Conservative management of orbital lymphangioma

Interventions for orbital lymphangioma

BACKGROUND

Orbital lymphangiomas are a subset of localized vascular and lymphatic malformations, which most commonly occur in the head and neck region. Orbital lymphangiomas typically present in the first decade of life with signs of ptosis, proptosis, restriction of ocular motility, compressive optic neuropathy, and disfigurement. Therefore, early and effective treatment is crucial to preserving vision. Due to proximity to vital structures, such as the globe, optic nerve, and extraocular muscles, treatment for these lesions is complicated and includes a large array of approaches including observation, sclerotherapy, systemic therapy, and surgical excision. Of these options, there is no clear gold standard of treatment.

OBJECTIVES

To assess the evidence supporting medical and surgical interventions for the reduction/treatment of orbital lymphangiomas in children and young adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 5); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 May 2018.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) comparing at least two of the following interventions with each other for the treatment of orbital lymphangiomas: observation; sildenafil therapy; sirolimus therapy; sclerotherapy; surgery (partial or complete resection). We planned to include trials that enrolled children and adults up to 32 years of age, based on a prior clinical trial protocol. There were no restrictions regarding location or demographic factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles, abstracts, and full articles to assess their suitability for inclusion in this review. No risk of bias or data extraction was performed because we did not find any trials for inclusion. If there had been RCTs, two authors would have assessed the risk of bias and abstracted data independently with discrepancies being settled by consensus or consultation with a third review author.

MAIN RESULTS

There were no RCTs that compared any two of the mentioned interventions (medical or surgical) for treating orbital lymphangiomas in children and young adults.

AUTHORS' CONCLUSIONS

Currently, there are no published RCTs of orbital lymphangioma treatments. Without these types of studies, conclusions cannot be drawn regarding the effectiveness of the medical and surgical treatment options for patients with orbital lymphangiomas. The presence of only case reports and case series on orbital lymphangiomas makes it clear that RCTs are needed to address the differences between these options and help guide treatment plans. Such trials would ideally compare outcomes between individuals randomized to one of the following treatment options: observation, sclerotherapy, systemic sirolimus therapy, systemic sildenafil therapy, and surgical excision.

D-dimer evaluation of hemorrhagic orbital lymphangioma

An 8-year-old boy with recurrent acute bleeding of lymphangioma of the left orbit is described. D-dimer levels increased as the size of the mass became stable, showing the effect of fibrinolysis within the hemorrhagic mass after clotting. D-dimer levels confirmed the possible use of conservative management of this lymphangioma.

[Vascular lesions of the orbit in children]

Vascular lesions of the orbit in children are most often hemangiomas and lymphangiomas. Hemangioma is a tumor that tends toward spontaneous regression. Lymphangioma is a malformation that tends to increase in size with growth spurts that can occur until adulthood. The treatment is decided according to the functional impact.

Lymphangioma of the conjunctiva and nasal cavity in a child presenting with diffuse subconjunctival hemorrhage and nosebleeds

A 4-year-old girl had extensive subconjunctival hemorrhage in the right eye. She had recurrent minor nosebleeds starting at 6 months. Visual acuity was 20/20. Anterior segment examination showed diffuse, blood-filled, multilobulated cystic channels in the conjunctiva. Bleeding resolved, leaving transparent cystic channels. Conjunctival lymphangioma can manifest as temporary subconjunctival lymphangioma.

Sclerosing therapy as first line treatment for low flow vascular lesions of the orbit

PURPOSE

To evaluate the outcome of sodium morrhuate 5% injections in patients with low flow vascular lesions, which consist of orbital lymphangiomas, and in one patient with intraosseous cavernous hemangioma.

DESIGN

Prospective, interventional consecutive case series.

METHODS

Intralesional sodium morrhuate 5% was injected under direct visualization or under radiographic guidance to six patients with orbital lymphangiomas and one patient with intraosseous cavernous hemangioma. Comprehensive eye examination and follow-up imaging studies were performed. main outcome measures: Lesion size was evaluated by orbital imaging and clinical examination, visual acuity, exophthalmos, and posttreatment complications.

RESULTS

Seven patients (four female, three male; average age, 33 years) were included. Six patients were diagnosed with orbital lymphangioma, and one patient was diagnosed with intraosseous cavernous hemangioma. Patients received an average of 2.6+/-2 intralesional injections of sodium morrhuate, with a range of one to six injections and a mean volume of 0.9+/-0.8 ml (range, 0.2 to 2.1 ml). Lesions showed a decrease in size an average of 50% (33%) and ranged from minimal (10%) to near total resolution (85%). Visual acuity and intraocular pressure remained unchanged; exophthalmos decreased an average of 1.5+/-1.8 mm. Complications included one case of orbital hemorrhage that resolved spontaneously and transient keratopathy in all patients with anterior orbital lesions.

CONCLUSION

Intralesional sclerosing therapy with sodium morrhuate 5% is effective in tumor debulking in patients with orbital lymphangioma and is not associated with vision-threatening complications. It may be a better alternative to surgery for low flow orbital tumors, which includes lymphangioma.

Lack of Response to Systemic Corticosteroids in Patients with Lymphangioma

Lymphangioma is a benign nonencapsulated orbital tumor that is difficult to treat. Recently, systemic corticosteroids were advocated as a safe and effective alternative to surgical drainage of the cysts. We describe our experience with 3 cases in which proptosis progressed or did not improve despite the exclusive use of systemic steroids for 1 week, necessitating urgent surgical intervention. These three cases demonstrate that at least in some cases, steroids alone may be ineffective, and alternative interventions must be undertaken.

Intralesional Injection of Tisseel Fibrin Glue for Resection of Lymphangiomas and Other Thin-Walled Orbital Cysts

PURPOSE

Surgical removal of orbital lymphangiomas is often difficult because the capsule of these lesions is fragile, and, once violated, it tends to collapse, making identification of residual tumor difficult and dissection often incomplete. A surgical technique combining partial controlled decompression of the lesion with intralesional injection of Tisseel fibrin glue is evaluated to determine its effectiveness in resecting the lesion and preventing recurrences.

METHODS

This is a retrospective interventional case series. Three young patients, two with lymphangiomas and one with congenital hydrocystoma, underwent surgical resection of their thin-walled cystic lesions of the orbit with the use of intralesional injection of Tisseel fibrin glue. Resolution of the signs and symptoms, complications of the surgery, and recurrence of bleeding are the parameters studied.

RESULTS

All 3 patients had improvement of their signs and symptoms. None had complications related to the surgery, and no recurrence of bleeding occurred during the follow-up period.

CONCLUSIONS

Our study suggests that this surgical technique with intralesional injection of Tisseel fibrin glue is an effective treatment modality for the resection of lymphangiomas and other orbital thin-walled cystic lesions.

Two cases of orbital lymphangioma associated with vascular abnormalities of the retina and iris

PURPOSE

To report 2 patients with combined intraocular and orbital vascular abnormalities.

DESIGN

Two interventional case reports.

MAIN OUTCOME MEASURES

Clinical and pathologic findings. INTERVENTION/TESTING: Orbitotomy, fluorescein angiography, magnetic resonance imaging, and radiation therapy.

RESULTS

Two patients presented with vision loss, intermittent proptosis, and cosmetic deformity. These patients had orbital lymphangioma, ipsilateral retinal and iris vascular malformations, and smaller corneal diameter on the affected side.

CONCLUSIONS

The coexistence of these diverse vascular anomalies supports the established hypothesis of pluripotential orbital vascular anlagen. Disruptive influences of various types during embryogenesis or development may produce a variety of congenital orbital and intraocular vascular malformations.

Systemic corticosteroid use in orbital lymphangioma

PURPOSE

To describe the clinical results of systemic corticosteroid use in a series of patients with orbital lymphangioma.

METHODS

Four patients (two adults and two children) were treated with corticosteroids using intravenous, oral, or both routes for 2 days to a month. Corticosteroids were used with and without other therapies for symptomatic exacerbations.

RESULTS

The adults showed more improvement with pain than with swelling, whereas the children had improvement with both the signs and symptoms. There were no complications in any patient.

CONCLUSIONS

Systemic corticosteroids are a useful therapeutic option for patients with orbital lymphangioma and can be used as an adjuvant treatment to surgery and other modalities. Resolution of symptoms with corticosteroids was expedited compared with the natural history of the disease in the patients studied.