Experience with eyelid-sparing orbital exenteration: the 2000 Tullos O. Coston Lecture

Review of orbital exenteration from an eye care centre in Western India

PURPOSE

Indications for orbital exenteration performed over a 10-year period from a tertiary eye care center in Western India.

METHOD

Retrospective review of medical records of all patients who underwent exenteration of orbit over a period from January 1999 to April 2009, at a tertiary eye care center in western India.

RESULT

Out of total 236 major orbital surgeries performed, 15 (6%) underwent orbital exenteration. Age ranged from 19 years to 75 years. Of these 9 were male and 6 female. Except for one case all exenteration were for malignant neoplasm. Lesions originated from eyelid in 8 (54%) cases, orbit in 5 (33%) cases and bulbar conjunctiva in 2 (13%) cases. Histopathological classification of the neoplasm were sebaceous carcinoma (4 cases), basal cell carcinoma (3 cases), squamous cell carcinoma (3 cases), adenoid cystic carcinoma (1 case), transitional cell carcinoma (1 case), malignant fibrous histiocytoma (1 case), lymphoma (1 case) and mucormycosis (1 case).

CONCLUSION

Majority of exenterations performed were for neglected ocular or adnexal malignant lesions that could have been avoided provided patients reported earlier for treatment. Exenterations can be reduced by aggressive patient education about eye malignancy.

Orbital exenteration: a 15-year study of 38 cases

PURPOSE

To determine the clinical indications and outcomes after orbital exenteration when histologic margins were reported as "clear," examining factors affecting local and systemic recurrences and mortality.

METHODS

Retrospective case review of exenterations performed in Sydney Eye Hospital in Sydney, Australia, between 1990 and 2004. Reviewed data indications for exenteration, histopathologic diagnosis, and recurrences on follow-up.

RESULTS

Secondary intraorbital spread of malignant adnexal tumors was the most common indication for exenteration (34 of 38). Among these, the site of the primary neoplasm was the eyelid in 19 cases and the ocular surface in 12 cases. Exenteration was total in 26 cases, subtotal in 8 cases, and extended in 4 cases. In 11 cases, a dermis-fat graft was used for socket reconstruction; 24 cases were allowed to granulate spontaneously. The average healing time was 5 months (range, 4-6 months) for spontaneous granulation, and 6 weeks (range, 4-8 weeks) for dermis-fat grafts. Perineural spread was demonstrated histopathologically in 7 specimens. During follow-up (median, 48 months), there were 9 recurrences (23.7%): 3 local and 6 systemic. Seven patients (18.4%) died of the disease during the follow-up period.

CONCLUSIONS

Dermis-fat grafts for reconstruction of the exenterated socket seem to optimize the aesthetic results. The first year is the most important period for follow-up of local recurrences, but systemic examination is needed for the longer follow-up. This may have implications in terms of reconstruction and adjunctive treatment following exenteration surgery.

Selective removal of sebaceous gland carcinoma of the lower eyelid with orbital infiltration

A 74-year-old woman presented with a nodule on the right lower eyelid. An incisional biopsy was significant for sebaceous gland carcinoma, whereas magnetic resonance imaging revealed infiltration of the ipsilateral orbit, including the medial and lower rectus muscles. The lesion was selectively excised, including the infiltrated part of the lower lid and the intraorbital part of the tumor. Two years postoperatively, no recurrence or metastasis have been noted. Preoperative orbital imaging is mandatory in cases of sebaceous gland carcinoma because it can reveal clinically silent orbital invasion. In such cases, selective surgical excision may be used, avoiding orbital exenteration.

Destruction of the orbit and globe by recurrence of basal cell carcinoma

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin malignancy and represents 90% of eyelid malignancies. Of those that occur on the eyelids, most involve the lower lid. Risk factors for BCC include environmental and genetic factors. There are several clinical presentations, the 2 main forms of which are 1) nodular and 2) morpheaform (or sclerosing). Several treatment options exist, including surgical excision, cryotherapy, radiotherapy, laser surgery, chemotherapy, and photodynamic therapy. The average rate of recurrence is 5%, depending on the type of BCC, the size, the location, and therapeutic approach.

CASE REPORT

The patient described in this case report had basal cell carcinoma of the upper right lid 4 to 5 years prior to examination. At that time the patient was treated with surgical excision and radiotherapy. Subsequently, he had not received any eye care since the initial surgery to remove the malignancy. His entering complaint was drainage and an odor emanating from his right eye. The upper lid was retracted and had a lesion suspicious for BCC. The globe was keratinized, inflamed, and proptotic. He was referred to the oculoplastics service to confirm the recurrence of BCC. They found that the BCC had infiltrated the right globe and the retro-orbital region and probably invaded the adjacent bony margins. He had extensive surgery to remove the tumor and subsequent skin grafting.

CONCLUSION

BCC, when treated early, has excellent surgical outcomes. However, there is no procedure that has a zero recurrence rate. BCC, although rarely metastatic, can be invasive. This case underscores the importance of proper follow-up protocol for all surgical patients as well as patient education that reinforces the importance of follow-up care and self-monitoring on the part of the patient.

Orbital exenteration for advanced periorbital skin cancers: 20 years experience

PURPOSE

Orbital exenteration is a disfiguring procedure that results in a significant deformity which poses a reconstructive challenge, especially in elderly patients with significant comorbidities. We reviewed our experience of orbital exenteration.

METHODS

A retrospective analysis was conducted identifying all patients undergoing orbital exenteration over a 20-year period. Patient demographics, tumour characteristics and reconstructive techniques used were recorded.

RESULTS

Thirty-two patients were treated by orbital exenteration. The majority of these were for basal cell carcinomas (53%). Most patients (62.5%) were ASA grade II or more. Reconstructive techniques included split skin grafting (63%), forehead (25%), scalp (6%) and cervicofacial (6%) flaps. Following reconstruction of the exenterated orbit, 29 patients had a prosthesis. Twenty-six of these rated their final result with their definitive prosthesis as good.

CONCLUSIONS

Though there are various options available for reconstruction after orbital exenteration, a split skin graft and orbital prosthesis provide a simple solution for a very difficult problem of advanced periorbital skin cancer in the elderly population with significant comorbidities. The final outcome is comparable to that of more complex flap reconstruction with comparable satisfaction rates.

Orbital exenteration for invasive skin tumours

Orbital exenteration aims at local control of disease invading the orbit that is potentially fatal or relentlessly progressive. Of all exenterations presenting to ophthalmologists, 40-50% are required for tumours in the eyelid or periocular skin. 99% of these are basal cell carcinomas and 4-6% each are squamous cell carcinomas or sebaceous gland carcinomas. Orbital invasion results in progressive fixation of the tumour to bone and reduced ocular motility. Perineural invasion of branches of the trigeminal nerve leads to numbness or pain, and that the facial nerve, to weakness. Biopsy identifies the cell type and the presence of perineural invasion. CT and MRI scanning help in the assessment of tumour spread within the orbit. Management should be in collaboration with an oncologist. Exenteration may be total-the removal of all orbital contents-or lid-sparing if the tumour is placed posteriorly. The socket may be allowed to heal by granulation or lined with a split skin graft or local flap. Complications may be seen following 20-25% of exenterations and include fistulae, tissue necrosis, exposed bone, and infection. Incomplete clearance of tumours occurs in about 38% of total exenterations and 17% of subtotal. The overall 5-year survival is 55-65%, but significantly worse if there was perineural spread. Facial prostheses may be mounted on glasses or secured with tissue glue or osseointegrated implants. Excellent cosmetic results can be achieved but many patients prefer to wear a patch.

Orbital exenteration--a retrospective study over an 11 year period analyzing all cases from a single unit

PURPOSE

A retrospective analysis of all cases of orbital exenteration performed at the National Scottish Ocular Oncology Center over an 11 year period.

METHODS

We sought all exenteration cases (1993-2003) from ocular oncology and oculoplastic databases. Fifteen exenterations were performed. One case record was irretrievable. Clinicopathological features and outcome of 14 patients were analyzed. All operations were performed by the same consultant.

RESULTS

The male to female ratio was 1:1 and the average age at surgery was 66 years. There was a left sided predominance of pathology demonstrated (right to left orbit ratio was 1:1.3. The average follow up period postsurgery was 35 months. The most common underlying diagnosis was malignant melanoma (9/14). Ocular/orbital discomfort was the most frequent presenting symptom (7/14); a mass lesion (10/14) was the most common presenting sign. The average duration of symptoms/signs prior to tertiary institution referral was 10.9 months (range: 0.5-60 months). Exenteration was performed on average 39.7 months (range: 0.13-204) after initial tertiary center presentation. This included patients managed from the outset who failed treatment(s) and then required exenteration. The eyelids were sacrificed in ten cases (10/14). Sockets were lined with eyelid skin (4/10), split skin (thigh) (3/10) or healed secondarily (7/10). Thirteen cases (13/14) had clear histological margins. The average post operative stay was 8.3 days. The most common complication was socket fistula formation (7/14). Ethmoid sinuses were always involved. The average time to fistula development was 4.9 months (sockets lined by skin = 2.2 months compared with sockets left to heal secondarily = 6.9 months). The majority of patients wore occlusive shields long term.

CONCLUSION

The most common pathology necessitating exenteration was malignant melanoma. Most patients presented with a mass lesion. Histological tumor free margins were obtained in thirteen of fourteen cases. The most common complication was socket fistula formation.

Orbital Reconstruction After Eyelid- and Conjunctiva-Sparing Orbital Exenteration

PURPOSE

To describe the technique and results of eyelid- and conjunctiva-sparing orbital exenteration with temporalis transfer and dermis-fat graft.

METHODS

Five patients who underwent this procedure were studied, based on retrospective chart review. Schematic drawings were produced to illustrate the surgical technique.

RESULTS

The study included three female and two male patients with an age range of 7 to 76 years. Two patients required surgery for invasive optic nerve sheath meningioma, one for hemangiopericytoma, and the fourth for mesenchymal chondrosarcoma. The last patient had eyelid-sparing exenteration performed more than 20 years earlier for retinoblastoma and underwent a similar reconstruction. One case was complicated by infection and graft atrophy. The remaining four cases retained orbital volume and eyelid structures with a reasonable cosmetic outcome. Average follow-up period was 21 months, during which one patient had development of intracranial meningioma at the proximal end of the optic canal.

CONCLUSIONS

Eyelid- and conjunctiva-sparing orbital exenteration with temporalis transfer and dermis-fat graft is a useful technique that minimizes the usual deformity and achieves good results. Case selection is emphasized, as this technique is mainly reserved for histopathologically benign orbital lesions that exhibit local aggressive behavior and for malignant lesions only if there is no eyelid, lacrimal gland, or orbital fissure involvement nor significant conjunctival or deep extension of an intraocular tumor.

Neoadjuvant Chemotherapy in the Management of Sebaceous Gland Carcinoma of the Eyelid With Regional Lymph Node Metastasis

A 55-year-old Asian Indian woman who had recurrent sebaceous gland carcinoma of the left lower eyelid with orbital extension and regional lymph node metastasis was treated with neoadjuvant chemotherapy, using a combination of carboplatin and 5-fluorouracil. Eyelid-sparing orbital exenteration was performed after 3 cycles of chemotherapy, followed by radiotherapy to the regional lymph nodes. Subsequently, 3 cycles of adjuvant chemotherapy were administered. Significant eyelid and orbital tumor volume reduction was achieved with neoadjuvant chemotherapy, making eyelid-sparing orbital exenteration possible. Chemotherapy also spared the patient from radical neck dissection. The patient had limited morbidity and was free of local, regional, and systemic disease at 26 months of follow-up.

Choroidal melanoma with massive extrascleral extension in a young black man

The reported incidence of choroidal melanoma is low among the general population and is especially low among blacks. Choroidal melanoma is seen most commonly in whites in the sixth to seventh decades. The tumor is complicated by orbital invasion in only a small percentage of cases. This report describes the case of a 38-year-old black man diagnosed with a choroidal melanoma of the right eye. The tumor exhibited extensive orbital invasion. Primary or metastatic disease elsewhere in the body was ruled out, and the patient underwent an eyelid-sparing orbital exenteration. Histopathologic examination of the orbital specimen confirmed the diagnosis of spindle cell-type choroidal melanoma. Orbital invasion by a primary choroidal melanoma in a black person under the age of 40 is highly unusual. To our knowledge, this represents the youngest reported case of choroidal melanoma with extrascleral extension in a black patient. Ophthalmologists should consider the possibility of this potentially deadly tumor, even in young, black patients.

Sebaceous carcinoma of the ocular region: a review

Sebaceous carcinoma of the ocular region is a malignant neoplasm that is being recognized more frequently and managed by innovative techniques of local resection, cryotherapy, topical chemotherapy, and radiotherapy, resulting in improved visual and systemic prognosis.

Orbital exenteration: one size does not fit all

PURPOSE

To evaluate the clinical indications for orbital exenteration in a tertiary referral center and to compare clinicopathologic correlation and cosmetic outcome with previously reported data.

DESIGN

Retrospective, nonrandomized, consecutive case series.

METHODS

Review of Electronic Medical Record system, Orbital Clinic, Jules Stein Eye Institute, between January 1999 and December 2003. main outcome measures: Surgery type, clear margins histologically, survival, and wearing an eye patch.

RESULTS

Thirty-four patients (mean age 67 years) underwent orbital exenteration; mean follow-up 1.2 +/- 1.5 years (6 months to 6 years). Diagnosis included orbital, ocular, and adnexal malignancies, with squamous and basal cell carcinoma being the most common. Twenty-one patients (62%) underwent total or extended orbital exenteration, and 13 patients (38%) underwent subtotal exenteration including tissue reconstruction. Clear surgical margins were obtained in 23 cases (68%), whereas positive margins were left in 11 cases (32%). Many of the patients preferred an eye patch to cover the surgical region regardless of surgical reconstruction. Only 4 patients (11.8%) who underwent subtotal exenteration with orbital prosthesis did not use a patch. During follow-up period 3 patients expired, only 1 of which was tumor-related.

CONCLUSIONS

Clinical indications for orbital exenteration remain similar over the last four decades with a higher prevalence of squamous cell carcinoma in our institute. Orbital exenteration is considered curative in cases of basal or squamous cell carcinoma but not in cases of malignant infiltrative processes such as adenoid cystic carcinoma of the lacrimal gland. Patients are likely to wear an eye patch regardless of any attempt at surgical reconstruction.

Recent developments in the management of choroidal melanoma

PURPOSE OF REVIEW

To describe recent advances in the management of choroidal melanoma.

RECENT FINDINGS

During the past 10 years, there has been a trend in the management of choroidal melanoma from enucleation to conservative nonenucleation treatments such as thermotherapy, plaque radiotherapy, charged-particle radiotherapy, and local resection. Recently published information regarding conservative management has revealed that plaque radiotherapy combined with thermotherapy offers 97% tumor control, similar to charged-particle radiotherapy. Additionally, patient survival after treatment of medium-size melanoma is similar when comparing plaque radiotherapy versus enucleation. Risk factors identifying small choroidal melanoma include patient symptoms, tumor thickness more than 2 mm, presence of associated subretinal fluid, presence of orange pigment on the tumor surface, and location of the tumor margin at the optic disc. These factors assist in early detection of choroidal melanoma.

SUMMARY

The management of choroidal melanoma continues to improve with earlier detection of tumors and better treatment methods. Local tumor control is excellent with radiotherapeutic methods. Future studies should investigate control of subclinical metastasis.

Pattern of orbital exenteration in a tertiary eye care centre in India

PURPOSE

This study aimed to determine the clinical indications for orbital exenteration, profile of these patients and clinicopathological correlations, and to compare these results with previous published data.

METHODS

A retrospective analysis was conducted of exenterations performed in adults at a tertiary eye care centre in India over a period of 10 years (January 1990 to December 2000). Patient records were reviewed to obtain demographic data, presenting symptoms and their duration, laterality, and clinical and histopathological diagnosis.

RESULTS

A total of 26 cases were identified. Patients ranged in age from 32 to 72 years (mean +/- SD 58.7 +/- 9.23 years). No sex predilection was observed. Classification of cases on histopathological criteria showed that exenterations were performed mostly for squamous cell carcinoma (10 cases), followed by sebaceous gland carcinoma (six cases) and basal cell carcinoma (two cases) of the eyelid. Conjunctival malignant melanoma contributed to 5 of 26 cases of exenteration. Adenoid cystic carcinoma of the lacrimal gland (one case), neurofibroma (one case) and orbital fungal infection (one case) were the other indications of exenteration. The clinicopathological correlation was 100% for squamous cell carcinoma, 100% for basal cell carcinoma, 80% for malignant melanoma and 75% for sebaceous gland carcinoma.

CONCLUSION

Exenteration is mainly performed as a life-saving treatment for advanced malignant tumours with epithelial tumours being the commonest. In comparison to previous published data, the indications of surgery in India differed, as squamous cell carcinoma and sebaceous gland carcinoma were the commonest indications for exenteration.

Tumors of the conjunctiva and cornea

Tumors of the conjunctiva and cornea comprise a large and varied spectrum of conditions. These tumors are grouped into two major categories of congenital and acquired lesions. The acquired lesions are further subdivided based on origin of the mass into surface epithelial, melanocytic, vascular, fibrous, neural, histiocytic, myxoid, myogenic, lipomatous, lymphoid, leukemic, metastatic and secondary tumors. Melanocytic lesions include nevus, racial melanosis, primary acquired melanosis, melanoma, and other ocular surface conditions like ocular melanocytosis and secondary pigmentary deposition. The most frequent nonmelanocytic neoplastic lesions include squamous cell carcinoma and lymphoma, both of which have typical features appreciated on clinical examination. The caruncle displays a slightly different array of tumors compared to those elsewhere on the conjunctiva, as nevus and papilloma are most common, but oncocytoma and sebaceous gland hyperplasia, adenoma, and carcinoma can be found. In this report, we provide clinical description and illustration of the many conjunctival and corneal tumors and we discuss tumor management.