtle orbital abnormalities that otherwise could be overlooked or mistakenly contributed to a nonorbital process. This article reviews the pertinent orbital anatomy, discusses the clinical evaluation and manifestations of orbital syndromes, and highlights several important orbital syndromes germane to the neurologist, including thyroid-associated orbitopathy, nonspecific orbital inflammation (also known as inflammatory orbital pseudotumor), perineural orbital invasion of cutaneous squamous cell carcinoma, rhino-orbital-cerebral mucormycosis, and carotid-cavernous sinus fistula.

Bilateral periorbital necrotizing fasciitis following exposure to Holi colors: a case report

Holi festival is celebrated in India traditionally by applying colors on one another. Various ocular adverse effects of these colors have been reported including conjunctivitis and corneal abrasion. We report a case of bilateral periorbital necrotizing fasciitis, following exposure to Holi colors. General physicians might encounter more such cases after exposure to Holi colors. In India, these colors are prepared on a small scale and lack any quality checks. Use of such toxic colors should be discouraged, and all doctors should caution people against using synthetic dyes. This case report highlights the need to put manufacturing of Holi colors under guidelines of the Food and Drug Cosmetic Act and the Bureau of Indian Standards.

Receptor expression in orbital inflammatory syndromes and implications for targeted therapy

To investigate the expression of multiple therapeutic targets in tissue specimens from patients with orbital inflammatory syndromes, the clinical records of 16 patients treated for orbital inflammation between January 2003 and November 2005 for whom tissue blocks were available were reviewed retrospectively. Immunohistochemical staining was performed on archived specimens using commercially available monoclonal antibodies against CD3, CD20, CD22, CD23, CD25, and CD52 antigens. The histologic diagnoses were confirmed, and the immunohistochemical staining patterns were agreed upon by both collaborating pathologists (JLJ and PC-B). The study included 13 women and 3 men who ranged in age from 4 to 79 years (mean, 46 years). The histologic diagnoses were as follows: orbital pseudotumor in six patients; sarcoidosis, three; eosinophilic granuloma, one; necrobiotic xanthogranuloma, one; nonspecified granulomatous inflammation, one; Graves' ophthalmopathy, one; Wegener's granulomatosis, one; and reactive lymphoid hyperplasia, two. One orbital lymphoma specimen and one foreign body reaction specimen were used as controls. CD20 was strongly expressed in all specimens except three (Wegener's granulomatosis, eosinophilic granuloma, and nonspecified granulomatous inflammation specimens), and CD25 was strongly expressed in all specimens except the Wegener's granulomatosis specimen, in which this antigen was only moderately expressed. CD20 and CD25 were strongly or moderately expressed in most of the tested specimens of orbital inflammation. If our findings are confirmed in a larger study, rituximab, which targets CD20, and denileukin diftitox (ONTAK), which targets CD25, should be considered for future clinical trials for orbital inflammatory syndromes.

Benign fibrous histiocytoma associated with a frontoethmoidal mucopyocele and orbital abscess

A 74-year-old man sought treatment for painful swelling in the right upper eyelid. CT demonstrated a frontoethmoidal mucocele extending in the right orbit with abscess formation. Following functional endoscopic sinus surgery, the inflammatory symptoms in the right eye nearly resolved. However, a firm mass was still noted in the same location. Histopathologic examination proved it to be a benign fibrous histiocytoma. Benign fibrous histiocytoma may occur in association with an orbital abscess secondary to mucocele.

Orbital Rosai-Dorfman disease: report of a case with fine needle aspiration cytology and histopathology

BACKGROUND

Rosai-Dorfman disease, or sinus histiocytosis with massive lymphadenopathy (SHML), is a rare, nonhereditary, benign histiocytic proliferative disorder, affecting mainly the lymph nodes. Orbital involvement in the absence of lymphadenopathy is relatively uncommon.

CASE

A 50-year-old woman presented to our hospital with gradual proptosis of the left eye for 5 years. Physical examination revealed no abnormalities, including lymphadenopathy. Ultrasonography and magnetic resonance imaging showed a soft tissue mass in the intraconal retroorbital region of the left eye. Fine needle aspiration cytology of the mass yielded a good number of mature lymphocytes, a few neutrophils, plasma cells and many histiocytes exhibiting emperipolesis. A provisional diagnosis of SHML was suggested and later confirmed by histology of the excised mass.

CONCLUSION

Though the orbit is a rare site of extranodal SHML, the disease should be entertained in the differential diagnosis of orbital swellings. To the best of our knowledge, this is the fourth case of SHML involving the orbit exclusively, with no nodal involvement.