Acute presentation of vascular disease within the orbit-a descriptive synopsis of mechanisms

Presentation of Spontaneous Orbital Hemorrhage

PURPOSE

To evaluate the presenting features of patients with nontraumatic orbital hemorrhage (NTOH) based on etiopathological factors.

METHODS

A retrospective case-note review for demographics and presenting features of patients with nontraumatic orbital hemorrhage. Patients were categorized into 3 groups: group I with known systemic vascular disease, group II with known or newly revealed orbital vascular anomalies, and group III with no known underlying vasculopathy.

RESULTS

One hundred and seventeen patients (68 female; 58%), with 37 (32%) in group I, 47 (40%) in group II, and 33 (28%) in group III. The average age at presentation was 70.9, 30.1, and 49.9 years, respectively, but the incidence peaked in the first decade for patients with underlying local vascular anomalies and in the eighth for those without. Of the group I patients with known cardiovascular disease, 43% were on antithrombotic agents. The most common presenting symptoms were orbital pain (59%), proptosis (56%), and diplopia (45%), while 13% had associated nausea or vomiting. Ipsilateral optic neuropathy occurred in 14% of cases, higher in group II (22%), along with nonaxial globe displacement (25%), reduced eye movements (47%), optic disc swelling (10%), and choroidal folds (9%). Imaging in patients without evident vascular anomalies showed that hemorrhages commonly occurred in the inferotemporal quadrant (32%), with about half of these having a "beached whale" configuration (46%).

CONCLUSION

Nontraumatic orbital hemorrhages affect all ages, typically presenting with acute proptosis or pain (over half), various degrees of visual impairment, and reduced motility. About half of those without vascular anomalies had cardiovascular risk factors, imaging often revealing an inferotemporal mass with a "beached whale" appearance.

Case report of cavernous haemangioma in the supraorbital region in the extraconal space: A rare location

Introduction

Cavernous haemangioma is the most common benign non-infiltrative neoplasm of the orbit. Most cavernous haemangiomas are intraconal and lateral in location.

Case report

We present a rare case of a cavernous haemangioma with an unusual location in the supraorbital region of the orbit, presenting with soft tissue swelling.

Discussion

Cavernous haemangiomas are the most common benign non-infiltrative neoplasms of the orbit and have a slowly progressive mass effect. A slowly progressive proptosis is the typical presenting symptom. Extraocular muscle impairment and impaired visual function are seen with large lesions and with lesions located at the orbital apex. Most cavernous haemangiomas are typically intraconal and lateral in location. Extraconal and medial locations are uncommon. Ultrasound, computed tomography and magnetic resonance imaging are useful imaging techniques for the evaluation of such tumours. Treatment of the tumour is surgical excision. Complete excision is generally accomplished as the tumour is well-encapsulated with relatively few feeding vessels.

Cribra orbitalia is a vascular phenomenon unrelated to marrow hyperplasia or anemia: Paradigm shift for cribra orbitalia

The orbital phenomenon, cribra orbitalia, has long been a source of controversy, especially with regard to its nature, derivation, and relationship to anemia. Therefore, the external surfaces of orbital roofs were systematically examined microscopically in human skulls from historical collections. Superior orbital surfaces of 278 individual crania within the Hamann-Todd collection were assessed at various magnifications using epi-illumination microscopy to identify the presence of cribra orbitalia and characterize its nature. Also, 12 additional individuals with diagnosed anemia in the Hamann-Todd collection were evaluated. Orbital roof alterations, present in one-third of examined crania, had two discrete appearances: Vascular grooves (45%) and application of new bone in a vascular branching pattern on the orbit surface (55%). Porosity of the orbit was not observed. Evaluation of the orbits of 12 individuals with diagnosed anemia revealed one with a single deep defect, suggesting a space-occupying phenomenon, but no evidence of bone accretion, vascular grooves, or porosity. Cribra orbitalia has often been lumped indiscriminately as an indicator of organismal stress, rather than identified as a indicating a specific etiology. Neither that perspective nor porosity are supported by high resolution examination of orbital roof changes. Recognition of the blood vessel imprint pattern falsifies previous speculations and provides a new paradigm. The actual character of cribra orbitalia is documented and new hypotheses generated. While population prevalence of cribra orbitalia seems excessive for explanation on the basis of these hypotheses, the imprints are clearly vascular in origin.

Ophthalmic and orbital considerations in the evaluation of skull base malignancies

INTRODUCTION

The orbital contents, afferent and efferent visual pathways, and the cranial nerves involved in eye movement, corneal sensation and eyelid closure traverse the skull base, a region bounded by the intracranial cavity, the paranasal sinuses, and the deep spaces of the face and head. As such, tumors from above or below have potential to affect some aspect of the visual system.

METHODS

We discuss here the clinical ophthalmologic and orbital considerations in the evaluation of patients with these tumors, as well as the ophthalmic sequelae of treatment with radiation or surgery (or both). And for the surgeon, we discuss the ophthalmic and orbital considerations in surgical planning, the role of the orbital surgeon in skull base surgery, and briefly discuss transorbital approaches to the skull base.

RESULTS AND CONCLUSION

Ophthalmic and orbital dysfunction may be the main source of disability in patients with skull base malignancy; it is thus incumbent on those who manage patients with tumors of this region to be aware of the ophthalmic, neuro-ophthalmic and orbital manifestations, so as to best tailor therapy and monitor treatment outcomes.

Cavernous hemangioma of the orbit: an unusual acute presentation

We report an unusual presentation of an orbital cavernous hemangioma in a 26-year-old female, who noted sudden redness and swelling of the left eye (LE) on waking up. At presentation, upper eyelid edema with periorbital ecchymosis and subconjunctival hemorrhage were noted in the LE. Although there was transient symptomatic relief with topical medications, blurring of vision developed in the LE. When seen 10 days later, the patient’s LE showed axial proptosis. Magnetic resonance imaging revealed an intraconal soft tissue mass in the superomedial quadrant of the left orbit. Superior orbitotomy with mass excision was done; histopathological examination of the excised mass revealed a cavernous hemangioma. The patient had complete visual recovery following surgery. To our knowledge, an acute presentation of an orbital cavernous hemangioma with subconjunctival hemorrhage and periorbital ecchymosis has not previously been reported.

[Orbito-palpebral vascular pathology]

Orbito-palpebral vascular pathology represents 10% of all the diseases of this area. The lesion may be discovered during a brain CT scan or MRI, or because it causes clinical symptoms such as orbital mass, visual or oculomotor alteration, pain, proptosis, or acute bleeding due to a complication of the lesion (hemorrhage, thrombosis). We present these lesions using an anatomical, clinical, imaging and therapeutic approach. We distinguish four different entities. Vascular tumors have common imaging characteristics (hypersignal on T2 sequence, contrast enhancement, abnormal vascularization well depicted with ultrasound and Doppler, and possible bleeding). The main lesions are cavernous hemangiomas, the most frequent lesion of that type during adulthood; infantile hemangiomas, the most frequent vascular tumor in children; and more seldomly, hemangioperitcytomas. True vascular malformations are divided according to their flow. Low flow lesions are venous (orbital varix), capillarovenous or lymphatic (lymphangioma). High flow malformations, more rare, are either arteriovenous or arterial malformations (aneurisms). Complex malformations include both low and high flow elements. Lesions leading to modifications of the orbito-palpebral blood flow are mainly due to cavernous sinus abnormalities, either direct carotid-cavernous fistula affecting young adults after severe head trauma, or dural fistula, more insidious, found in older adults. The last section is devoted to congenital syndromic vascular malformations (Sturge-Weber, Rendu-Olser…). This classification allows for a better understanding of these pathologies and their specific imaging features.

Peribulbar anesthesia causing bilateral orbital hemorrhage

We report a case of bilateral orbital hemorrhage as a complication of peribulbar anesthesia in a 78 year old man. Initially, unilateral orbital hemorrhage occurred but quickly spread to the contralateral side. Neuroophthalmological assessment revealed a proptosed tense globe with normal retinovascular findings. Visual acuity was adversely affected and this was conservatively managed with no lasting ophthalmic sequela. This patient’s case was reported as it illustrates an unusual complication of bilateral spread of orbital hemorrhage secondary to peribulbar anesthesia. It highlights how early ophthalmic assessment can ensure a good visual outcome in the setting of appropriate ophthalmic monitoring. The mechanisms of orbital hemorrhage spread and appropriate management options are discussed.

Bilateral eyelid ecchymosis and subconjunctival haemorrhage manifesting as presenting feature in a case of dengue haemorrhagic fever

We report a case of bilateral eyelid ecchymosis and subconjunctival haemorrhage, a rare presenting feature of dengue haemorrhagic fever. A 17-year-old boy presented to the emergency department with complaints of redness in both eyes and vomiting. He had bilateral eyelid ecchymosis with subconjunctival haemorrhage. Complete blood count revealed a significantly reduced platelet count of 11000/µL suggestive of dengue haemorrhagic fever (DHF). Ocular manifestations were followed by other systemic haemorrhagic manifestations of dengue later on which violates the usual sequence of events of dengue fever. Bilateral eyelid ecchymosis is a rare clinical manifestation and a rare presenting feature of dengue fever and one has to keep high index of suspicion for presence of dengue whenever a case of fever presents with lid ecchymosis/haemorrhage.

Nontraumatic orbital hemorrhage

Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, "encysted" hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome.