Surgical management of orbital cavernous angiomas: prognosis for visual function after removal

Evaluation of orbital lesions with DCE-MRI: a literature review

PURPOSE

To provide a major review on the applications of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in evaluating orbital lesions. This review also outlines selected scenarios where DCE-MRI may be helpful.

METHODS

A comprehensive retrospective literature review of all English language publications on PubMed, EMBASE, and Google Scholar between 1994 and 2022. This literature review examined the specific applications and clinical scenarios surrounding the utility of DCE-MRI in orbital lesions and various findings that have been presented in the current literature.

RESULTS

DCE-MRI provides information on tissue physiology and permeability, beyond the anatomical features displayed on static imaging. Various measured parameters (qualitative, semi-quantitative, and quantitative) obtained by DCE-MRI have been used to differentiate between benign and malignant lesions, specific orbital lymphoproliferative diseases (OLPD), lacrimal gland lesions, and various rare orbital tumours. DCE-MRI has a limited role as an initial diagnostic imaging modality. However, DCE-MRI may prove to have benefit in predicting and monitoring treatment response in orbital lymphoma as a critical imaging study, but literature specific to orbital malignancies remains limited.

CONCLUSION

The value of DCE-MRI may be in situations of diagnostic uncertainty, where it may be an additional imaging aid following conventional imaging techniques. It may also act as a critical imaging modality for monitoring of orbital tumour treatment response, but the literature remains limited. Standardisation of imaging protocol, measured parameters, and statistical analysis remain limitations of this imaging technique.

An Unusual Presentation of Retrobulbar Cavernous Hemangioma in a Young Woman

A 38-year-old woman presented with sudden-onset painful lid swelling, proptosis and external ophthalmoplegia on the right side for 20 days, associated with loss of vision for nine days. On contrast-enhanced computed tomography (CECT), a retrobulbar mass was noted involving intraconal and extraconal spaces, extending up to the orbital foramina with enhancement and thickening of meninges. CT arteriography further revealed multiple feeding vessels from the maxillary artery. Embolization of feeding vessels followed by right orbital exenteration with primary reconstruction using forehead flap was done. This is an unusual case of orbital cavernous hemangioma (OCH) which emphasizes the importance of CT arteriography in specific cases of OCH, where routine neuroimaging may be inconclusive.

Risks and Benefits of Surgical Excision of Orbital Cavernous Venous Malformations (So-Called Cavernous Hemangioma): Factors Influencing the Outcome

PURPOSE

To assess risks and benefits associated with surgical excision of orbital cavernous venous malformation and analyze factors influencing the outcome.

METHODS

Design: cohort study. Participants: 164 consecutive patients undergoing surgical removal of orbital cavernous venous malformation. Intervention: lateral or anterior orbitotomy. Outcome measures: visual acuity, visual field, pupillary function, ocular motility, and fundus examination. Influence of the mass volume and tumor location on the outcome was evaluated. The threshold value and risk group for the volume were evaluated using the receiver operating characteristic analysis; 8 orbital different quadrants, extraconal/intraconal position, and orbital apex extension were considered as variables to evaluate the location.

RESULTS

Postoperatively overall visual acuity (p = 0.0084), visual field (p < 0.0001), diplopia (p < 0.0001), proptosis (p < 0.0001), ocular motility (p = 0.02), ptosis (p = 0.033), choroidal fold (p < 0.0001), disk edema (p = 0.0004) were significantly improved. The commonest location was the lateral quadrant (28%). Choroidal folds were associated with tumor greater than 1100 mm3 (p = 0.001). Visual loss occurred in 2 patients (1.2%) and tonic pupil in 5 (3%,) Visual deterioration was associated with the apical extension (p = 0.001). Pupil efferent defect was associated with lateral quadrant location (p = 0.011) and apical extension (p = 0.05).

CONCLUSIONS

Surgical removal of orbital cavernous venous malformation is a useful treatment modality, particularly for large size tumors. Removal of cavernous venous malformations located at the lateral aspect of the orbit carries an increased risk of permanent tonic pupil. Postoperative blindness is rarely seen and is often associated with the apical extension. Tailoring the surgical approach, depending on the relative position to the optic nerve, may have an important bearing on outcome.

Exclusively endoscopic endonasal resection of benign orbital tumors: a systematic review and meta-analysis

BACKGROUND

The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) classification system was developed to standardize prospective outcome analysis following orbital cavernous hemangioma (OCH) resection. The goal of this study was to retroactively apply the CHEER system to all prior existing reports of endoscopic resection of primary benign orbital tumors (BOTs) to: (1) compare patient presentations, perioperative characteristics, and outcomes between OCH and other BOTs; and (2) determine whether the CHEER categorization regime could be expanded to other BOTs.

METHODS

A systematic review of studies reporting exclusively endoscopic resections of OCH and other BOTs (eg, solitary fibrous tumor, schwannoma, and meningioma) was performed. Patient, tumor characteristics, and operative outcomes were recorded. All tumors with adequate reporting were retrospectively assigned a CHEER stage. Outcomes were compared using chi-square or Fisher's exact tests.

RESULTS

Ninety-three studies met inclusion criteria, and sufficient data were available in 36 studies, comprising 105 tumors (n = 87 OCHs; n = 18 other BOTs). Baseline patient and tumor characteristics, as well as intraoperative and short-term postoperative outcomes were not significantly different between OCHs and other BOTs. Long-term outcomes (eg, visual deficits, diplopia, eye position, and recurrence) also did not differ when controlling for CHEER stage.

CONCLUSION

This review represents the largest collection of outcomes data following exclusively endoscopic endonasal resection of BOTs. Short-term and long-term outcomes appear similar between OCHs and other BOTs. These results suggest that exclusively endoscopic resection of orbital tumors may be effective in a range of benign pathologies. Furthermore, these results support a broader application of the CHEER system to other benign primary orbital tumors.

Transconjunctival Cryo-Assisted Extraction of Intraconal Cavernous Hemangioma.. [DOI: 10.21203/rs.2.14177/v4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: The aim of this study is to evaluate the safety and efficacy of cryo-assisted transconjunctival orbitotomy for the extraction of intraconal cavernous hemangiomas. Methods: The study was performed at the Mansoura Ophthalmic Center, Mansoura University, Egypt from May 2017 to August 2018 and included 18 patients with orbital intraconal cavernous hemangiomas. In all the cases, preoperative orbital magnetic resonance imaging (MRI) with contrast was performed, the transconjunctival approach was used and cryo-assisted lesion extraction was performed. Cases were followed for six months after the surgery. Results: This study included 18 patients with intraconal cavernous hemangiomas, ten females (55.6%) and eight males (44.4%) with a mean age of 35.6 years. .The hemangiomas were lateral to the optic nerve in eight(44.5%), above the optic nerve in four cases(22.2%), and below the optic nerve in six cases(33.3%). Eight cases had postoperative complications: three cases (16.7%) had postoperative diplopia due to lateral rectus paresis that improved in all three cases within six months, one case (5.6%) had postoperative retrobulbar hemorrhage and proptosis that resolved within two weeks without sequelae, and four cases (22.2%) showed subconjunctival hemorrhages which resolved within two weeks. Of the two cases with preoperative decreases in visual acuity preoperative, one case (5.6%) showed improvement and one case (5.6%) did not improve. Conclusions: Cryoprobe-assisted transconjunctival orbitotomy for the excision of intraconal cavernous hemangiomas is a good approach with minor resolvable complications . Trial registration : Mansoura institutional review board (IRB) Registration number : R/17.05.26 Registration date : 10/5/2017

Transconjunctival Cryo-Assisted Extraction of Intraconal Cavernous Hemangioma.. [DOI: 10.21203/rs.2.14177/v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: The aim of this study is to evaluate the safety and efficacy of cryo-assisted transconjunctival orbitotomy for the extraction of intraconal cavernous hemangiomas.Methods: The study was performed at the Mansoura Ophthalmic Center, Mansoura University, Egypt from May 2017 to August 2018 and included 18 patients with orbital intraconal cavernous hemangiomas. In all the cases, preoperative orbital magnetic resonance imaging (MRI) with contrast was performed, the transconjunctival approach was used and cryo-assisted lesion extraction was performed. Cases were followed for six months after the surgery.Results: This study included 18 patients with intraconal cavernous hemangiomas, ten females (55.6%) and eight males (44.4%) with a mean age of 35.6 years. .The hemangiomas were lateral to the optic nerve in eight(44.5%), above the optic nerve in four cases(22.2%), and below the optic nerve in six cases(33.3%). Eight cases had postoperative complications: three cases (16.7%) had postoperative diplopia due to lateral rectus paresis that improved in all three cases within six months, one case (5.6%) had postoperative retrobulbar hemorrhage and proptosis that resolved within two weeks without sequelae, and four cases (22.2%) showed subconjunctival hemorrhages which resolved within two weeks. Of the two cases with preoperative decreases in visual acuity preoperative, one case (5.6%) showed improvement and one case (5.6%) did not improve. Conclusions: Cryoprobe-assisted transconjunctival orbitotomy for the excision of intraconal cavernous hemangiomas is a good approach with minor resolvable complications.Trial registration: Mansoura institutional review board (IRB)Registration number: R/17.05.26 Registration date: 10/5/2017

Transconjunctival Cryo-Assisted Extraction of Intraconal Cavernous Hemangioma.. [DOI: 10.21203/rs.2.14177/v2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: The aim of this study is to evaluate safety and efficacy of transconjunctival cryo-assisted orbitotomy for extraction of intraconal cavernous hemangioma.Methods: The study was performed at the Mansoura ophthalmic center, Mansoura University, Egypt from May 2017 to August 2018, It included 18 patients with orbital intraconal cavernous hemangioma. In all cases, preoperative orbital MRI(magnetic resonance imaging) with contrast was performed, transconjunctival approach was used and cryo-assisted extraction of the lesions was performed. Cases were followed for six months after surgery.Results: This study included 18 patients with intraconal cavernous hemangioma, ten females (55.6%) and eight males (44.4%) with a mean age 35.6 years. Eight cases (44.5%) were lateral to the optic nerve, four cases (22.2%) were above the optic nerve, and six cases (33.3%) were below the optic nerve. Postoperative complications included three cases (16.7%) with postoperative diplopia due to lateral rectus paresis that improved in all cases within six months, one case (5.6%) with postoperative retrobulbar hemorrhage and proptosis that resolved within two weeks without sequelae, and four cases (22.2%) showed subconjunctival hemorrhage which resolved within two weeks. Of the two cases with drop of visual acuity preoperative, one case (5.6%) showed improvement of and one case (5.6%) did not improve. Conclusions: Transconjunctival orbitotomy assisted by the use of the cryoprobe for excision of intraconal cavernous hemangioma represents a good approach with minor resolvable complicationsTrial registration: Mansoura institutional review board (IRB)registration number: R/17.05.26 registration date: 10/5/2017 Keywords: transconjunctival orbitotomy, cryo-assisted extraction of hemangioma, intraconal cavernous hemangioma.

[The transpalpebral keyhole approach in surgery of orbital cavernomas: a case report and literature review]

AIM

Currently, there are many different surgical approaches to orbital pathology. This pathology rarely occurs in neurosurgical practice, and neurosurgeons have often used approaches that can be accompanied by negative cosmetic and functional outcomes.

MATERIAL AND METHODS

We present a case report of orbital cavernoma removal via a minimally invasive approach.

RESULTS

The presented case demonstrates successful removal of orbital cavernoma using the transpalpebral approach: a skin incision along a natural fold of the upper eyelid and orbitofrontal keyhole craniotomy. In the postoperative period, existing symptoms regressed; the patient assessed the cosmetic effect as excellent.

CONCLUSION

The transpalpebral keyhole approach can be an excellent alternative to traditional approaches to orbital cavernomas. This approach demonstrated its efficacy and safety in skull base surgery and provided excellent functional and cosmetic outcomes.

The application of technetium-99m-red blood cell scintigraphy in the diagnosis of orbital cavernous hemangioma

Objective

The purpose of this study was to evaluate the clinical value of technetium-99m-red blood cell (^99mTc-RBC) scintigraphy in the diagnosis of orbital cavernous hemangioma (OCH).

Patients and methods

Forty-one patients with pathologically confirmed orbital mass, of which 10 were OCH, underwent ^99mTc-RBC scintigraphy in this study. The scanning procedure included an initial perfusion phase, followed by an early and a delayed blood pool phase. All patients underwent ultrasonography and computed tomography (CT), and 15 patients also underwent MRI.

Results

All 10 OCH patients had no abnormal findings on radionuclide angiographic images and early blood pool phase, but increased activity was found during delayed blood pool phase. All other non-OCH orbital tumours did not have this tracer pattern. The radioactivity ratios of tumour to nontumour were 2.96±0.05 and 1.14±0.25, respectively, which had a statistically significant difference (t=15.18, P<0.001). Although nine of 10 OCH patients were diagnosed correctly with one false-positive case using ultrasound, both CT and MRI could not provide a definitive diagnosis.

Conclusion

^99mTc-RBC scintigraphy is a reliable and useful procedure for the diagnosis of OCH. It may be considered as one of the routine clinical screening tools for the diagnosis of OCH and as a complement investigation to ultrasonography and CT.

Superolateral Orbitotomy for Intraorbital Tumors: Comparison with the Conventional Approach

Objectives This study aims to compare the surgical and functional outcomes of superolateral orbitotomy (group A) and conventional superior orbitotomy (group B) for benign orbital tumors. Design A retrospective review of 31 consecutive orbital tumor surgeries with the fronto-orbital approach was conducted. Setting Procedures were performed at two institutions by a single surgeon. Participants A total of 31 orbital tumor patients participated in this study. Overall, 11 intraconal and 2 extraconal tumors in group A and 11 intraconal and 7 extraconal tumors in group B were resected by superolateral orbitotomy, respectively. Main Outcome Measures Demographic information, pre- and postoperative neurological findings and neuroimaging data, and pathological data were collected. Surgical and functional outcomes were compared and statistically analyzed between the two different surgical procedures. Results The surgical outcomes were not significantly different between the two groups. In patients with intraconal tumors, the functional outcome was significantly better in group A than in group B. Conclusion Superolateral orbitotomy provides better functional outcomes.

Endonasal endoscopic approach for removal of intraorbital cavernous hemangioma in childhood

BACKGROUND

Orbital cavernous hemangiomas are the most common primary benign orbital tumors in adults. Although a rudimentary lesion may be present at birth, cavernous hemangiomas do not usually become symptomatic until the third to fifth decade of life and lesions occurring in pediatric age are quite rare. Surgical treatment is indicated in symptomatic cases, and surgical approach is planned according to the localization of the tumor in the orbit.

METHODS AND RESULTS

We described the first case of pediatric intraorbital extraconal cavernous hemangioma, treated successfully by a pure endoscopic endonasal approach, and demonstrated the minimal invasiveness of this approach, without skin incision and neurovascular retraction. Review of the literature, surgical technique, pitfalls, and differences from previous reports are discussed.

CONCLUSION

Endoscopic transnasal approaches can now be considered as an alternative option to traditional external approaches in the management of medial and inferior orbital lesions in childhood.

A case of branch retinal artery occlusion following orbital cavernous hemangioma excision

PURPOSE

To report the first case of branch retinal artery occlusion (BRAO) following surgical excision of orbital cavernous hemangioma.

METHODS

A 34-year-old man was referred to our department with an orbital cavernous hemangioma compressing the optic nerve, the medial rectus muscle, and the eyeball, and resulting in a hyperemic optic disc, vascular tortuosity, and pronounced choroidal folds at fundus biomicroscopy. The patient underwent transconjunctival inferior orbitotomy and the lesion was excised entirely without intraoperative complications.

RESULTS

On the second postoperative day, best-corrected visual acuity (BCVA) decreased from 2/10 to counting fingers and fundus examination showed occlusion of the inferotemporal branch retinal artery. Fluorescein angiography and spectral-domain optical coherence tomography (SD-OCT) confirmed the diagnosis. One month of corticosteroid therapy and anticoagulation therapy were prescribed. The patient was followed up for 6 months; SD-OCT showed resolution of the retinal thickening and the retinoschisis but a new hyporeflective space in the outer retina at the fovea had appeared at 6 months follow-up. The patient's BCVA improved to 9/10 after 6 months but an absolute superior visual field defect was still present at the end of the follow-up.

CONCLUSIONS

We describe the first reported case of BRAO following orbital cavernous hemangioma excision with significant improvement of the BCVA at 6-month follow-up. The SD-OCT could be a useful tool to monitor morphologic changes of the area corresponding to the retinal ischemia.

Orbital fibrous histiocytoma mimicking cavernous hemangioma on dynamic contrast-enhanced MRA imaging

Orbital lesions include a broad spectrum of tumors, vascular abnormalities, and inflammatory conditions. High-resolution imaging has become an invaluable tool toward formulating an accurate diagnosis, and facilitates proper counseling regarding appropriate interventions. Imaging may guide whether partial excision to minimize damage to orbital structures, or en bloc removal to prevent potential recurrence, as seen in mesenchymal tumors, is indicated., Recently, dynamic contrast-enhanced magnetic resonance angiography (MRA) has demonstrated use in helping differentiate orbital vascular lesions. This imaging modality uses rapid MRI acquisition to provide noninvasive, dynamic flow information with high spatial resolution. However, even with modern imaging, reaching a diagnosis prior to histopathological analysis can be challenging. We present a case of orbital fibrous histiocytoma that appeared nearly identical to cavernous hemangioma on dynamic contrast-enhanced MRA.

Stereotactic fractionated radiotherapy for cavernous venous malformations (hemangioma) of the orbit

PURPOSE

Cavernous malformations (hemangioma) of the orbit, when symptomatic, can often be treated successfully with complete surgical excision. However, when they involve local structures in their capsule, are situated in the orbital apex, or extend through the superior orbital fissure, the risks of surgery increase significantly. In such cases, alternative treatment modalities can be explored. In this study, the authors report on the use of fractionated stereotactic radiotherapy (SFRT) for the treatment of surgically complicated cavernous malformations.

METHODS

In this retrospective cohort study, the authors reviewed the clinical and radiologic records of 5 patients treated with SFRT over the past 5 years.

RESULTS

Patients ranged in age from 30 to 65 years, and 3 out of 5 were female. Two cases involved the cavernous sinus, one involved the ophthalmic artery, one involved the posterior ciliary artery, and the last traversed the superior orbital fissure. Four had significant visual field defects. Each was treated with SFRT. A total dose of 4000 cGy divided into 20,200 cGy fractions was applied for 3 cases, while 2 other cases were treated with total doses of 4563 and 4959 cGy divided into 28 × 162 cGy and 29 × 171 cGy fractions, respectively. Rapid resolution of visual field defect was noted by 3 months, and overall tumor shrinkage was on average 60% (range: 32-79%). Follow-up was on average 23.4 months (range: 5-50 months). No complications of treatment were noted.

CONCLUSIONS

For symptomatic cavernous malformations demonstrating anatomical position that may increase risk of surgical excision, SFRT is an effective and safe method to control lesion size and improve visual function.

The role of surgical treatment in orbital vascular anomalies

BACKGROUND

The details of the surgical treatment of orbital vascular anomalies (OVAs) are not fully defined in the literature.

METHODS

Two hundred forty-nine patients who underwent surgical treatment of OVAs at our institution between January 1995 and December 2005 were included in a consecutive-series study. Each patient's clinical data, technique details, and clinical outcomes were prospectively collected. The aesthetic results were analyzed according to clinical features and treatment by using the χ (2) association test or Fisher's exact test.

RESULTS

Thirty-seven percent of the patients had OVAs involving the upper eyelid, 23% the lower lid, and 40% both eyelids. A complete resection was performed in 65.9% of the patients. A total of 379 surgeries were performed to achieve the final result. The majority of patients (98.3%) had no complaints about surgical scars. The majority of patients had no clinical treatment prior to the surgery. One or more clinical deformities were identified in association with the OVA. Those deformities included ptosis, scar sequelae due to ulceration/infection, eyelash or tarsal/ligament distortions, fibroadipose tissue residues, proptosis, or strabism. Bone deformities were present in 11.3% of the patients. A complete functional and aesthetic restoration was achieved in 66.6% of the patients.

CONCLUSIONS

Outcomes with a significant relationship to not obtain complete functional and aesthetic restoration included involvement of both eyelids, upper-eyelid involvement, older age, bilateral involvement, diffuse facial pattern OVAs, and OVAs with dimensions greater than one third of the orbit dimension.

Surgical treatment of orbital cavernomas: clinical and functional outcome in a series of 20 patients

PURPOSE

The aim of this study is to assess the efficacy and safety of surgical treatment of orbital cavernomas in terms of clinical and functional results.

METHODS

Twenty consecutive patients underwent surgical removal of a unilateral orbital cavernoma between 1999 and 2009. Indications for surgical treatment were: visual impairment, diplopia due to ocular movement impairment, progressive and disfiguring unilateral proptosis, severe retroorbital pain clearly related to the orbital cavernoma. We used a topographic classification of the lesions within the orbit. The orbit has been divided into an anterior and a posterior compartment on the axial plane and into three sectors on the coronal plane. The proptosis was quantified on MRI scans.

RESULTS

The location of the cavernoma determined the choice of the surgical approach. We performed eight lateral orbitotomies and 12 fronto-orbito-zygomatic approaches. All the tumors were completely removed as assessed at follow-up MRI. We did not record any intraoperative or major postoperative complication requiring a reoperation. The postoperative visual acuity improved in four of five patients with visual impairment, it worsened in the other case. Proptosis improved in all the patients. Diplopia improved in four patients, and did not recover in another case.

CONCLUSION

Surgical treatment of symptomatic orbital cavernomas is safe and effective. Tumor location dictates the choice of surgical approach. Visual function and cosmetic result are the main parameters to evaluate the clinical outcome. Surgical approach and dissection technique are crucial in determining the visual outcome.

Orbital cavernous hemangiomas: ultrasound and magnetic resonance imaging evaluation

Cavernous hemangioma is the most common intraorbital lesion in adults. The aim of our study was to evaluate the magnetic resonance imaging (MRI) and ultrasound (US) characteristics of cavernous hemangioma and their role in the differential diagnosis of orbital tumors. Eight patients with orbital cavernous hemangiomas, five women and three men with a mean age of 48 years were examined in a period of six years. All patients underwent MRI examination and four patients were also evaluated by US. In all cases MRI depicted a well-defined intraconal tumor. The lesions were homogeneous, isointense to muscle on T1-weighted sequence and hyperintense to muscle on T2-weighted sequence in six patients. In one patient the mass was isointense on T1WI with heterogeneous signal intensity on T2WI and in one patient the lesion had heterogeneous signal intensity on both T1- and T2-weighted sequences. After intravenous contrast medium administration, the tumors showed initial inhomogeneous enhancement with progressive accumulation of contrast material on delayed images in seven patients and initial homogeneous enhancement in one patient. On ultrasonography, the orbital masses appeared slightly hyperechoic, heterogeneous with small areas of slow blood flow. The analysis of imaging characteristics of a well-defined intraconal lesion in an adult patient with painless progressive proptosis can be highly suggestive of the diagnosis of cavernous hemangioma.

Extraconal cavernous hemangioma of orbit: A case report

Cavernous hemangioma is the most common benign noninfiltrative neoplasm of the orbit. Most cavernous hemangiomas are intraconal and lateral in location. We present a case of a cavernous hemangioma with an unusual extraconal and superomedial location.

Transconjunctival orbitotomy for orbital cavernous hemangiomas

BACKGROUND

Orbital cavernous hemangiomas, particularly those within the retrobulbar space, are approached by neurosurgeons as well as by ophthalmic surgeons. Several surgical techniques have been applied over the past decades. Less traumatic approaches in this functionally and cosmetically important region are desirable. We describe a transconjunctival approach in 39 patients with orbital cavernous hemangiomas.

METHODS

Thirty-nine patients with orbital cavernous hemangiomas were treated with transconjunctival orbitotomy. The clinical and radiologic characteristics of orbital cavernous hemangiomas were analyzed in the course of their appropriate treatment.

RESULTS

In all patients, cavernous hemangiomas were just behind the globe or were compressing it. Computed tomography and magnetic resonance imaging showed orbital cavernous hemangiomas as round, well-defined intraconal masses. In 37 cases, the tumors were removed intact, and only 1 patient suffered permanent vision loss as a result of intraoperative hemorrhage. In the other 2 cases, the tumor fragments were incompletely removed. Visual acuity increased in 6 of the 9 cases with primary visual impairment. Thirty-two patients with primary proptosis were resolved completely. Six patients with visual field defect were also improved.

INTERPRETATION

Retrobulbar intraconal cavernous hemangiomas can be removed successfully through a transconjunctival approach. However, if the tumor is close to, or touching, the orbital apex, adhering tightly to retrobulbar tissue, or combined with large draining veins, operation through other approaches must be considered.

[Craniofacial approach for orbital tumors and ultrasonic bone cutting]

BACKGROUND

Removal of orbital tumors is a difficult problem. The goal of this study was to evaluate the advantages of the craniofacial approach to remove such tumors and to evaluate ultrasonic bone cutting during the procedure.

METHOD

The authors reviewed their experience with 57 tumors of the posterior cavity using lateral craniofacial and frontal transsinus approaches. Orbital osteotomies were performed with mechanical instruments or piezoelectric bone surgery as a minimally invasive surgery. For each case, the quality of bone cutting and soft tissue damage were evaluated.

RESULTS

Craniofacial approaches are simple and fast. Under the microscope, they provide a good view of the entire posterior orbital cavity. Using Piezosurgery, the functional results are good with no soft tissue damage. These advantages balance with the increased operative time required by ultrasonic bone cutting.

CONCLUSION

This study shows the advantages of craniofacial approaches for removal of posterior orbital tumor. Moreover, the present preliminary report introduces and demonstrates the utility of piezoelectric bone surgery in craniofacial approaches for orbital tumors.

Combined transconjunctival–eyebrow approach providing minimally invasive access to all orbital quadrants

✓Surgical approaches to treat orbital disease should provide a good exposure of intraorbital anatomical structures, allow their functional preservation, and provide good cosmetic results. The authors describe a minimally invasive, combined transconjunctival–eyebrow approach to all orbital quadrants in a step-wise manner. The indications, advantages, and limitations of the technique are highlighted.

A transconjunctival approach via the postseptal area is described. It allows exposure of the medial, inferior, and lateral parts of the orbit. Depending on the orbital space to be exposed, a lateral or a medial eyebrow incision is then made. The eyebrow and the conjunctival incisions are connected by subperiosteal dissection. This combined access provides exposure to all intraconal muscles and to the superior, medial, lateral, and inferior portions of the optic nerve.

The combined transconjunctival–eyebrow approach provides an excellent orbital exposure, with minimal damage to the circumjacent structures. It requires less operative time than other approaches and yields good cosmetic results. Intracranial or intrafacial tumor extension and tumors located purely in the orbital apex are limitations for the use of this technique.

The "devil's touch"; visual loss and orbital surgery. A synopsis of the Mustardé Lecture, 2006

Visual loss is a devastating complication after orbital surgery, particularly that at the orbital apex or alongside the optic nerve. The clinical characteristics of 14 such patients, representing less than 1% of orbital surgery performed, are presented and the possible mechanisms discussed. The majority of patients suffered a posterior ischaemic optic neuropathy and this is likely to be related to postoperative vasospasm induced by extravasated blood and inflammatory mediators.

Cavernous malformations of the orbit: a distinct entity? A review of own experiences

We collected data to provide evidence that orbital cavernous malformations (CMs) are histopathologically, neuroradiologically, and clinically different from cerebral CMs and may represent a distinct entity. In this study, the main clinical, histopathological and radiological characteristics of 19 patients (11 females and eight males, mean age 49.1 years) with orbital CMs out of a series of 376 orbital tumors are analyzed and compared with 107 cases with cerebral CMs treated in the same period. Decrease of visual acuity and painless progressive proptosis were the main clinical signs observed in 17 patients (89%). Complete microsurgical excision of lesions via individualized approaches was obtained in all cases. Follow-up examinations were obtained after a mean of 3.1 years (11 months to 7 years) and yielded complete recovery in 14 patients, while five remained clinically unchanged. Based on clinicopathological and neuroradiological studies of these 19 patients with orbital and 107 patients with cerebral CMs treated in the same period, we found evidence that orbital CMs have specific features to distinguish them from cerebral CMs. Orbital CMs, in contrast to the cerebral CMs, showed non-degenerated well-developed vessel walls and were covered by a hard and compact capsule. Clinical symptoms are characterized by the growth of orbital CMs due to intraluminal thrombosis and subsequent recanalization of cavernous vessels; there were no signs of hemorrhage. We found evidence to suggest that orbital CMs represent a distinct clinicopathologic and neuroradiologic entity.

Transconjunctival approach for retrobulbar intraconal orbital cavernous hemangiomas. Orbital surgeon's perspective

BACKGROUND

Cavernous hemangioma is the most common benign intraorbital tumor found in adults. Most cavernous hemangiomas are located within the intraconal space. When indicated, complete surgical removal is the only treatment option. Several surgical techniques have been refined over the past decades. We describe our experience over transconjunctival approach in 24 patients with retrobulbar intraconal orbital cavernous hemangiomas.

METHOD

This retrospective study includes 24 nonrandomly selected patients who had retrobulbar intraconal tumors. The presumptive preoperative diagnosis was based on magnetic resonance imaging findings. Compression on the optic nerve and/or the globe and proptosis constituted indications for surgery. The tumor was exposed via a transconjunctival route after temporarily disinserting an extraocular muscle depending on the location of the lesion.

RESULTS

In all patients, the tumor was in touch with the globe and in most cases extended to the orbital apex. All tumors were removed intact. In 14 patients, tumors were extirpated with the aid of a cryoprobe. Visual acuity increased in 8 patients and remained stable in the rest. No serious or permanent complications were observed during or after the operation.

CONCLUSIONS

Retrobulbar intraconal cavernous hemangiomas can be removed successfully through a transconjunctival approach with minimal damage to surrounding tissues. This method is best for tumors whose anterior borders are in contact or very close to the eye even if the posterior border abuts the orbital apex.

Differentiation of cavernous hemangioma from schwannoma of the orbit: a dynamic MRI study

OBJECTIVE

The purpose of this study was to determine the capability of dynamic contrast MRI to differentiate hemangioma from schwannoma of the orbit.

MATERIALS AND METHODS

Sixteen patients (three males and 13 females; mean age, 39 +/- 17.3 [SD] years; age range, 10-71 years) with unilateral orbital tumors, including eight cavernous hemangiomas and eight schwannomas, were examined. In addition to conventional MRI, we performed a dynamic contrast study (fast spin-echo sequence, 20-sec interval) after bolus administration of the contrast material (gadopentetate dimeglumine, 0.1 mmol/kg). We evaluated the features of the contrast enhancement spread pattern and the tumors' time-intensity curves.

RESULTS

In the early phase, all the hemangiomas started the enhancement from one point or portion, although all the schwannomas started the enhancement from a wide area. The difference in the contrast-enhancement spread pattern features between the two types of tumors was statistically significant (p < 0.0001). The gradient of the time-intensity curve did not show a significant difference.

CONCLUSION

Hemangioma and schwannoma of the orbit can be differentiated by the contrast-enhancement spread pattern on dynamic MRI.

Orbital Cavernous Hemangioma: Role of Imaging

CT and MR imaging are particularly important in the diagnostic investigation of patients with vascular disorders of the orbit. The improved image quality of CT and MR imaging, along with dynamic CT angiography, MR angiography, MR venography, and multiphase dynamic contrast CT/MR imaging, has proven useful to delineate as well as differentiate various orbital vascular lesions. This article presents the current classification of orbital vascular disorders and describes the CT/MR imaging characteristics of orbital cavernous hemangiomas and simulating lesions.

Radiologic and surgical aspects of pure spinal epidural cavernous angiomas. Report on 5 cases and review of the literature

BACKGROUND

Cavernous angiomas (CAs) that are localized completely in the spinal epidural space are uncommon vascular malformations. Although they have increasingly been reported in the literature in recent years, diagnostic and surgical features are not clearly defined.

METHODS

We report five patients with pure spinal epidural cavernous angiomas (PSECAs) and review the literature, focusing on their radiologic and surgical characteristics. We also compare these tumors with other extra-axial CAs as well as with their intra-axial counterparts.

RESULTS

PSECAs, like all other extra-axial CAs, differ from intra-axial ones on MRI: the hemorrhagic variant is less frequent, hemosiderin rim is rare, the signal is different, and contrast enhancement is the rule. They are very similar to spinal meningiomas but they differ in their growth pattern and morphology, since they infiltrate intervertebral foramina and have an oval shape. In PSECA, intraoperative bleeding is rarely profuse, in contrast to other extra-axial CAs, especially those of the cavernous sinus.

CONCLUSIONS

On MRI, PSECAs and other extra-axial CAs constitute a homogeneous group since they enhance significantly. At operation, since there is rarely enough bleeding to limit removal, radical excision of PSECAs can be achieved with good results.

Transnasal endoscopic removal of an orbital cavernoma

The approach to posterior and medial orbital tumors is still a challenge, since poor functional results are frequent. We report a case of cavernoma successfully removed by a modified transnasal endoscopic procedure. The patient, a 56-year-old woman, complained of a decrease in vision of the left eye. Magnetic resonance imaging evidenced a lesion in the posterior part of the orbital cavity, inferior to the optic nerve, extending to the sphenoidal cleft. The lesion was isodense on T1-weighted images and showed contrast enhancement. Because of the medial location of the tumor, the patient was referred to the otolaryngology department by the neurosurgeons, and a transnasal endoscopic approach was chosen. A large exposure of the operative field was obtained, and a cavernoma was removed. Rapid relief of the symptoms was obtained. In view of this good result, we advocate the transnasal endoscopic approach in cases of inferomedial and posterior intraconal lesions as an alternative and addition to the standard techniques of orbital surgery.