Etiologies of Proptosis: A review

Novel cause of bilateral proptosis in a child: orbital extramedullary haematopoietic tissue due to iron deficiency anaemia

SummaryChildhood proptosis is an emergency with prevalence of 1.2% in hospital admissions. It has a wide spectrum of aetiologies ranging from infective and inflammatory to neoplastic. Iron deficiency anaemia (IDA)-induced extramedullary haematopoesis (EMH) is known to cause hepatosplenomegaly but proptosis is very rare. We describe a girl in middle childhood with subacute bilateral proptosis because of orbital EMH, secondary to chronic nutritional IDA. There was no hepatosplenomegaly. Haemogram depicted severe microcytic hypochromic anaemia with wide red cell distribution width. Red blood cell indices were suggestive of IDA, but serum ferritin was elevated. Bone marrow examination showed absent iron and MRI brain was suggestive of EMH tissue in the orbits. Red blood cell transfusion was given before attempting a biopsy after which the proptosis dramatically reduced and disappeared. IDA is a common entity that rarely can cause EMH at sites other than liver and spleen.

Orbital Lesions: A bird's eye view of series of 2068 cases in 27 years in a tertiary care hospital in Pakistan

Objective

To determine the relative frequency of orbital lesions based on the site of origin and histopathology at a Tertiary care hospital (Mayo Hospital, Lahore Pakistan) from 1996 till 2022 (27 years).

Methods

This descriptive case series included 2651 patients of all age groups presenting with orbital lesions who initially got enrolled at Institute of Ophthalmology Mayo Hospital, Lahore from 1996 till 2022. Of these, 583 patients left against medical advice. So, clinical data of 2068 patients were completely analyzed. Lesions were managed medically and/ or surgically. Final clinical diagnosis, with the help of histopathology, was used to classify the lesions.

Results

There were 1258 (60.9%) adults and 810 (39.1%) children, 1358 (65.66%) were neoplastic while 710 (34.33%) non-neoplastic lesions. Amongst the neoplastic lesions, 405 (29.8 %) were benign and 953 (70.2%) malignant. Primary orbital lesions were 1676 (81.04%), Secondary orbital lesions were 300 (14.51%), Endocrine/ hematopoietic reticulo-endothelial system lesions were 84 (4.06%) and Metastatic lesions from distant organs were 08 (0.39%).

Conclusion

Retinoblastoma, rhabdomyosarcoma, optic nerve gliomata were common in children. Pleomorphic adenoma & adenocystic carcinoma of lacrimal gland, cavernous hemangioma, optic nerve meningioma, neurofibroma, schwannoma, squamous cell carcinoma of eyelid, carcinoma of maxillary antrum and lymphomas were more common in adults.

Deep learning methods for diagnosis of graves' ophthalmopathy using magnetic resonance imaging

Background

The effect of diagnosing Graves' ophthalmopathy (GO) through traditional measurement and observation in medical imaging is not ideal. This study aimed to develop and validate deep learning (DL) models that could be applied to the diagnosis of GO based on magnetic resonance imaging (MRI) and compare them to traditional measurement and judgment of radiologists.

Methods

A total of 199 clinically verified consecutive GO patients and 145 normal controls undergoing MRI were retrospectively recruited, of whom 240 were randomly assigned to the training group and 104 to the validation group. Areas of superior, inferior, medial, and lateral rectus muscles and all rectus muscles on coronal planes were calculated respectively. Logistic regression models based on areas of extraocular muscles were built to diagnose GO. The DL models named ResNet101 and Swin Transformer with T1-weighted MRI without contrast as input were used to diagnose GO and the results were compared to the radiologist's diagnosis only relying on MRI T1-weighted scans.

Results

Areas on the coronal plane of each muscle in the GO group were significantly greater than those in the normal group. In the validation group, the areas under the curve (AUCs) of logistic regression models by superior, inferior, medial, and lateral rectus muscles and all muscles were 0.897 [95% confidence interval (CI): 0.833-0.949], 0.705 (95% CI: 0.598-0.804), 0.799 (95% CI: 0.712-0.876), 0.681 (95% CI: 0.567-0.776), and 0.905 (95% CI: 0.843-0.955). ResNet101 and Swin Transformer achieved AUCs of 0.986 (95% CI: 0.977-0.994) and 0.936 (95% CI: 0.912-0.957), respectively. The accuracy, sensitivity, and specificity of ResNet101 were 0.933, 0.979, and 0.869, respectively. The accuracy, sensitivity, and specificity of Swin Transformer were 0.851, 0.817, and 0.898, respectively. The ResNet101 model yielded higher AUC than models of all muscles and radiologists (0.986 vs. 0.905, 0.818; P<0.001).

Conclusions

The DL models based on MRI T1-weighted scans could accurately diagnose GO, and the application of DL systems in MRI may improve radiologists' performance in diagnosing GO and early detection.

Unilateral Proptosis and Bilateral Compressive Optic Neuropathy in a Meningioma Patient

Unilateral proptosis can be a sign of a potential threat to vision or life. Here, we report a case of unilateral proptosis with bilateral asymmetrical compressive optic neuropathy. A 36-year-old Malaysian indigenous female presented with painless right-eye proptosis associated with progressive blurring of vision for the past month. She had painless progressive left-eye vision loss for eight years. There was marked right-eye proptosis with partial ophthalmoplegia. The optic nerve functions were significantly reduced in the left eye with a positive relative afferent pupillary defect (RAPD). Humphry perimetry showed a right superior nasal field defect. Brain imaging showed two different masses located at the suprasellar and right greater wing of the sphenoid extraaxial lesion likely representing a meningioma. She was diagnosed with bilateral compressive optic neuropathy secondary to intracranial mass and was referred to the neurosurgical team for further intervention. This case highlights that painless proptosis with early vision loss of the fellow eye may be the early presenting symptom of meningioma, without any symptoms of raised intracranial pressure. Brain imaging is warranted to rule out any intracranial pathology if a visual field defect is present.

Unusual case of 'scorbutic proptosis'

Proptosis is a frequent presenting symptom/sign of many paediatric malignancies. Acute-onset proptosis is an ophthalmic emergency that can endanger vision if not treated promptly. Appropriate treatment must be instituted only after investigating for the underlying aetiology. Here, we report a developmentally delayed boy in middle childhood who presented with recent onset bilateral proptosis. Clinical examination followed by radiological evaluation suggested scurvy to be the underlying cause and vitamin C supplementation led to prompt reversal of proptosis. The relevant literature has been reviewed and presented here to apprise the paediatric oncologists about this rare but easily treatable cause of proptosis.

Severe proptosis during cataract surgery

PURPOSE

We report an unusual case of severe proptosis during phacoemulsification in a 58-year-old female with a history of Crohn's disease, bilateral chronic panuveitis, prior bilateral central retinal vein occlusion, and uncontrolled steroid-associated ocular hypertension requiring bilateral Ahmed glaucoma drainage device (GDD) implantation with pars plana tube placement.

OBSERVATIONS

During phacoemulsification of the right eye, the patient developed significant proptosis. Following lid speculum removal and mechanical eyelid manipulation, the proptosis resolved within 20 minutes without requiring a lateral canthotomy. The patient had no permanent visual complications.

CONCLUSIONS AND IMPORTANCE

The likely pathophysiology of intraoperative proptosis in this case was accumulation of fluid in the retrobulbar space due to a functioning Ahmed tube shunt with the tube placed in the vitreous cavity. To avoid this complication, concurrent cataract surgery may be considered for patients with pars plana tube placement GDD surgery.

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.

Rare forms of inflammatory myopathies - part II, localized forms

INTRODUCTION

The idiopathic inflammatory myopathies traditionally comprise dermatomyositis, polymyositis, the anti-synthetase syndromes, immune-mediated necrotizing myopathy and inclusion body myositis. However, there are uncommon localized forms that are less known. In this review, we aimed to cover these uncommon forms.

AREAS COVERED

We identified rare forms of localized myositis on the basis of list provided by the homepage of the Neuromuscular disease center of Washington University, USA and on the basis of the authors' knowledge. We searched PubMed® for relevant articles on these forms with the aim of providing as much as possible information on their clinical manifestations as well as guidance on their work-up and treatment.

EXPERT OPINION

herein, we provide un updated description of rare forms of localized myositis. These forms are often difficult to diagnose because of their localized nature and are sometimes misdiagnosed as tumors. Knowledge about these rare forms of localized myositis can aid in their recognition and treatment.

Peripheral primitive neuroectodermal tumor of the orbit in Graves' ophthalmopathy - A rare presentation

Graves' ophthalmopathy is the most common cause of both unilateral and bilateral proptoses in adults. Peripheral primitive neuroectodermal tumor (pPNET) is a small round cell malignant lesion of neuroectodermal origin which very rarely affects the orbit. In this case report, we have discussed about a young woman with existing Graves' ophthalmopathy who presented with worsening proptosis; computed tomography imaging revealed an irregular mass lesion in the right orbit without bone erosion. Biopsy and immunohistochemistry of the mass lesion revealed features of primitive neuroectodermal tumor (PNET). The tumor was MIC-2 gene positive, and on follow-up, no recurrence was noted after successful surgical resection. PNET of the orbit is very rare, and to our best knowledge, this is the first case of peripheral PNET in patent with Graves' ophthalmopathy.

Retrobulbar Hematoma in a Patient with Thyroid Eye Disease

A 37-year-old female with a history of thyroid eye disease presented after trauma to the right side of her face. Visual acuity was light perception and a relative afferent pupillary defect was detected. There was gross proptosis of the unruptured right globe with diffuse conjunctival hemorrhage. Computed tomography revealed an intraconal retrobulbar hematoma (RBH) with anterior herniation of the globe. The extraocular muscles were thickened, consistent with her thyroid eye disease, and her superior rectus was avulsed. The optic nerve was on stretch, but there was no evidence of transection. The patient ultimately underwent enucleation with the plan for an eventual ocular prosthesis. In RBH, blood accumulates in the retrobulbar space and can lead to an increase in intraocular pressure, optic nerve stretch, or mechanical blockage of ocular perfusion. A brief review of RBH is included to emphasize the most important aspects of diagnosis and management of this vision-threatening emergency.

Acute Proptosis: A Sign of Venous Hemorrhagic Infarct

Acute proptosis is a very rare condition presenting to the emergency department. As there are very few case reports of patients with acute onset proptosis, it is important to report each new case. This case report is of a 38-year-old lady who presented to our emergency department with a headache for three days, altered sensorium for eight hours, and acute proptosis of the left eye for 40 minutes. She was diagnosed to have a venous hemorrhagic infarct in the left parietal-occipital-temporal region with thrombosis of the left transverse and sigmoid sinuses. To the best of our knowledge, there is no documented case report or study which featured acute proptosis as a clinical sign in a patient with venous hemorrhagic infarct or where acute proptosis was associated with thrombosis of a cerebral venous sinus other than cavernous sinus. This study shows that acute proptosis can be a presenting sign even in venous hemorrhagic infarct and acute proptosis can be associated with cerebral sinus venous thrombosis even without the involvement of cavernous sinus. So although rare, venous hemorrhagic infarct and cerebral venous sinus thrombosis irrespective of the venous sinus involved should be considered in any patient presenting to the emergency department with acute onset proptosis.

Predictors of Surgical Intervention for Pediatric Acute Rhinosinusitis with Periorbital Infection

Background: Medical versus surgical management of pediatric periorbital infection secondary to acute bacterial rhinosinusitis (ABRS) can be a dilemma for clinicians. This study aimed to evaluate the prognostic factors related to the need for surgical drainage and to help direct management decisions. Methods: Children admitted for periorbital infection secondary to ABRS between 2001 and 2019 were retrospectively reviewed. Demographics, clinical presentations, laboratory data, comorbidities, and computed tomography results were collected from medical records. Results: A total of 141 pediatric patients were enrolled. Forty-two patients (29.8%) required surgical intervention. Multivariate logistic regression analysis identified that delayed initiation of intravenous antibiotics from the onset of periorbital swelling (odds ratio [OR] = 1.94; p < 0.001) and proptosis at initial presentation (OR = 6.63; p = 0.008) were significantly associated with the need for surgical intervention. A C-reactive protein value of > 55.73 mg/L and initiation of intravenous antibiotic treatment > 2 days from the onset of periorbital swelling showed the best predictive power for surgery. Conclusions: Pediatric patients with delayed initiation of intravenous antibiotic treatment and initial presentation of proptosis had worse outcomes and required surgical intervention.

Adenoid cystic carcinoma of sinonasal origin masquerading as an intraconal lesion

Adenoid cystic carcinoma is an uncommon tumour of the salivary glands, although affliction of mucin-producing glands present in the oral cavity, oropharynx and paranasal sinuses is not uncommon. Other possible sites are lacrimal, oesophagus, trachea-bronchial tree, lungs, uterus, cervix, prostate. These tumours have a tendency to be aggressive and most show invasion into the adjacent region. Adenoid cystic carcinoma contributes to about 0.3% of all sinonasal tumours.

Evaluation of Proptosis: A Primer

Collapse