ORBIT Part 2 May resolve spontaneously

Dr. Sua
CAPILLARY HEMANGIOMA
• Most common orbital tumour in children
• Presents - 30% at birth and 100% at 6
mos
• Most common superior anterior orbit
• May enlarge on coughing or straining
• Associated ‘strawberry’ naevus
Natural history
• Growth during first year
• Subsequent resolution - complete in 70%
by age 7 yr
Systemic associations
• High output cardiac failure
• Kasabach-Merritt syndrome -
thrombocytopenia, anaemia
• Maffuci syndrome - skin haemangiomas,
enchondromata
Treatment
• Steroid injections - for superficial
component
• Systemic steroids
• Local resection - difficult
CAVERNOUS HEMANGIOMA
• Most common benign orbital tumour in
adults
• Usually located just behind globe
• Female preponderance - 70%
• Presents - 4th to 5th decade
NEURAL TUMORS
OPTIC NERVE GLIOMA
• Typically affects young girls
• Associated neurofibromatosis -1 is
common
• Presents - end of first decade with
gradual visual loss
• Gradually progressive proptosis
• Optic atrophy
Treatment
• Observation - no growth, good vision and
good cosmesis
• Excision - poor vision and poor cosmesis
• Radiotherapy - intracranial extension
Histo: Rosanthal Bodies
OPTIC NERVE SHEATH MENINGIOMA
Typically affects middle-aged women
Gradual visual loss due to optic nerve
compression
Optociliary shunts in 30%
Proptosis due to intraconal spread
Thickening and calcification on CT
Treatment
• Observation - slow-growing tumours
• Excision - aggressive tumours and poor
vision
• Radiotherapy - slow-growing tumours and
good vision
NEUROFIBROMAS

Slowly progressive axial proptosis Consist of Schwann cell within nerve sheaths
May cause choroidal folds Plexiform type are vascularized lesions
May have axons, fibroblast and mucin
Treatment - surgical excision contents

HEMANGIOPERICYTOMA NEUROFIBROMATOSIS

Rare tumor Von Reklinghausen (neurofibromatosis type

Encapsulated, hypervascular, hypercellular 1)
Middle age preponderance Hamartomas involve skin, eyes, nervous
Pericytes surround capillary network system, viscera
Several associated disorders:
LYMPHANGIOMA  Café-au-lait spots
 Fibroma
Vascular malformation with venous and  Neurofibroma
lymphatic components
 Glaucoma
Infiltrative growth is characteristic and are
 Optic nerve glioma
non-encapsulated
May present as “chocolate cyst” if
SCHWANOMMA
hemorrhages occur
Neurillemoma
Schwann cell proliferation with perineurium
encapsulation
Seldom undergoes malignant transformation
MESENCHYMAL TUMOR
RHABDOMYOSARCOMA
• Most common primary childhood orbital
malignancy
• Rapid onset in first decade ( average 7
yrs )
• May involve any part of orbit
• Palpable mass and ptosis in about 30%
Treatment
• Radiotherapy and chemotherapy
• Exenteration for radio-resistant or
recurrent tumours
LYMPHOPROLIFERATIVE DISORDER
LYMPHOMA
Presents - 6th to 8th decades
Affects any part of orbit and may be bilateral
Anterior lesions are rubbery on palpitation
May be confined to lacrimal glands
Treatment
• Radiotherapy - localized lesions
• Chemotherapy - disseminated disease
LACRIMAL GLAND TUMOR
PLEOMORPHIC LACRIMAL GLAND
ADENOMA
 Presents - 4th to 5th decade
 Painless and very slow-growing, smooth
mass in lacrimal fossa
 Inferonasal globe displacement
 Posterior extension may cause proptosis
and ophthalmoplegia
 Smooth, encapsulated outline
 Excavation of lacrimal gland fossa without
destruction
LACRIMAL GLAND CARCINOMA
• Presents - 4th to 6th decades
• Very poor prognosis
• Painful, fast-growing mass in lacrimal
fossa
• Infero-nasal globe displacement
• Posterior extension may cause proptosis,
ophthalmoplegia and episcleral
congestion
• Trigeminal hypoaesthesia in 25%
Management
• Biopsy
• Radical surgery and radiotherapy
METASTATIC TUMORS
CHILDHOOD METASTATIC TUMORS
A. NEUROBLASTOMA
• Presents in early childhood
• May be bilateral
• Typically involves superior orbit
B. CHLOROMA
• Presents at about age 7yrs
• Rapid onset proptosis
• Subsequent dissemination to full-
blown leukaemia
ADULT METASTATIC TUMORS
Common primary sites - breast, bronchus,
prostate, skin melanoma, gastrointestinal
tract and kidney
Presentations
 Anterior orbital mass with non-axial globe
displacement
 Enophthalmos with schirrous tumours
 Similar to pseudo-tumour
 Cranial nerve involvement at apex and
mild proptosis
TRAUMA
Transferred by: Jobern Hipol
ORBITAL FLOOR BLOW-OUT FRACTURE
Slides courtesy of: EJ Go
Signs of orbital floor blow-out fracture
• Periocular ecchymosis and edema
• Infraorbital nerve anaesthesia
• Ophthalmoplegia - typically in up-
and down-gaze (double diplopia)
• Enophthalmos - if severe

Investigations of orbital floor blow-out

fracture
Coronal CT scan
• Right blow-out fracture with ‘tear-
drop’ sign
Hess test
• Restriction of right upgaze and
downgaze
• Secondary overaction of left eye

Surgical treatment of blow-out fracture

(a) Subciliary incision
(b) Periosteum elevated and entrapped
orbital contents freed
(c) Defect repaired with synthetic material
(d) Periosteum sutured
• Coronal CT scan following repair of
right blow-out fracture with synthetic
Material

MEDIAL WALL BLOW-OUT FRACTURE

Signs
Periorbital subcutaneous emphysema
Ophthalmoplegia - adduction and abduction
If medial rectus muscle is entrapped
Treatment
• Release of entrapped tissue
• Repair of bony defect