Survey of 1264 patients with orbital tumors and simulating lesions

Orbital schwannoma arising within inferior rectus muscle: A rare orbital tumor

Purpose

To report a rare orbital schwannoma arising within inferior rectus muscle in a young woman.

Observations

In this case report, we describe a young patient with slowly progressive proptosis for one year. Preoperative imaging was suggestive of a benign tumor arising within inferior rectus muscle, and histopathologic evaluation revealed an orbital schwannoma with cystic degeneration.

Conclusion and importance

This case report highlights the importance of including schwannoma in the differential diagnosis of any orbital tumor arising within muscle.

Non-Surgical Management of Recurrent Naso-Orbital Hemangiomas with Bevacizumab: A Case Report

In this case report, we describe a 21-year-old man with recurrent hemangiomas in his left eye socket and nasal cavity. Traditional surgeries were unsuccessful, so we used Bevacizumab, a drug that inhibits blood vessel growth. This approach significantly reduced the tumor size and stopped frequent nosebleeds. Over two years, the tumor remained controlled without major side effects, suggesting Bevacizumab as a promising non-surgical treatment for recurrent hemangiomas.

Image-guided navigation in posterior orbital tumour surgery: a comparative cohort study

PURPOSE

The posterior orbit is a confined space, harbouring neurovascular structures, frequently distorted by tumours. Image-guided navigation (IGN) has the potential to allow accurate localisation of these lesions and structures, reducing collateral damage whilst achieving surgical objectives.

METHODS

We assessed the feasibility, effectiveness and safety of using an electromagnetic IGN for posterior orbital tumour surgery via a comparative cohort study. Outcomes from cases performed with IGN were compared with a retrospective cohort of similar cases performed without IGN, presenting a descriptive and statistical comparative analysis.

RESULTS

Both groups were similar in mean age, gender and tumour characteristics. IGN set-up and registration were consistently achieved without significant workflow disruption. In the IGN group, fewer lateral orbitotomies (6.7% IGN, 46% non-IGN), and more transcutaneous lid and transconjunctival incisions (93% IGN, 53% non-IGN) were performed (p = .009). The surgical objective was achieved in 100% of IGN cases, with no need for revision surgery (vs 23% revision surgery in non-IGN, p = .005). There was no statistically significant difference in surgical complications.

CONCLUSION

The use of IGN was feasible and integrated into the orbital surgery workflow to achieve surgical objectives more consistently and allowed the use of minimal access approaches. Future multicentre comparative studies are needed to explore the potential of this technology further.

Toward Precision Diagnosis: Machine Learning in Identifying Malignant Orbital Tumors With Multiparametric 3 T MRI

BACKGROUND

Orbital tumors present a diagnostic challenge due to their varied locations and histopathological differences. Although recent advancements in imaging have improved diagnosis, classification remains a challenge. The integration of artificial intelligence in radiology and ophthalmology has demonstrated promising outcomes.

PURPOSE

This study aimed to evaluate the performance of machine learning models in accurately distinguishing malignant orbital tumors from benign ones using multiparametric 3 T magnetic resonance imaging (MRI) data.

MATERIALS AND METHODS

In this single-center prospective study, patients with orbital masses underwent presurgery 3 T MRI scans between December 2015 and May 2021. The MRI protocol comprised multiparametric imaging including dynamic contrast-enhanced (DCE), diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), as well as morphological imaging acquisitions. A repeated nested cross-validation strategy using random forest classifiers was used for model training and evaluation, considering 8 combinations of explanatory features. Shapley additive explanations (SHAP) values were used to assess feature contributions, and the model performance was evaluated using multiple metrics.

RESULTS

One hundred thirteen patients were analyzed (57/113 [50.4%] were women; average age was 51.5 ± 17.5 years, range: 19-88 years). Among the 8 combinations of explanatory features assessed, the performance on predicting malignancy when using the most comprehensive model, which is the most exhaustive one incorporating all 46 explanatory features-including morphology, DWI, DCE, and IVIM, achieved an area under the curve of 0.9 [0.73-0.99]. When using the streamlined "10-feature signature" model, performance reached an area under the curve of 0.88 [0.71-0.99]. Random forest feature importance graphs measured by the mean of SHAP values pinpointed the 10 most impactful features, which comprised 3 quantitative IVIM features, 4 quantitative DCE features, 1 quantitative DWI feature, 1 qualitative DWI feature, and age.

CONCLUSIONS

Our findings demonstrate that a machine learning approach, integrating multiparametric MRI data such as DCE, DWI, IVIM, and morphological imaging, offers high-performing models for differentiating malignant from benign orbital tumors. The streamlined 10-feature signature, with a performance close to the comprehensive model, may be more suitable for clinical application.

An Evidence-Based Approach to Diagnosing Patients Presenting With Orbital Inflammatory Syndromes (An American Ophthalmological Society Thesis)

PURPOSE

The initial management of patients presenting with orbital inflammatory syndromes varies-with some pursuing a diagnostic workup while others treat without any testing. The evidence behind this rationale is limited. A review of patients with orbital inflammation is performed with an analysis of diagnostic testing to develop a workflow for such patients.

DESIGN

A retrospective review of patients presenting with acute orbital inflammation at a single institution from 2011 to 2020 was conducted.

METHODS

Orbital imaging was required for inclusion. Patients with high suspicion of neoplasm, bacterial infection, vascular malformation, or thyroid eye disease were excluded. A review of presenting clinical findings, laboratory workup, orbital imaging, and biopsy were performed. Statistical analysis was performed identifying statistically significant diagnostic and treatment maneuvers.

RESULTS

In total, 172 patients met inclusion criteria (66% female, mean age 46 years). The primary clinical presentation was myositis, dacryoadenitis, and infiltrative in 67, 73, and 32 patients (39.0%, 43.0%, 18.6%, respectively). Laboratory studies were conducted in 145 (84%) while biopsy was performed in 55 (32%). Specific orbital inflammation (SOI) was diagnosed in 29 (16.9%) with the most frequent diagnoses being sarcoidosis, IgG4-related disease, inflammatory bowel disease, and systemic lupus erythematosus. The majority (147, 85.5%) was initially treated with steroids, but steroid-sparing agent use was statistically higher in patients with SOI.

CONCLUSIONS

In patients presenting with orbital inflammatory syndromes, distinguishing myositis, dacryoadenitis, and infiltrative disease has workup and differential diagnosis impacts. Because SOI is relatively common, sequelae of SOI, and potential steroid-sparing therapy needs, diagnosis via an evidence-based systemic approach is critical. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Orbital Myeloma and Plasmacytoma: An Australian Study

PURPOSE

The purpose of this study was to provide Australian data on the clinical and radiological features and outcomes in patients with orbital plasmacytomas.

METHODS

Multicentre retrospective review of orbital plasmacytoma and orbital involvement in multiple myeloma (MM) from 2005 to 2022 in Australia.

RESULTS

Twenty-one participants were identified. The median age was 62 years (range 34-88 years), and 11 (52%) were females. Eighteen (84%) had a known diagnosis of MM prior to their orbital presentation, with all patients eventually being diagnosed with systemic MM. Thirteen (72%) were receiving active treatment for systemic myeloma on presentation, while 3 (17%) were in remission. All but 1 had unilateral orbital involvement (n = 20, 95%). Common presenting symptoms and signs were decreased visual acuity (n = 13, 62%), proptosis (n = 11, 52%), limited motility (n = 15, 71%), and optic neuropathy (n = 5, 24%). Radiologically, 15 (71%) involved the superotemporal orbit, 7 (33%) inferotemporal orbit, and 16 (76%) involved ≥1 extraocular muscle. Sixteen (76%) were biopsied and confirmed orbital plasmacytoma on histopathology. Treatment modalities included intravenous and oral steroids (n = 7, 33%), chemotherapy (n = 9, 43%), radiotherapy (n = 13, 62%), stem cell transplant (n = 3, 14%), and surgical debulking and decompression (n = 3, 14%). Mortality was high, with 15 (71%) having MM-related mortality.

CONCLUSIONS

This is the largest cohort of Australian data on orbital plasmacytomas. Most patients have a diagnosis of systemic MM at presentation. It is crucial to recognize and treat these patients early due to a poor systemic prognosis.

Population-Based Incidence and Clinical Characteristics of Ocular Adnexal Tumors in Olmsted County, Minnesota

PURPOSE

To determine the incidence and clinical characteristics of ocular adnexaltumors in Olmsted County, Minnesota.

METHODS

Retrospective population-based cohort study of all patients residing in Olmsted County, Minnesota diagnosed with any ocular tumor from January 1, 2006, to December 31, 2015. The medical records of all patients with an incident diagnosis of any ocular adnexal tumor were reviewed using the Rochester Epidemiology Project medical record linkage system for patient demographics, tumor type, and histopathologic confirmation. Incidence rates were calculated per 100,000 person-years. Poisson regression analysis was used to analyze changes in incidence over time.

RESULTS

There were 717 patients diagnosed with ocular adnexal tumors during the 10-year study period, yielding an age- and sex-adjusted incidence rate of 59.7 per 100,000 (95% CI 55.4 to 64.0, p < 0.05) per year. In total, 764 tumors were diagnosed. Most tumors were eyelid lesions (N = 756, 99.0%), which were mostly benign (N = 512, 67.8%) with epidermal inclusion cysts (N = 275, 36.0%), hidrocystoma (N = 70, 9.2%), and eyelid sebaceous cysts (N = 46, 6.1%) accounting for the majority. Malignant eyelid lesions (N = 244, 31.9%) were relatively common with basal cell carcinoma (N = 184, 24.1%) and squamous cell carcinoma (N = 49, 6.4%) having the highest frequencies. Orbital tumors (N = 8, 1.0%) were infrequent. Of the orbital tumors, the most common was lacrimal gland adenoidcystic carcinoma (N = 2, 25.0%).

CONCLUSIONS

In a population-based setting, most ocular adnexal tumors were benign eyelid lesions. Understanding the epidemiology of ocular adnexal tumors is important to aid providers in diagnosing and facilitating appropriate referrals of potentially vision- and life-threatening malignancies.

The utility of orbital imaging in the evaluation of orbital disease

PURPOSE

This study investigates the accuracy of either computerized tomography (CT) or magnetic resonance imaging (MRI) for the evaluation of various orbital diseases.

METHODS

We collected 126 CT scans and 65 MRI scans from 144 subjects and asked two radiologists to interpret the images without clinical information. Images included 14 with a clinical diagnosis of orbital infection, 144 with orbital inflammation, and 33 with orbital neoplasm. The inflammatory diseases included thyroid eye disease (TED, n = 69), non-specific orbital inflammation (NSOI, n = 44), IgG4-related disease (IgG4-RD, n = 15), sarcoidosis (Sarcoid, n = 9), granulomatosis with polyangiitis (GPA, n = 5), and Erdheim-Chester disease (ECD, n = 2).

RESULTS

The balanced accuracy (BA) for the two radiologists ranged from 0.87 to 0.90 for cellulitis, 0.81 to 0.86 for inflammation, and 0.82 to 0.85 for neoplasm. Radiologists were excellent at recognizing GPA (BA = 0.98 to 0.99) and very good for TED (BA = 0.80 to 0.86). They also did well identifying IgG4-RD (BA = 0.75 to 0.77), but slightly less well for NSOI (BA = 0.69 to 0.75) and poorly for Sarcoid (BA = 0.48 to 0.50).

CONCLUSIONS

CT or MRI scanning contributes to the evaluation of patients with orbital disease, but accuracy does varies based depending on the diagnosis. We could not evaluate issues such as determination of disease activity, variability based on the unit used for imaging or the skills beyond those of our two specialized neuroradiologists. Future studies should directly compare the two imaging modalities and assess the utility of imaging to determine disease activity.

Intraosseous venous malformation of the frontal bone with extension into the frontal sinus and orbit

We present a novel case of intraosseous venous malformation of the frontal bone with dehiscence of the inner table of the frontal calvarium and extension into the frontal sinus and orbit. This case report discusses the surgical management of this intraosseous lesion achieved with a multidisciplinary approach involving otolaryngology and neurosurgical teams. We also present a review of the literature of the pathophysiology of venous malformations, the imaging modalities that aid in diagnosis of these lesions and the management options.

Global incidence and prevalence of malignant orbital tumors

Purpose

Aims to provide an overview of the contemporary epidemiology of malignant orbital tumors by analyzing population-based incidence patterns across various regions worldwide.

Methods

In this article, we retrieved orbital malignancy data from the MEDLINE database and analyzed the incidence and prevalence of orbital malignancies worldwide. We performed the literature search by searching on the Mesh terms for malignant orbital tumors ("orbital", "tumor", "lymphoma", "malignant", "cancer", "incidence", and "epidemiology"). All included studies were published between 1993 and 2023 and were written in English.

Results

Ocular or ophthalmic lymphoma most frequently occurred in the orbit, with a prevalence ranging from 47% to 54%. The incidence of malignant orbital tumors was increasing in the USA (2.0 per million (1981-1993), Netherlands (0.86 (1981-1985) to 2.49 (2001-2005) per million) and South Korea (0.3-0.8 per million (1999-2016)), respectively. Ophthalmic lymphoma which includes orbit lymphoma was increasing in Canada (0.17-1.47 per million (1992-2010)), Denmark (0.86 per million (1981-1985) to 2.49 per million (2001-2005)), respectively.

Conclusions

The predominant primary malignant orbital tumor in adults was lymphoma. Ocular or ophthalmic lymphoma most frequently occured in the orbit. The limited data available suggested an increasing trend in the incidence of malignant orbital tumors in each country included, which were mainly attributed to the increase in lymphoma. Generally, incidence rates were found to increase with advancing age, with no difference between males and females.

From Breast to Orbit: A Case Report of Metastatic Breast Cancer With Orbital Involvement

The approach to manage breast cancer has undergone a significant transformation, leading to longer survival rates. However, there is still a rise in metastasis occurring in less common locations such as the orbit. We report the case of a 40-year-old female diagnosed with luminal A, left-side breast cancer, back in September 2020. She presented with de novo metastatic diseases to the liver, bone, lung, and orbit. She received palliative radiation therapy (RT) to the orbit at the dose of 25 Gray (Gy) in five fractions, and follow-up brain magnetic resonance imaging (MRI) indicated a positive response to treatment with a slight reduction in the size of the left infraorbital lesion. Systemic treatment was started with hormonal therapy fulvestrant and luteinizing hormone-releasing hormone (LHRH), leuprolide, accompanied by palbociclib. As the incidence of ocular metastasis from breast cancer increases, oncologists need to be vigilant about symptoms and use appropriate diagnostic techniques.

A minimally invasive, combined approach to the recurrent/recalcitrant sino-orbital mucocele

PURPOSE

To evaluate the results of a minimally invasive combined endoscopic and eyelid crease/medial suprabrow incision approach in collaboration with oculoplastic and sinus surgeons for the treatment of recurrent/recalcitrant sino-orbital mucoceles.

METHODS

Eighteen cases of recurrent/recalcitrant sino-orbital mucoceles, treated in collaboration with oculoplastic and sinus surgeons at the University of Michigan, were retrospectively reviewed. The recurrence of mucocele, reduction in proptosis, and complications were evaluated.

RESULTS

The mean age at the time of surgery was 49 years (range: 17-76 years). All cases had a history of previous sinus or orbital surgeries for mucoceles. Among 18 cases, eight were due to chronic sinus infections, six due to trauma, three due to Schneiderian papilloma, and one case was secondary to an inflammatory sinus disease. Thirteen cases (72%) presented with orbital or facial cellulitis, while five cases (38%) experienced periocular swelling and limited extraocular motility. Following a mean follow-up of 19 months (range: 1-76 months)), recurrence was observed in two cases (11%): one in a cystic fibrosis patient with chronic sinusitis, and the other in a case of Schneiderian papilloma. The mean pre-operative proptosis in the affected eye was 2.78 mm, with an average decrease of 2.33 mm after surgery. Complications occurred in two cases, including one case of hypoesthesia in the forehead and one case of post-operative strabismus.

CONCLUSION

Our series of 18 cases of recurrent/recalcitrant mucoceles, with only two cases of recurrence, demonstrates that this minimally invasive approach can be successfully employed for advanced sino-orbital disease, with a low rate of adverse outcomes and aesthetically pleasing results.

Rare Case of Non-Keratinizing Squamous Cell Carcinoma in the Lacrimal Sac Treated with Surgery

Background and Objectives: The objective of this study was to present a rare case of non-keratinizing squamous cell carcinoma (SCC) of the lacrimal sac (LS). Neoplasms of the lacrimal drainage system are extremely rare. These lesions are predominantly malignant and are associated with a high mortality rate. Case Presentation: A 51-year-old woman was referred to an ophthalmologist with a history of unilateral epiphora, presbyopia, and abnormal eye discharge. Antibiotic therapy was applied and modified later due to persisting symptoms. After five months, edema of the medial left eye angle occurred. A lacrimal sac incision was performed, and a subsequent magnetic resonance imaging (MRI) scan revealed a 2 cm, contrast-enhanced solid tumor. The patient was qualified for dacryocystectomy, which was conducted by the otolaryngology department. Postoperative histopathologic findings indicated the presence of non-keratinizing SCC. During a reoperation, margins were extended, and the surgery was found to be radical. Following the reoperation, no alarming symptoms were observed. However, a follow-up MRI and positron emission tomography (PET) scan six weeks later revealed metastases. Further treatment is being planned. Conclusions: LS tumors are life-threatening conditions that are challenging to diagnose at an early stage. Surgical excision is the preferred treatment option. Imaging studies play an important role in post-operative follow-up because of the possibility of recurrence and metastasis, even after radical surgery.

Analyzing histopathological aspects and cell populations in orbital inflammatory involvement in systemic diseases: A case series from the Rheumatologist’s perspective

Orbital inflammatory disease (OID) comprises approximately 6% of orbital conditions, affecting individuals across all ages. The range of the primary orbital inflammation’s differential diagnosis is extensive, encompassing autoimmune disorders such as thyroid diseases, vasculitis, sarcoidosis, connective tissue diseases, immunoglobulin G4-related disease (IgG4-RD), and giant cell myositis, whereas secondary causes span from infections to drug-induced causes. Analyzing histopathological aspects and cell populations could enhance our comprehension of the etiology of orbital inflammatory involvement in systemic diseases such as IgG4-RD. We present a series of four patients from our Rheumatology clinic, each with distinct systemic diseases, illustrating diverse manifestations of OID. This series was conducted to facilitate discussions and diagnoses of challenging cases of OID in a rheumatologic setting. The difficulty in the differential diagnosis arises from the extensive range of structures involved, resulting in a significant variation of clinical manifestations. Furthermore, the lack of definitive diagnostic laboratory tests and, often, histological findings add to the complexity. OID poses diagnostic challenges with variable clinical manifestations and overlapping imaging findings. As a diagnosis of exclusion, a comprehensive evaluation is crucial, often necessitating an orbital biopsy for confirmation. Collaborative efforts among specialists are essential for managing these intricate cases.

Clinical features and treatment outcomes of intraocular and ocular adnexal metastasis

The aim of this study was to investigate the primary sites, clinical characteristics, and treatment outcomes of patients with metastatic tumors in the eye and ocular adnexa. This retrospective case series consisted of 42 patients diagnosed with intraocular metastasis (IM) or ocular adnexal metastasis (OAM) at a tertiary center between January 2001 and June 2023. The patients comprised 18 men and 24 women; 24 (57%) and 18 (43%) patients were diagnosed with IM and OAM, respectively. In the IM group, the primary tumors originated from the lungs (79%), followed by the breasts (17%). In the OAM group, the primary tumors originated from the breasts (33%). Previously, 57% of the patients had been diagnosed with cancer. In the IM group, 38% exhibited bilateral involvement. Only 6% of the patients with OAM had bilateral diseases. The 1-, 3-, and 5-year overall survival (OS) was 42%, 18%, and 7%, respectively. The median OS since metastasis diagnosis in the lungs and breast was 11.8 and 10.5 months, respectively. Lung cancer remains the predominant primary cancer in IM, whereas breast cancer is the major cancer in OAM. Despite poor OS, early detection will facilitate the prompt treatment of primary cancer and metastatic sites.

Radiologic Features of Well-circumscribed Orbital Tumors With Histopathologic Correlation: A Multi-center Study

PURPOSE

To delineate specific imaging characteristics of solitary fibrous tumors, schwannomas, cavernous venous malformations, and well-circumscribed orbital lymphoma.

METHODS

Patients undergoing excisional biopsy of solitary fibrous tumor, schwannomas, cavernous venous malformations, or well-circumscribed orbital lymphoma with preoperative MRIs available for review were identified at 3 academic centers in the United States and Australia. An exploratory statistical analysis was performed to identify important radiologic features, which were subsequently included in a random forest model. Histopathologic correlates were evaluated in representative cases.

RESULTS

A total of 91 cases were included with a mean age of 52.9 ± 17.2 years. Nearly all solitary fibrous tumors were located in the anterior or mid orbit (87.5%) and they more commonly demonstrated intralesional heterogeneity on T2-weighted imaging (45.5%) ( p < 0.01). Compared with the other tumors, schwannomas tended to be intraconal (66.7%) and were often in the mid or posterior orbit (83.4%) ( p < 0.01). Cavernous venous malformations characteristically demonstrated progressive contrast enhancement (93.9%; p < 0.01). Most lesions in all 4 groups were hypointense on T1-weighted imaging (80%-100%; p = 0.14) and only well-circumscribed orbital lymphoma tended to also be hypointense on T2 (81.8%) ( p < 0.01). Finally, cases of lymphoma had significantly lower apparent diffusion coefficient ratios (0.9 ± 0.2) ( p < 0.001), while the other 3 groups were not significantly different from one another (cavernous venous malformations: 1.8 ± 0.4; schwannomas: 1.8 ± 0.5; and solitary fibrous tumor: 1.6 ± 0.6) ( p = 0.739).

CONCLUSIONS

Key features that aid in the differentiation of these 4 tumors from one another include T2 intensity and homogeneity, early contrast-enhancement pattern, and ADC ratio.

A CASE OF HERPES SIMPLEX VIRUS AND CYTOMEGALOVIRUS RETINITIS COINFECTION

PURPOSE

The purpose of this study was to describe a case of a 64-year-old man presenting with cytomegalovirus and herpes simplex virus retinitis coinfection in the setting of Burkitt lymphoma.

METHODS

A case report including multimodal imaging and anterior chamber polymerase chain reaction results was used.

RESULTS

This case highlights the importance of the clinical examination and maintaining high diagnostic suspicion for viral retinitis in immunocompromised patients.

CONCLUSION

Aqueous fluid PCR can be a useful adjunctive test to distinguish and confirm a diagnosis of viral retinitis. Given the limited sample volume of aqueous biopsy, it is important to prioritize the order of PCR testing based on clinical suspicion of the causative agent.

Primary orbital sarcoma in adults: a case series with emphasis on post-irradiation sarcoma

PURPOSE

To describe a series of eight adult patients with primary orbital sarcoma and to review the existing literature on orbital sarcoma and post-irradiation sarcoma.

METHODS

Report of eight cases and literature review.

RESULTS

We report eight cases of primary orbital sarcoma, three of which were radiation-induced. Only one patient had a history of retinoblastoma. The most common presentations were painful proptosis and reduced vision. Most tumours arose in the extraconal compartment. The overall median age at diagnosis was 50 years. The pathology comprised a diverse group of tumours. Treatment and outcome varied between patients and their clinical circumstances.

CONCLUSIONS

Adult primary orbital sarcomas are rare. They can comprise a variety of tumour types and are difficult to treat. Irradiation is a significant risk factor, and the incidence of post-irradiation sarcoma of the orbit may be increasing due to the widespread use of radiotherapy and improved survival of patients with cancer. Post-irradiation sarcoma should be considered in the differential diagnosis of an orbital space-occupying lesion in a patient with a history of radiotherapy.

Ocular and Periocular Metastasis in Breast Cancer: Clinical Characteristics, Prognostic Factors and Treatment Outcome

BACKGROUND

Breast cancer remains a leading cause of cancer-related mortality and morbidity worldwide. Ocular and periocular metastasis present as a rare but clinically significant manifestation. This study aims to explore demographics and clinical aspects of ocular and periocular metastasis in breast cancer patients.

METHODS

A retrospective cohort study comprising 45 breast cancer patients with ocular or periocular metastasis treated between 2013 and 2023. Patient demographics, tumor characteristics, diagnostic methods, treatment modalities, visual outcomes, and survival data were analyzed.

RESULTS

Among 9902 breast cancer patients, 0.5% developed ocular or periocular metastasis, constituting 2.4% of metastatic cases. The median age was 50 years. Ocular metastasis timing varied: 5% before breast cancer, 24% concurrent, 22% within a year, and 49% after. The most common presentations included incidental MRI findings (42%) and vision decline (31%). Metastasis involved the orbit (47%), choroid (40%), optic nerve (11%), and iris (2%), with 44% having bilateral involvement. Predictive factors included invasive lobular carcinoma (ILC) (p < 0.0001) and brain metastasis (p < 0.0001), with ILC exhibiting a sixfold higher likelihood of ocular metastasis than invasive ductal carcinoma (IDC). Primary treatment was radiation therapy (89%), yielding a 55% maintenance of excellent vision (<0.5), with 93% developing dry eye disease. Patients with ocular metastasis faced an increased risk of disease-related mortality (p < 0.0001), with 71% succumbing within 10 months post-diagnosis.

CONCLUSIONS

Ocular metastasis in breast cancer is rare (0.5%) but signifies poor outcome. It is linked to ILC and concurrent brain metastasis. Primary treatment involves radiation therapy, with a favorable visual prognosis.

The role of surgical factors eliciting oculocardiac reflex of patients undergoing orbital tumor surgery: a retrospective study

PURPOSE

Orbital tumors are an interdisciplinary disease, and surgery is one of the main treatment methods. The oculocardiac reflex (OCR) is a condition of surgery for orbital tumors. The aim of this study was to investigate whether there is an association between many surgical factors and the incidence of OCR in orbital tumor surgery.

METHODS

Comparisons were made between patients with and without OCR using the Mann-Whitney test, Fisher's exact test, and Chi-square test. When comparing multiple groups (groups > 2), to explain which two groups had differences, post hoc testing was used for analysis, and the differences between groups were judged according to the adjusted standardized residuals.

RESULTS

The results showed that the incidence of intraoperative OCR was different based on the different exposed operative field locations (p = 0.021). The OCR incidence in those with lesions involving the orbital apex and lesions adhering to extraocular muscles was higher than that of others (p < 0.001 and p = 0.003). In addition, multivariate logistic regression analysis revealed that orbital apex involvement and extraocular muscle adhesion were highly associated with a higher incidence of OCR (p < 0.001 and p = 0.013), while the operative field located in the lateral-superior orbit was highly associated with a lower incidence of OCR (p = 0.029).

CONCLUSION

In orbital tumor surgery under general anesthesia, lesions involving the orbital apex and lesion adhesion to the extraocular muscles were independent risk factors for OCR, and an operative field located in the lateral-superior orbit was a protective factor for OCR.

Recurrence rate of pleomorphic adenoma of the lacrimal gland: systematic review and meta-analysis

PURPOSE

The aim is to increase the understanding of lacrimal gland pleomorphic adenoma's recurrence rate and the factors that influence it.

METHODS

A systematic search of PubMed, SCOPUS, Cochrane Library, and CINAHL was conducted following PRISMA guidelines. The data in the included studies were extracted and analyzed.

RESULTS

Twenty-two studies were included representing 963 patients from 12 different countries. The pooled analysis of the recurrence rate was 8.83% (95% CI: 5.08-13.50). In the event of recurrence, there was a 75.17% (95% CI: 65.98-82.94) chance of benign recurrence and a 28.35% (95% CI: 19.66-38.41) chance of malignant recurrences, with malignant recurrence occurring almost exclusively after a benign recurrence. The results showed that 47.09% (95% CI: 24.60 to 70.22) of recurrent tumors had a ruptured pseudocapsule and 6.35% (95% CI: 0.82 to 16.54) had an intact pseudocapsule with a significant difference between the two. Of the recurrent tumors, 51.50% (95% CI: 9.28 to 92.39) were biopsied compared to 8.83% (95% CI: 3.40 to 16.49) of the total; the difference between these two proportions was also found to be significant.

CONCLUSION

There was a statistically significant difference in the rates of recurrence between tumors that were either biopsied or had a ruptured pseudocapsule compared to those that did not. This evidence adds additional support for excisional biopsy being the procedure of choice for LGPA and reinforces the importance of keeping the pseudocapsule intact during surgical resection.

Diagnostic Performance of Dynamic Contrast-Enhanced 3T MR Imaging for Characterization of Orbital Lesions: Validation in a Large Prospective Study

BACKGROUND AND PURPOSE

Orbital lesions are rare but serious. Their characterization remains challenging. Diagnosis is based on biopsy or surgery, which implies functional risks. It is necessary to develop noninvasive diagnostic tools. The goal of this study was to evaluate the diagnostic performance of dynamic contrast-enhanced MR imaging at 3T when distinguishing malignant from benign orbital tumors on a large prospective cohort.

MATERIALS AND METHODS

This institutional review board-approved prospective single-center study enrolled participants presenting with an orbital lesion undergoing a 3T MR imaging before surgery from December 2015 to May 2021. Morphologic, diffusion-weighted, and dynamic contrast-enhanced MR images were assessed by 2 readers blinded to all data. Univariable and multivariable analyses were performed. To assess diagnostic performance, we used the following metrics: area under the curve, sensitivity, and specificity. Histologic analysis, obtained through biopsy or surgery, served as the criterion standard for determining the benign or malignant status of the tumor.

RESULTS

One hundred thirty-one subjects (66/131 [50%] women and 65/131 [50%] men; mean age, 52 [SD, 17.1] years; range, 19-88 years) were enrolled. Ninety of 131 (69%) had a benign lesion, and 41/131 (31%) had a malignant lesion. Univariable analysis showed a higher median of transfer constant from blood plasma to the interstitial environment (K trans) and of transfer constant from the interstitial environment to the blood plasma (minute-1) (Kep) and a higher interquartile range of K trans in malignant-versus-benign lesions (1.1 minute-1 versus 0.65 minute-1, P = .03; 2.1 minute-1 versus 1.1 minute-1, P = .01; 0.81 minute-1 versus 0.65 minute-1, P = .009, respectively). The best-performing multivariable model in distinguishing malignant-versus-benign lesions included parameters from dynamic contrast-enhanced imaging, ADC, and morphology and reached an area under the curve of 0.81 (95% CI, 0.67-0.96), a sensitivity of 0.82 (95% CI, 0.55-1), and a specificity of 0.81 (95% CI, 0.65-0.96).

CONCLUSIONS

Dynamic contrast-enhanced MR imaging at 3T appears valuable when characterizing orbital lesions and provides complementary information to morphologic imaging and DWI.

[Orbital tumors]

Orbital tumours include a variety of orbital diseases of different origins. In the case of malignant orbital tumours, early detection is important so that treatment can be initiated promptly. Neuroradiological imaging, in particular magnetic resonance imaging (MRI), plays an important role in the diagnostic of orbital tumours. In adults, lymphoproliferative diseases, inflammations and secondary orbital tumours are most frequently found, whereas in children mostly dermoid cysts, optic gliomas and capillary haemangiomas are found. Optic glioma is a pilocytic astrocytoma and accounts for two thirds of all primary optic tumours. Optic nerve sheath meningiomas mostly affect middle-aged women. In childhood, retinoblastoma is the most common intraocular tumour. This is an aggressive malignant tumour which can occur unilaterally or bilaterally. Based on the imaging findings, differential diagnoses can usually be easily narrowed down using criteria such as age of manifestation, frequency, localisation and imaging characteristics.

Transorbital and endonasal resection of a rare orbital ectopic atypical meningioma

A female patient in her early 20s presented with increasing proptosis of her left eye over 2 months. She had no other signs of diplopia, pain or visual loss on initial presentation. Subsequent imaging of her orbits revealed a medial rectus tumour. A transorbital open biopsy of this tumour was non-diagnostic/inconclusive, hence a combined transorbital and endonasal resection of this tumour was performed. Histopathology of the resected tumour revealed an unusual inflammatory-rich spindle cell neoplasm, which was determined to be a primary orbital ectopic atypical meningioma. These tumours are exceedingly rare, with only case reports/series reported in the literature. Complete surgical resection with margins is the proposed treatment. The role of radiotherapy is still controversial. More studies are required to improve our knowledge of this condition.

Clinical and Imaging Characteristics of Metastatic Orbital Tumours in North China

Purpose

This study was designed to review the primary sites, clinical manifestations, imaging features, treatments, and outcomes of 36 patients with orbital metastasis in North China.

Methods

This was a retrospective review of 36 patients with orbital metastasis at Tianjin Eye Hospital between January 2010 and December 2020 in North China as well as a review of the literature.

Results

Thirty-six patients were included in the study; 17 were male, and 19 were female, with an age range of 1-82 years (average 54.9 ± 19.8 years). All the tumours were unilateral. The mean duration from the onset of orbital signs to presentation at the hospital was 2.4 months (range 1-10 months). Breast carcinoma, gastrointestinal tract carcinoma, and lung carcinoma were the most common histological types. Proptosis, ocular pain, and diplopia were the most common clinical manifestations. The superior orbit was the most common quadrant involved. All patients received comprehensive therapy, including surgery, radiotherapy, or chemotherapy. The average follow-up time was 2.45 years (range 7 months to 5.5 years). Ten patients in this study died as a result of disseminated metastasis from the primary tumour.

Conclusions

In North China, the most common primary cancer that metastasizes to the orbit is breast cancer, followed by gastrointestinal tract carcinoma and lung cancer. The increasing trend of orbital gastrointestinal tract metastases in North China in recent years is noteworthy. The survival rate of patients with orbital metastasis of neuroblastoma is low.

Bilateral enlargement of all extraocular muscles: a presenting ophthalmic sign of hematologic malignancy

Hematologic malignancies such as leukemia and lymphoma can frequently present in the orbit; however, involvement of the extraocular muscles is rare. The authors report two cases of systemic hematologic malignancy presenting with bilateral extraocular muscle enlargement and associated compressive optic neuropathy (CON). Both patients experienced clinical and radiographic improvement of ocular and systemic manifestations of disease with prompt initiation of targeted chemotherapy. These cases highlight the importance of including hematologic malignancy in the differential diagnosis of atypical bilateral extraocular muscle enlargement.

Clinical spectrum and clinicopathological correlation of pediatric orbital tumors: 20 years' experience from a tertiary eye care center

PURPOSE

To study the epidemiological profile of various pediatric orbital tumors and determine their clinicopathological correlation over 20 years.

METHODS

A retrospective analysis of all pediatric patients with orbital tumors from the medical records between 1995 and 2015 was done. Tumors were categorized based on their cellular origin. Demographic details, clinical and histopathological diagnoses, frequency, and clinicopathological correlation were studied.

RESULTS

A total of 265 pediatric patients with orbital tumors were analyzed, of which 145 (54.7%) patients were males and 120 (45.3%) were females. The mean age was 7 years (median: 6 years; range: 10 days-16 years). The distribution of lesions in each group was as follows: vasculogenic, 76 (28.7%); lipogenic and myxoid, 66 (25%); myogenic, 31 (11.7%); optic nerve and meningeal, 22 (8.3%); lymphoid and lymphoproliferative, 18 (6.8%); secondary orbital tumors, 14 (5.2%); histiocytic, 9 (3.4%); miscellaneous, 9 (3.4%), lacrimal gland, 8 (3%); mesenchymal with neural differentiation, 6 (2%); osseous, 4 (1.5%), and fibrocystic, 2 (0.8%). The most common benign and malignant pediatric orbital tumors were dermoid cysts (65, 24.5%) and rhabdomyosarcoma (31, 11.7%). A statistically significant ( P < 0.0001) clinicopathological correlation was observed in 208 (83.2%) out of 250 biopsy-proven cases.

CONCLUSION

Pediatric orbital neoplasms include a broad spectrum of benign and malignant lesions. Vasculogenic tumors constitute the majority of them, followed by lipogenic and myxoid tumors. A thorough knowledge of the incidence, clinical profile, imaging features, and histopathology of specific orbital tumors aids in accurate diagnosis and their successful management.

Incidence, clinical features, and survival outcomes of primary malignant lacrimal gland tumors: A population-based analysis

BACKGROUND

Studies on the epidemiological information and prognosis of primary malignant lacrimal gland tumors (MLGTs) are rare for its low occurrence. The goal of our research was to investigate the epidemiological characteristics and survival outcomes of patients with MLGTs.

METHODS

Incidence and demographic information of patients with MLGTs were collected from the Surveillance, Epidemiology, and End Results (SEER) database. To identify independent prognostic factors for disease-specific survival (DSS) and overall survival (OS), univariate and multivariate Cox regression analysis were performed.

RESULTS

The overall incidence of primary MLGTs from 1975 to 2020 was 0.413/1,000,000 (according to the 2000 American standard population), with a steadily increasing incidence over years. A total of 964 patients with primary MLGTs were diagnosed, with an average age of 59.3 years. Of these, 53.2% were aged ≥60 years, 57.4% were female, and 77.1% were whites. Multivariate Cox regression analysis demonstrated that year of diagnosis, age, sex, histological type, SEER stage, surgery, and chemotherapy were independent prognostic factors of DSS or OS.

CONCLUSIONS

Although primary MLGT is rare, its incidence has steadily increased in the past 46 years, and surgery was related to a better prognosis.

Successful management of bilateral orbital metastases from invasive lobular breast cancer with abemaciclib and letrozole: a case report and literature review

Breast cancer is a significant global health concern, contributing to substantial morbidity and mortality among women. Hormone receptor-positive (HR+)/HER2-negative (HER2-) breast cancer constitutes a considerable proportion of cases, and significant advancements have been made in its management. CDK4/6 inhibitors (CDK4/6is) are a new targeted therapy that has demonstrated efficacy in adjuvant, advanced and metastatic settings. The propensity of lobular breast carcinomas for estrogen-rich sites, such as periocular tissues and orbital fat, may explain their tendency for orbital metastases. Current treatment strategies for these cases are predominantly palliative, and the prognosis remains poor. This article presents a unique case of a 51-year-old female with progressive right periorbital edema, pain, and limited ocular motility. An imaging work-up showed bilateral intra and extraconal orbital infiltration, which was biopsied. The histopathologic analysis disclosed mild chronic inflammatory infiltrate with thickened fibrous tissue and moderately differentiated lobular carcinoma cells, positive for GATA3 and CK7 markers, with 100% of tumor nuclei expressing estrogen receptors (ER+). A systemic evaluation showed a multicentric nodular formation in both breasts. Further diagnostic assessments unveiled an HR+/HER2- bilateral lobular breast carcinoma with synchronous bilateral orbital metastases. Systemic treatment was initiated with abemaciclib 150mg twice daily and letrozole 2.5mg once a day. However, this regimen was interrupted due to toxicity. After two weeks, treatment was resumed with a reduced abemaciclib dose (100mg twice daily) alongside letrozole, with a reasonable tolerance. Nearly two years after the initial diagnosis of inoperable metastatic cancer, the patient remains on the same systemic treatment regimen with no signs of invasive disease. This case report is the first of a patient presenting with bilateral orbital metastases from bilateral lobular breast cancer, showing an impressive and sustained response to a first-line treatment regimen combining abemaciclib and letrozole. A literature review on bilateral orbital metastases from breast cancer is also presented.

Clinical Applications of Anterior Segment Optical Coherence Tomography: An Updated Review

Since its introduction, optical coherence tomography (OCT) has revolutionized the field of ophthalmology and has now become an indispensable, noninvasive tool in daily practice. Most ophthalmologists are familiar with its use in the assessment and monitoring of retinal and optic nerve diseases. However, it also has important applications in the assessment of anterior segment structures, including the cornea, conjunctiva, sclera, anterior chamber, and iris, and has the potential to transform the clinical examination of these structures. In this review, we aim to provide a comprehensive overview of the potential clinical utility of anterior segment OCT (AS-OCT) for a wide range of anterior segment pathologies, such as conjunctival neoplasia, pterygium, scleritis, keratoconus, corneal dystrophies, and infectious/noninfectious keratitis. In addition, the clinical applications of AS-OCT (including epithelial mapping) in preoperative planning and postoperative monitoring for corneal and refractive surgeries are discussed.

Can 18F-FDG PET/CT findings be used to predict orbital tumor histology?

PURPOSE

To investigate whether 18F-FDG PET/CT might be useful to predict the histology of various orbital tumors based on the maximum standard uptake value (SUVmax) and the OMSUV (orbital max SUV)/MLSUV (mean liver SUV) ratio.

PATIENTS AND METHODS

A retrospective single-center study was conducted between May 2019 and December 2020. Patients with an orbital mass who underwent preoperative 18F-FDG PET/CT followed by an orbital biopsy were included. Tumor histology was classified as follows: orbital inflammation, solid tumor, low-grade lymphoid tumor, and high-grade lymphoid tumor. Orbital tumors were also classified as indolent or aggressive. Data recorded included the orbital SUVmax, OMSUV/MLSUV ratio and additional extra-orbital SUV sites.

RESULTS

Forty-five patients (24 men) were included. There were 15 (33.3%), 14 (31.1%), 9 (20%), and 7 (15.5%) cases of orbital inflammation, solid tumor, low-grade lymphoid tumor, and high-grade lymphoid tumor, respectively. No correlation was found between the OMSUV/MLSUV ratio and orbital SUVmax and tumor histology (Z = -0.77, Z = -0.6, Z = -1.6, and Z = 0.94, all P > 0.05, respectively). No correlation was found between the OMSUV/MLSUV ratio (Z = -1.42, P > 0.05) and orbital SUVmax (Z = -0.82, P > 0.05) and tumor aggressiveness (indolent versus aggressive). Subgroup analyses showed that SUVmax was predictive of lymphoma aggressiveness (P = 0.05) and was able to distinguish orbital cancers (all lymphomas+solid tumors) from benign tumors (P = 0.02).

CONCLUSION

18F-FDG PET/CT could not be used to predict the underlying orbital tumor histology. However, more aggressive tumors, especially high-grade lymphomas and cancers, tended to have a higher orbital SUVmax compared to indolent lesions.

Radiotherapy of Orbital and Ocular Adnexa Lymphoma: Literature Review and University of Catania Experience

Orbital and ocular adnexa lymphomas are rare neoplasms confined to the orbital region. The prognosis is generally favorable, with a high proportion of localized disease, indolent clinical course, prolonged disease-free intervals, and low lymphoma-related mortality rate. We report our experience on eleven patients with confirmed histological diagnosis of lymphoma stage IE-IIE, treated between 2010 and 2021 with radiotherapy alone or in association with chemotherapy or immunotherapy. Eight patients were treated with primary radiotherapy only, while three received previous systemic treatments. Six patients were treated with Proton beam therapy (PBT), and five with external beam radiotherapy (EBRT). The five-year local control rate was 98%; only one patient developed an out-of-field recurrence. We also conducted a comprehensive literature review using electronic databases (PubMed, EMBASE, and Cochrane Library). Articles were selected based on their pertinence to treatment of the ocular and adnexal lymphoma focusing on radiotherapy techniques (electron beam radiotherapy, photon beam radiotherapy, or proton beam radiotherapy), treatment total dose, fractionation schedule, early and late radio-induced toxicities, and patient's clinical outcome. Radiotherapy is an effective treatment option for orbital lymphoma, especially as standard treatment in the early stage of orbital lymphoma, with excellent local control rate and low rates of toxicity.

Composition and diversity analysis of the TCR CDR3 repertoire in patients with idiopathic orbital inflammation using high-throughput sequencing

BACKGROUND

Idiopathic orbital inflammation (IOI) is a nonspecific orbital inflammatory disease with the third highest prevalence among orbital diseases, and its pathogenesis is associated with T-cell-mediated immune responses. This study aimed to investigate the differences in T-cell receptor (TCR) expression between IOI patients and healthy subjects by high-throughput sequencing and to characterize TCR expression in patients with IOI and with respect to glucocorticoid response.

METHODS

A total of 19 subjects were enrolled in this study and were divided into the idiopathic orbital inflammation group (IOI group, n = 13) and the healthy control group (HC group, n = 6), and within the IOI group were further divided into the glucocorticoid therapy sensitive group (IOI(EF) group, n = 6) and the glucocorticoid therapy ineffective group (IOI(IN) group, n = 7) based on the degree of effectiveness to glucocorticoid therapy. High-throughput TCR sequencing was performed on peripheral blood mononuclear cells of IOI patients and healthy control individuals using 5' RACE technology combined with Unique Identifier (UID) digital tag correction technology. The TCR CDR3 region diversity, sharing patterns, and differential sequences between the IOI and HC groups, and between the IOI(EF) and IOI(IN) groups were analyzed.

RESULTS

It was found that the diversity of TCR CDR3 in the IOI group was significantly lower than that in the HC group, and the frequency of V gene use was significantly different between groups. The diversity of TCR CDR3 in patients in the IOI(EF) group was significantly lower than that in patients in the IOI(IN) group, and the frequency of V and J gene use was significantly different between the IOI(EF) group and the IOI(IN) group. Additionally, we found 133 nucleotide sequences shared in all IOI samples and screened two sequences with higher expression from them.

CONCLUSIONS

Our results suggested that abnormal clonal expansion of specific T-cells exists in IOI patients and that TCR diversity may had an impact on the prognosis of glucocorticoid-treated IOI. This study may contribute to a better understanding of the immune status of IOI and provide new insights for T-cell -associated IOI pathogenesis, diagnosis and treatment prediction.

Cytogenetic and survival analysis in 315 multiple myeloma patients; five with orbital and eight with extramedullary disease

PURPOSE

To describe cytogenetic abnormalities in five patients with orbital involvement of multiple myeloma (MM) and to determine if high-risk cytogenetic abnormalities were more prevalent in patients with extramedullary disease (EMD). The final goal was to determine predictors of poor survival in the entire cohort.

METHODS

Retrospective cohort study of 315 patients diagnosed with multiple myeloma over a 9-year period at a single institution.

RESULTS

Males comprised 61% of the 315 patients and the majority (54.3%) were stage II at diagnosis of MM. Follow-up ranged 6 months to 18 years, mean 5.3 ± 3.7 years. Eight patients (2.5%), two of which had orbital involvement, developed EMD and an additional three patients had orbital involvement from adjacent bone disease. No genetic abnormality reached statistical significance between non-EMD and EMD groups. At the time of analysis 127 (41%) non-EMD patients and 6 (75%) EMD patients have died. The median survival time for the EMD group was 2 years, whereas for the non-EMD group it was 9 years (P-value of log rank test = .00015). Stage at time of MM diagnosis and age were associated with worse prognosis. Median survival for patients over 65 years of age was 7 years, compared to 12 years for patients 65 or younger (P-value for the log-ranked test <.001).

CONCLUSIONS

Cytogenetic abnormalities are described in five patients with orbital involvement of MM. No genetic abnormality reached statistical significance between non-EMD and EMD groups. EMD status, stage of MM at diagnosis and age are associated with poorer overall survival.Abbreviation: MM: Multiple Myeloma; EMD: Extramedullary disease; FISH: fluorescence in situ hybridization; B2M: beta-2 microglobulin; LDH: lactate dehydrogenase; OS: overall survival.

Recurrent lacrimal gland pleomorphic adenoma

Pleomorphic adenoma is the most common tumour of the lacrimal gland. Correct preoperative diagnosis is essential as the tumour should be removed en bloc. Incisional biopsy is contraindicated due to risk of recurrence and subsequent risk of malignancy. We identified 13 patients who were diagnosed with lacrimal gland pleomorphic adenoma in our institution over a 31-year period from 1990 to 2021. Of these, we describe four patients, three males and one female, who underwent incisional biopsy. One of these patients had a number of recurrences and required an orbital exenteration. The other two were treated with radiation to the orbit and experienced severe dry eye post-radiotherapy. All three patients are currently disease-free. The fourth patient underwent an incisional biopsy of his lacrimal gland pleomorphic adenoma (LGPA) within the last 6 months and has been referred for radiotherapy. The reasons for a lack of preoperative diagnosis of LGPA included clinical uncertainty and broad radiologic differential. None of the patients who had an en bloc resection experienced recurrence. We recommend that a fine needle aspirate (FNA) biopsy in lieu of a tissue biopsy should be performed where LGPA is included in the clinical and radiological differential diagnosis. If incisional biopsy is required, the suture track should be marked so that the entire biopsy track is removed with the specimen.

Prevalence and clinical features of orbital vascular anomalies in children

PURPOSE

To report the prevalence, clinical characteristics, and natural history of orbital vascular anomalies diagnosed among children over a 50-year period.

METHODS

The medical records of all patients <19 years diagnosed with any form of an orbital vascular anomaly (OVA) at Mayo Clinic, Rochester, Minnesota from January 1 1966, through December 31 2015, were retrospectively reviewed.

RESULTS

A total of 109 children were diagnosed with OVA during the 50-year period, of which 24 were from Olmsted County, MN, yielding a birth prevalence of 1 in 4,305 live births. The median age at diagnosis for the 109 patients was 1.2 years (range, 0-17.9 years) and 67 (61.5%) were female. Common presenting symptoms included proptosis in 80 (73.4%) patients, abnormalities in skin color in 45 (41.3%) patients, and pain in 18 (16.5%) patients. There were 55 (50.5%) vascular malformations [50 (91%) low-flow lymphatic malformations, 3 (5.5%) high-flow arteriovenous malformations, and 2 (3.5%) low-flow venous malformations] and 54 (49.5%) vascular tumors [53 (98%) capillary hemangiomas and 1 (2%) kaposiform hemangioendothelioma]. During a mean follow-up of 5.95 years (range 0-27.7 years), amblyopia and/or strabismus were diagnosed in 46 (43.4%) patients.

CONCLUSIONS

Capillary hemangiomas and low-flow lymphatic malformations comprise most of the orbital vascular anomalies in this cohort of children. Amblyopia and strabismus are common sequelae, highlighting the importance of early diagnosis and appropriate management.

Orbital histiocytosis and fibrohistiocytosis: the clinicopathological characteristics of 117 patients, over a decade of experience

PURPOSE

To describe the clinicopathological features of a large cohort of patients with orbital histiocytoses and fibrohistiocytosis, such as Langerhans cell histiocytosis (LCH) and non-LCH disorders, and correlate patients' clinical characteristics with their pathological diagnosis.

METHODS

In this retrospective study, medical records of patients presenting to Farabi Eye Hospital, a tertiary eye care center in Tehran, Iran, from 2010 until 2022, were reviewed. Patients' demographics, chief complaint, location and laterality of the tumor, best-corrected visual acuity, presence of bone erosion on imaging, and their pathological diagnosis were retrieved. Excisional biopsy was performed and evaluated through light microscopy and immunohistochemistry study for their respective markers, including CD1a, CD68, CD207, and S100.

RESULTS

A total of 117 patients with 11 pathological subtypes of histiocytoses and fibrohistiocyosis were identified, with 56.4% male and 43.6% female patients. The mean age at presentation was 23.4 years (range 1.5 months-73 years). Swelling and palpable mass were the most common chief complaints. LCH was the most common pathology (32.5%), followed by juvenile xanthogranuloma (26.5%) and adult xanthogranuloma (21.4%). Age, lesion location, and bone erosion had a statistically significant difference among the various diagnosed subtypes.

CONCLUSIONS

Histiocytoses and fibrohistiocytosis are diverse and rare disorders potentially involving multiple organ systems. Ophthalmic manifestations of these diseases are even more uncommon. We reviewed their orbital presentation along with their respective histopathological findings. Our results also suggested that an orbital CT scan can be of diagnostic value to discriminate LCH from other histiocytic pathologies.

Ophthalmological and Interdisciplinary Surgical Approaches to the Orbit

The treatment of orbital masses often requires an interdisciplinary approach. Ophthalmological surgical approaches include the anterior transcutaneous approach for removal of dermoids or taking biopsies. Anterior transconjunctival orbitotomy is suitable for masses of the inferior orbit or the intraconal compartment, but is inappropriate for masses of the orbital apex. The lateral transosseous orbitotomy often fits for masses of the lateral or intraconal compartment, especially for neoplasms of the lacrimal gland e.g. pleomorphic adenoma. Cryoextraction is often the technique of first choice for cavernous haemangiomas of all localisations. Transfrontal approaches are suitable for the resection of tumours of the optic nerve and of the orbital apex.

Inflammation and Fibrosis in Orbital Inflammatory Disease: A Histopathologic Analysis

PURPOSE

The purpose of this study was to compare the histopathologic inflammation and fibrosis of orbital adipose tissue in orbital inflammatory disease (OID) specimens.

METHODS

In this retrospective cohort study, inflammation, and fibrosis in orbital adipose tissue from patients with thyroid-associated orbitopathy (TAO), granulomatosis with polyangiitis (GPA), sarcoidosis, nonspecific orbital inflammation (NSOI), and healthy controls were scored by 2 masked ocular pathologists. Both categories were scored on a scale of 0 to 3 with scoring criteria based on the percentage of specimens containing inflammation or fibrosis, respectively. Tissue specimens were collected from oculoplastic surgeons at 8 international centers representing 4 countries. Seventy-four specimens were included: 25 with TAO, 6 with orbital GPA, 7 with orbital sarcoidosis, 24 with NSOI, and 12 healthy controls.

RESULTS

The mean inflammation and fibrosis scores for healthy controls were 0.0 and 1.1, respectively. Orbital inflammatory disease groups' inflammation (I) and fibrosis (F) scores, formatted [I, F] with respective p -values when compared to controls, were: TAO [0.2, 1.4] ( p = 1, 1), GPA [1.9, 2.6] ( p = 0.003, 0.009), sarcoidosis [2.4, 1.9] ( p = 0.001, 0.023), and NSOI [1.3, 1.8] ( p ≤ 0.001, 0.018). Sarcoidosis had the highest mean inflammation score. The pairwise analysis demonstrated that sarcoidosis had a significantly higher mean inflammation score than NSOI ( p = 0.036) and TAO ( p < 0.0001), but no difference when compared to GPA. GPA had the highest mean fibrosis score, with pairwise analysis demonstrating a significantly higher mean fibrosis score than TAO ( p = 0.048).

CONCLUSIONS

Mean inflammation and fibrosis scores in TAO orbital adipose tissue samples did not differ from healthy controls. In contrast, the more "intense" inflammatory diseases such as GPA, sarcoidosis, and NSOI did demonstrate higher histopathologic inflammation and fibrosis. This has implications in prognosis, therapeutic selection, and response monitoring in orbital inflammatory disease.

An Unusual Case of Lacrimal Gland Dacryops in a 10-Year-Old Child

Lacrimal gland dacryops are an unusual type of benign epithelial neoplasm. Most of the literature refers to dacryops of the lacrimal palpebral lobe, with orbital lobe involvement less frequent. The authors report a case of dacryops in a 10-year-old child involving the orbital lobe of the lacrimal gland. [J Pediatr Ophthalmol Strabismus. 2023;60(6):e79-e82.].

Single fraction and hypofractionated radiosurgery for perioptic meningiomas-tumor control and visual outcomes: a systematic review and meta-analysis

Perioptic meningiomas, defined as those that are less than 3 mm from the optic apparatus, are challenging to treat with stereotactic radiosurgery (SRS). Tumor control must be weighed against the risk of radiation-induced optic neuropathy (RION), as both tumor progression and RION can lead to visual decline. We performed a systematic review and meta-analysis of single fraction SRS and hypofractionated radiosurgery (hfRS) for perioptic meningiomas, evaluating tumor control and visual preservation rates. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed articles published between 1968 and December 8, 2022. We retained 5 studies reporting 865 patients, 438 cases treated in single fraction, while 427 with hfRS. For single fraction SRS, the overall rate of tumor control was 95.1%, with actuarial rates at 5 and 10 years of 96% and 89%, respectively; tumor progression was 7.7%. The rate of visual stability was 90.4%, including visual improvement in 29.3%. The rate of visual decline was 9.6%, including blindness in 1.2%. For hfRS, the overall rate of tumor control was 95.6% (range 92.1-99.1, p < 0.001); tumor progression was 4.4% (range 0.9-7.9, p = 0.01). Overall rate of visual stability was 94.9% (range 90.9-98.9, p < 0.001), including visual improvement in 22.7% (range 5.0-40.3, p = 0.01); visual decline was 5.1% (range 1.1-9.1, p = 0.013). SRS is an effective and safe treatment option for perioptic meningiomas. Both hypofractionated regimens and single fraction SRS can be considered.

Case Report: an unusual orbital tumor

Introduction Orbital lipoma is an extremely rare tumor, representing less than 1% of all orbital tumors. We review the literature and describe the presentation, the differential diagnosis and the management of this tumor. Case report We report the case of a 63-year-old patient who was referred for a diplopia with recent hemi-cranial headache. Physical examination showed no exophthalmos nor decrease in visual acuity. The patient complained of diplopia on elevation and oculomotricity examination showed limited elevation of the right eye. The Hess Lancaster test was in favor of a limited course of the right inferior rectus muscle. Magnetic resonance imaging revealed a fusiform tissue process in the right inferior rectus muscle with a fatty signal. A complete excision of the tumor was performed by a trasncunjonctival approach. Cytopathological examination was consistent with a pleomorphic lipoma. The postoperative period was uneventful. The definitive histopathologic diagnosis was a lipoma. The postoperative Magnetic resonance imaging showed the complete disappearance of the lesion. With 3 years of follow up, there is no sign of recurrence or ocular motility trouble. Conclusion: Lipomas are rare tumors in the orbit. The clinic is variable depending on the size and the site. The clinical diagnosis is difficult to make. Only histology allows the final diagnosis.

A Retrospective Study of Ocular Cancer in Saudi Arabia: 25-Year Analysis

Background

Ocular malignancies are uncommon among eye diseases; however, they jeopardize both vision and life. The main objective of this study was to use to describe the epidemiology of eye and ocular adnexa malignancies across different ages and sex.

Methods

The King Khaled University institutional review board approved this study. Data on ocular cancer were retrieved from the Saudi Cancer Registry between 1994 and 2018. The registry collected important patient information such as demographic information (age, gender, and nationality), clinical details, and tumor classification.

Results

The total number of cases with ocular cancer diagnosed was 1051 cases. The highest number was recorded in Riyadh (35.39%, n=372), followed by Makkah (16.93%, n=178). The incidence was higher in the 0-4 years' age group (55.21%), and it got down as people got older. The data also revealed differences in the number of reported cases over time, as well as in the representation of eye cancer cases by gender and nationality. While many ocular cancer pathologies were seen, with "Retinoblastoma, not otherwise specified" being the most common (53.32%), the incidence rates for males and females remained largely stable over time.

Conclusion

The study emphasizes the need for continued monitoring, research, and analysis of potential of epidemiology of ocular cancer occurrence in Saudi Arabia. Identifying the geographical distribution and age pattern of Ocular malignancies have the potential to assist healthcare authorities and policymakers in developing precise strategies to reduce, recognize at an early stage, and successfully manage this condition.

Orbital inflammatory pseudotumor: new advances in diagnosis, pathogenesis, and treatment

Orbital inflammatory pseudotumor (OIP) is a benign, non-specific inflammatory disorder that commonly occurs in middle-aged adults and is usually unilateral but can occur bilaterally. Its clinical manifestations have tremendous clinical heterogeneity and vary according to the site of infiltration and the degree of lesions, including orbital pain, swelling, diplopia, proptosis, restricted eye movement, and decreased visual acuity. Clinical features, Image characteristics and pathological examinations often need to be evaluated to confirm the diagnosis. Currently, there is no systematic research on the pathogenesis of OIP, which may be related to immunity or infection. The first-line treatment is glucocorticoids. Radiotherapy, immunosuppressants, and biologics can be considered for treatment-resistant, hormone-dependent, or intolerant patients. In this review, we aim to summarize and focus on new insights into OIP, including new diagnostic criteria, pathogenesis, and discoveries in new drugs and treatment strategies. In particular, we highlight the literature and find that T cell-mediated immune responses are closely related to the pathogenesis of OIP. Further exploration of the mechanism and signaling pathway of T cells in the immune process will help to identify their therapeutic targets and carry out targeted therapy to treat refractory OIP and reduce the side effects of traditional treatments.

Incidence and Risk Factors for Poor Postoperative Visual Outcome After Excision of Orbital Cavernous Venous Malformations

AIMS

To determine the incidence and risk factors for poor postoperative visual outcome (PPVO) after removal of orbital cavernous venous malformations (OCVMs).

METHODS

Retrospective case-note and imaging review for patients undergoing excision of OCVMs, with estimation of odds-ratios (ORs) and relative risks (RRs) for visual loss in relation to the position of the mass, surgical approach, and patient factors.

RESULTS

The 290 patients (179 female; 62%) presented at a mean age of 46.4 years: 243/287 (85%) OCVMs were intraconal, with 213/243 (88%) located freely in the posterior two-thirds of the orbit, and 30/243 (12%) wedged tightly in the apex. PPVO was observed in 6.9% (20/290) patients, solely after removal of intraconal lesions, Univariate analysis showed increased risk with preoperative relative afferent pupillary defect (RAPD) (14/107 [13%]; RR 2.9; P = 0.011), apical lesions (9/30 [30%]; RR 5.8; P < 0.001), situated below optic nerve (15/115 [13%]; RR 3.3; P = 0.007), fibrous masses (14/78 [18%]; RR 6.7; P = 0.005), or intraoperative diastolic blood pressure below 50mmHg (10/64 [16%]; RR 2.8; P = 0.007). Multivariate analysis found apical extension (OR 4.9; P = 0.036) and fibrous lesions (OR 10.0; P = 0.035) as strongest predictors for PPVO. The incidence of complete visual loss (no light perception) was 4.1% (12/290); half of these patients had preoperative acuity of counting fingers or worse, 8 (67%) had RAPD, 7 (58%) wedged apical lesions, and 8 (67%) were below the optic nerve.

CONCLUSION

PPVO after excision of OCVMs can occur in up to 5% of "free" retrobulbar intraconal lesions and in approximately one-third of apical lesions.

Adenocarcinoma in situ (ductal type) ex pleomorphic adenoma of the lacrimal gland

Purpose

To present the clinical and histopathological characteristics of a rare case of ductal carcinoma in situ ex pleomorphic adenoma in the lacrimal gland.

Observations

A 73-years-old Caucasian female presented with complaints of double vision and pain in the left eye region. Clinical examination revealed ptosis and exophthalmos of the left eye as well as diplopia on downward gaze. Magnetic resonance imaging of the left orbit demonstrated a 17 × 22 mm homogeneous tumor in the left lacrimal fossa. The tumor was excised in toto. Histopathological examination revealed a pleomorphic adenoma with ductal structures with benign looking epithelial cells, surrounded by myoepithelial cells. Tumor areas with cribriform architecture consisting of ductal structures with abnormal luminal epithelial cells and intact myoepithelial cell layer were also present. The surgical margins were clear. All luminal and myoepithelial cells were positive for cytokeratin 7, the luminal cells in the cribriform areas were positive for human epidermal growth factor 2 and androgen receptor. The myoepithelial cells were positive for cytokeratin 5, calponin and focally for glial fibrillar acid protein. The findings were diagnostic for ductal carcinoma in situ ex pleomorphic adenoma. Next generation sequencing Oncomine Comprehensive Assay mutation analysis found mutations in the BRCA2 (p.K3326*), BAP1 (p.S395*), and TP53 (p.E285K) genes in the ductal carcinoma in situ and BRCA2 (p.C9976A) in the pleomorphic adenoma part.

Conclusion and importance

To our knowledge, this tumor is only the second described ductal carcinoma in situ ex pleomorphic adenoma of the lacrimal gland.

Diffusion-Weighted Imaging of the Orbit: A Case Series and Systematic Review

PURPOSE

To describe the findings of diffusion-weighted imaging (DWI) for a series of orbital lesions and provide a systematic review of relevant literature.

METHODS

A retrospective review of 20 patients with orbital lesions who underwent MRI with DWI at two academic institutions between 2015 and 2020 was performed. Lesion diagnosis was histopathologically confirmed except a presumed cavernous hemangioma. Echoplanar diffusion-weighted images had been acquired using 2 or 3 b values (b=0 and 1000 or b=0, 500, and 1000) at 1.5T or 3T. Lesions with significant artifacts were excluded. DWI sequences were analyzed by neuro-radiologists blinded to the diagnosis. Mean ADC values of lesions were calculated from a single region of interest. An independent two-tailed t test was used to compare categories of lesions with p < 0.05 considered significant. A systematic review of the literature was performed.

RESULTS

Our study included 21 lesions. ADC values were significantly lower for malignant lesions (0.628 ± 0.125 × 10 -3 mm 2 /s) than inflammatory lesions (1.167 ± 0.381 × 10 -3 mm 2 /s) ( p < 0.001). ADC values were significantly lower for orbital lymphoma (mean 0.621 ± 0.147 × 10 -3 mm 2 /s) than idiopathic orbital inflammation (mean 1.188 ± 0.269 × 10 -3 mm 2 /s) with no overlap ( p < 0.001).

CONCLUSIONS

Orbital malignancies demonstrated lower ADC values, while inflammatory processes demonstrated higher ADC values, except IgG4-related disease. DWI and ADC values differentiated idiopathic orbital inflammation from orbital lymphoma. This study highlights the role of DWI in evaluating orbital pathology.

Maligne Neoplasien der Orbita

Malignant masses of the orbit include a large variety of neoplasms of epithelial or mesenchymal origin. The treatment of orbital malignancies is an essential interdisciplinary field of medicine that integrates ENT medicine, facial surgery, plastic surgery, neurosurgery, oncology and radiology.The main symptom of malignant orbital masses is the exophthalmos. A symptom that can help to differentiate a benign from a malignant orbital mass can be the pain. The main diagnostic tool is the MRI including new sequences like DWI and DCE.After presenting symptoms and diagnostic strategies of malignant orbital masses, this article starts with the description of malignant epithelial neoplasms of the lacrimal gland. Furthermore, it describes new insights in orbital lymphomas, followed by the discussion of semimalignant orbital masses. Last but not least the text deals with malignant neoplasms of the skin that can grow secondarily in the orbit. Finally, the manuscript discusses orbital metastases.