Treatment of benign orbital pseudolymphomas with the monoclonal anti-CD20 antibody rituximab

OBJECTIVE

To report the results of treating patients with orbital pseudolymphomas with the anti-CD20 monoclonal antibody rituximab.

PATIENTS AND METHODS

Patients were included in the study if they had an orbital mass and biopsy-proven orbital pseudolymphomas between January 1, 1998, and December 31, 2005. The study focused on patients treated with rituximab.

RESULTS

Ninety-eight patients were evaluated, and the biopsy results revealed malignant non-Hodgkin lymphoma in 72 (73%); the other 26 (27%) had a pseudolymphoma. Eleven (42%) of the 26 patients with a pseudolymphoma were treated with rituximab, 375 mg/m2, intravenously each week for 4 doses, and 10 (91%) of the 11 responded. Seven patients were either treated with maintenance rituximab or successfully retreated with rituximab after relapse. None of the 10 responders has become refractory to rituximab.

CONCLUSION

Benign lymphoproliferative tumors are responsive to monoclonal antibody therapy targeted to B lymphocytes. Rituximab should be considered a treatment option for orbital pseudolymphomas.

Subglottic and tracheal stenosis associated with multifocal fibrosclerosis

This is the first case report in the literature of idiopathic subglottic and tracheal stenosis in a patient diagnosed with multifocal fibrosclerosis (MFS). The patient had unilateral orbital pseudotumour, bilateral pretibal cutaneous manifestations and raised thyroid antibodies, which might indicate subclinical thyroid involvement. Urgent permanent tracheostomy was needed. The patient also underwent tracheal dilatation for her dysphonia. There was no evidence of brain, lung, liver or renal involvement. Although extremely rare, laryngologists should consider the possibility of such a diagnosis in a stridulous patient with multifocal fibrotic manifestations.

Ectopic Brain in the Orbit With Congenital Adduction Deficit and Simultaneous Abduction

An 11-month-old girl was referred to us with enophthalmos and restriction of ocular movement in the right eye. There was restriction of supraduction and adduction with synergistic divergence on left gaze. MRI revealed a multiloculated cystic mass in the right inferior orbit. There was an atrophic and misinserted inferior rectus muscle and only a vestigial right medial rectus muscle. Excisional biopsy of the orbital cystic mass was performed. Microscopic examination disclosed that the mass was brain tissue composed of arachnoid tissue, brain parenchyma, choroid plexus, and dura mater. Our report describes a rare case of ectopic brain in the orbit that was combined with anomalies of the extraocular muscles.

Inflammatory myofibroblastic tumour of the orbit in a 7-year-old child

Inflammatory myofibroblastic tumour (IMT) is a rare low-grade lesion in the spectrum of myofibroblastic tumours. Systemic IMT is a well-described entity, but orbital IMT is extremely uncommon. These tumours are detected incidentally or through site-specific complaints. Their presentation may clinically and radiologically mimic that of a malignant neoplasm, thus necessitating a biopsy. Even with reports of persistence, local recurrence and malignant transformation the overall prognosis remains favourable.

Orbital Langerhans cell histiocytosis in adults

PURPOSE

To report 3 patients with adult-onset orbital Langerhans cell histiocytosis (LCH).

DESIGN

Retrospective interventional case reports.

PARTICIPANTS

Three adult patients with orbital LCH.

METHODS

Case reports from 2 different clinics and review of the scientific literature.

MAIN OUTCOME MEASURES

Clinical course and radiologic and histologic findings.

RESULTS

Three healthy patients, aged 20 to 36 (mean, 27) years, presented with biopsy-proven unilateral orbital LCH. The initial presenting complaints were mainly orbital pain and headache with or without orbital swelling and minimal effect on ocular movements. There was radiologic evidence of disease centered on the greater wing of sphenoid bone in all cases. Biopsy via lateral canthotomy was performed with LCH confirmed based on histologic and immunohistochemical findings. There was no evidence of disease elsewhere on systemic investigations. One patient had curettage and intralesional corticosteroids, 1 patient had a craniotomy for more complete resection of the lesion, and the third patient was referred for radiotherapy. All patients achieved complete resolution of symptoms and signs. None of the patients demonstrated any evidence of distant or recurrent disease at follow-up.

CONCLUSIONS

Orbital LCH in adults is a rare, usually unifocal, and relatively benign disease most commonly affecting the greater wing of sphenoid bone, where there is still active bone marrow in young adults. There is no consensus on cause or therapy, but our reported cases show that several treatment modalities are effective.

Assessment of ultrasonography and computed tomography for the evaluation of unilateral orbital disease in dogs

OBJECTIVE

To describe clinical, ultrasonographic, and computed tomographic (CT) features of confirmed neoplastic and nonneoplastic disease in dogs with unilateral orbital diseases, determine criteria to differentiate between the 2 conditions, and assess the relative value of ultrasonography and CT for the differential diagnosis of these 2 conditions.

DESIGN

Prospective study.

ANIMALS

29 dogs with unilateral neoplastic orbital disease and 16 dogs with unilateral nonneoplastic orbital disease.

PROCEDURES

Clinical history and results of physical and ophthalmologic examinations were recorded. Ultrasonographic and CT images were evaluated, and discriminating factors were identified to differentiate neoplastic from nonneoplastic diseases. Diagnostic value of ultrasonography and CT was assessed.

RESULTS

Dogs with neoplastic disease were significantly older; had clinical signs for a longer time before initial examination; had more progressive onset of clinical signs; and more frequently had protrusion of the nictitating membrane, fever, and anorexia. The most discriminating factor for both imaging modalities was delineation of the margins (odds ratio was 41.7 for ultrasonography and 45 for CT), with neoplastic lesions clearly delineated more often. Ultrasonographically, neoplastic lesions were more frequently hypoechoic and homogeneous, with indentation of the globe and bone involvement evident more frequently than for nonneoplastic lesions. Mineralization was detected only with neoplasia. Fluctuant fluid was seen more frequently in dogs with nonneoplastic disease. Computed tomography more frequently revealed extraorbital involvement. Diagnostic value was similar for both imaging modalities.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasonography and CT are valuable imaging modalities to assist in differentiating neoplastic from nonneoplastic unilateral orbital disease in dogs.

Bilateral orbital lymphangiomas in two patients with generalized lymphangiomatosis

SUMMARY

Generalized lymphangiomatosis is a rare congenital malformation of the lymphatics, characterized by cystic lesions in parenchymal organs and lytic bone lesions. In this report, we describe the radiographic and clinical features of 2 unusual cases of generalized lymphangiomatosis with bilateral orbital involvement.

Ocular presentation of Wegener granulomatosis

A 55-year-old woman presented with swelling of the right upper and lower eyelid, diplopia and proptosis. The clinical findings combined with imaging, pathology and full internal work-up allowed to make a diagnosis of limited Wegener granulomatosis. Treatment with systemic corticosteroids and cyclophosphamide markedly decreased the orbital swelling and diplopia.

Adult-onset asthma and periocular xanthogranulomas in a patient with lymphoplasmacytic sclerosing pancreatitis

The clinical syndrome of adult-onset asthma and periocular xanthogranulomas represents a rare systemic autoimmune disorder that has not been previously associated with autoimmune pancreatitis. Herein, we describe the case report of a 61-year-old man with the unique clinical association of adult-onset asthma, atopy, and periocular xanthogranulomas, who had previously been diagnosed with lymphoplasmacytic sclerosing pancreatitis. We have previously reported the case of a patient with lymphoplasmacytic sclerosing pancreatitis that developed postoperative inflammatory pseudotumor of the orbit. These unique, extrapancreatic, ocular manifestations of this disease add to the published observations that it is a systemic disorder with the potential for multiorgan involvement that may have a spectrum of clinical manifestations that includes adult-onset asthma and periocular xanthogranulomas.

[Solitary eosinophilic granuloma of the orbit: a case report]

The authors report a case of eosinophilic granuloma involving the roof of the orbit in a 3-year-old girl. The clinical presentation and the imaging features suggested a malignant tumor and the final diagnosis was obtained by biopsy with histopathologic examination. Despite its alarming radiologic appearance, there was spontaneous healing of the eosinophilic granuloma.

Clinical Anophthalmia With Orbital Heterotopic Brain Tissue

The authors describe the uncommon clinical presentation and treatment of a neonate with progressive proptosis, which turned out to be an ectopic cerebral rest in the orbit in the absence of a formed eye. The discussion examines the theories regarding the genesis of the condition, different locations in the body (including the orbit and the eye) in which ectopic cerebral rests have been described in the literature, and the management of the condition.

Preseptal cellulitis due to Mycobacterium marinum

Mycobacterium marinum is an atypical mycobacterium found in both salt and fresh water. It occasionally causes soft tissue infections after minor trauma, principally affecting the limbs.

A 17-year-old male aquarium worker presented with preseptal cellulitis of his right eye, after attempting to lance a hordeolum some days previously. The condition failed to respond to antibiotics and a necrotic area developed, which subsequently required debridement. Histology of the debrided area demonstrated granulomatous inflammation which when considered with his occupation led to the diagnosis of Mycobacterium marinum – ‘fish-tank granuloma’.

A Medline search did not demonstrate any previous cases of Mycobacterium marinum infection occurring peri-orbitally. The current literature regarding diagnosis and management is reviewed. Although infection with Mycobacterium marinum is rare in the general population, this case demonstrates the importance of considering the diagnosis when dealing with patients frequently exposed to fresh or salt water.

Management of congenital unilateral proptosis from an orbital epithelial cyst by cyst aspiration

A rare cause of axial proptosis, orbital epithelial cysts are presumed to be of conjunctival origin if the wall is composed of nonkeratinized squamous epithelium (especially if goblet cells are present). These cysts can occur at any age and are typically surgically resected if symptomatic. The subject of this report is the management of a congenital orbital epithelial cyst by needle aspiration in a newborn with ipsilateral esotropia and severe unilateral proptosis.

A surgical technique with connective tissue repair for the management of subconjunctival orbital fat prolapse

Abstract Subconjunctival orbital fat prolapse is an uncommon benign entity. In addition to insufficient information concerning the mechanisms of the prolapse, detailed surgical methods that can be followed are uncommon in the literature. We prospectively studied six consecutive eyes in four males who were to undergo our novel surgical sequence, attempting to avoid postoperative complications by reconstructing intermuscular septa on the basis of the assumption that the spontaneous prolapsed fat at the superior temporal quadrant stemmed from intraconal fat. Intraoperative findings were in agreement with our hypothesis that the anterior part of the herniated fat is covered by both the intermuscular septum and Tenon's capsule. All the surgeries were uneventful and cosmetic improvement without postoperative complications was obtained. Our early results indicated the safety and efficacy of this newly developed technique for spontaneous orbital fat prolapse.

Management of orbital xanthogranuloma with methotrexate

BACKGROUND/AIMS

To evaluate the efficacy of methotrexate (MTX) treatment for the periorbital findings in adult-onset xanthogranuloma (AOX).

METHODS

The medical records of three patients with AOX, with and without asthma, who were treated with MTX at Oregon Health & Science University, Portland, Oregon, USA were examined. Diagnosis of AOX was made by biopsy in all patients. The patients were evaluated between February 1998 and July 2006. All patients had failed prior medical and/or surgical treatment. MTX was administered at 10-20 mg/week with folate supplementation and a course of corticosteroids. Efficacy was assessed on the basis of improvement in skin discoloration, involvement of the visual axis and patients' report of inflammation.

RESULTS

All three patients were started on MTX, but one patient discontinued treatment after 3 weeks due to nausea. With follow-up as long as 3 years, the two patients who continued treatment lost the yellow discoloration of their skin, and they reported significantly less inflammation and ptosis after treatment. Oral corticosteroids could be reduced or discontinued.

CONCLUSIONS

AOX is a rare, persistent disease that commonly involves the preseptal fat. MTX is a therapeutic option for this illness.

Orbital cysts lined with both stratified squamous and columnar epithelia: a late complication of silicone implants

Two patients presented with orbital cysts 5 and 7 years after orbital blowout fracture repair with silicone plate implants. The orbital cysts caused significant exophthalmos and restriction in ocular motility. Surgical excision revealed thick-walled cysts that were displacing the globe and encapsulating the silicone implant. On histopathologic examination, the cysts were lined with both stratified squamous and ciliated columnar (respiratory) epithelia. We propose that squamous and respiratory epithelial cells may have been deposited during surgery from the conjunctival and sinus epithelia, respectively. This case series illustrates that although an uncommon complication, epithelium-lined inclusion cysts may develop several years after orbital fracture repair with a silicone implant. A transconjunctival surgical approach is a possible risk factor.

Pyogenic Granuloma as a Presenting Sign of Hydroxyapatite Orbital Implant Exposure: A Clinicopathologic Study

PURPOSE

We report 5 unusual cases of exposed hydroxyapatite orbital implants that presented as pyogenic granulomas. We propose pathogenesis and histopathologic correlations.

METHODS

A clinicopathologic study of 5 patients with hydroxyapatite implants who presented with pyogenic granuloma.

RESULTS

Pyogenic granulomas were detected 1.5 to 30 months after implantation in 5 patients. The lesions were multiple but were not related to the wound margin at the exposed area and were not covered by the surface epithelium in most instances. Exposure defects were detected in all patients at the time of lesion excision. The mean exposure size in the greatest dimension was 16 mm (range, 9-20 mm). Three patients were treated successfully with simple excision of the granulomas, burring down of the anterior surface of the implants, and direct repair of the exposure defects. Explantation of the implant was performed in 2 cases. Histopathologic examination revealed chronic inflammation and microabscess formation in the explanted implants.

CONCLUSIONS

Five patients with pyogenic granulomas were found to have hydroxyapatite exposure. Pyogenic granuloma should not be considered a benign lesion on a hydroxyapatite orbital implant, especially in recurrent cases. Ophthalmologists must be aware of the possibility of conjunctival dehiscence with hydroxyapatite-implant exposure beneath the lesion.

Update on orbital anatomy

The orbit is a confined space bounded by four bony walls. Apart from the globe, orbital fat, and extraocular muscles it contains many important neurovascular structures. It is intimately related to the paranasal sinuses as well as the anterior and middle cranial fossae. Consequently, sinus pathology and intracranial disease may spread to involve the orbit and the converse applies. A thorough understanding of orbital anatomy is essential to fully appreciate the effects of disease on the orbit and is of paramount importance for performing safe orbital surgery. The anatomy of the orbit is discussed with reference to relevant orbital disease.

Giant orbital cysts after strabismus surgery

PURPOSE

To describe a rarely reported complication of strabismus surgery.

DESIGN

Observational case series.

METHODS

A review of four eyes in three patients with orbital cysts following strabismus surgery.

RESULTS

Each patient had either a symptomatic strabismus or visible mass that brought them to medical attention many years, often decades after surgery (mean 34 years). All had some degree of incomitancy. During surgery, all cysts were found to be associated with the involved rectus muscle.

CONCLUSIONS

Orbital cysts are a rarely recognized complication of strabismus surgery. However, it should be considered in the differential of orbital cysts after strabismus surgery because of the risk of muscle damage during surgical excision.

Periocular necrotizing fasciitis with visual loss pathogenesis and treatment

OBJECTIVE

To illustrate the role of clinically necessary aggressive subcutaneous debridement with limited excision of necrotic skin in treating necrotizing faciitis, while demonstrating the histopathologic basis of orbital spread and blindness complicating this disorder.

DESIGN

Observational retrospective case series.

PARTICIPANTS

Seven consecutive patients cared for by the Eye Plastic and Orbital Surgery Services at the University of Michigan and University of Iowa.

METHODS

Retrospective review of ocular findings, systemic features, management, outcome, and histopathology of debrided tissue from 7 patients with periocular necrotizing fasciitis.

MAIN OUTCOME MEASURES

Patient survival and morbidity.

RESULTS

Bilateral involvement was present in 6 of the 7 patients. Five patients suffered ophthalmic or central retinal artery occlusion with loss of vision. All patients underwent extensive debridement of subcutaneous tissue with sparing of overlying nonnecrotic skin and intensive systemic antibiotic therapy. Four patients required unilateral exenteration. After a mean follow-up of 38 months, 6 patients were alive; 1 died perioperatively due to septic shock. Histopathology, not previously described, showed inflammation to spread preferentially along eyelid fibrofatty-fascial tissue planes into the orbit and along orbital fibrous septae, leading to intense perivascular inflammation, thrombosis, and ocular infarction.

CONCLUSIONS

Necrotizing fasciitis is a potentially fatal disease that often causes blindness when affecting the periocular region. To reduce morbidity and mortality in severe infections, prompt subcutaneous debridement and limited resection of necrotic skin are usually necessary.

Role of ivermectin in the treatment of severe orbital myiasis due to Cochliomyia hominivorax

We describe 2 patients with severe orbital myiasis due to Cochliomyia hominivorax (of the order Diptera and the family Calliphoridae) who had underlying skin carcinomas and were treated with oral ivermectin and debridement. We suggest that ivermectin plays an important role in the treatment of severe cases of myiasis.

Sarcomatoid carcinoma and orbital apex syndrome

PURPOSE

To report a case of sarcomatoid carcinoma and orbital apex syndrome in a previously healthy adult.

METHODS

A previously healthy 45-year-old man presented with exophthalmos of the left eye and a mass visible through his left nostril. A biopsy was performed and immunohistochemistry was used to confirm the diagnosis of the tumor. The patient was treated with chemotherapy and radiotherapy.

RESULTS

After treatment, we observed a substantial reduction in the size of the mass, but side effects of treatment developed. The visual acuity of the left eye was no light perception. Eight months later, the patient presented with bone and liver metastases, and he died 4 months later.

CONCLUSIONS

Sarcomatoid carcinoma is an aggressive tumor that can produce compressive symptoms with very poor visual and survival prognoses. A cranio-orbital computed tomography scan should be performed when patients present with symptoms of conjunctivitis and orbital apex syndrome.

[Pulmonary nocardiasis with abscesses spreading to cerebrum, cerebellum and orbits]

HISTORY AND ADMISSION FINDINGS

A 71-year-old woman presented with suspected tuberculosis. She reported having productive coughs, unwanted weight loss and subfebrile temperature in the preceding 3 months. She was known to have chronic obstructive pulmonary disease treated with corticoids given systemically and by inhalation. She was a heavy smoker.

INVESTIGATIONS

Computed tomography revealed a left apical lung abscess. In the further course of the disease magnetic resonance imaging of the head demonstrated multiple abscesses in both cerebral hemispheres and an abscess, 3.4 cm in diameter, in the right side of the cerebellum, as well as a intra-orbital tumor on the right. Needle aspirate of the eyeball grew Nocardia farcinica.

TREATMENT AND COURSE

Over 3 weeks antimicrobial treatment was given with imipenem and amikacin, followed by oral cotrimoxazole for 12 months. The abscesses completely regressed and after 12 months no recurrence was demonstrated either radiologically or clinically.

CONCLUSION

Although nocardiasis is rare in Germany it must be included in the differential diagnosis of pneumonia with abscesses. This is especially so if acid-fast bacilli are found. As the resistance pattern of N. farcinica to antibiotics varies, early treatment is essential with antibiotics to which it is sensitive.