Ординатура / Офтальмология / Учебные материалы / Color Atlas of Ophthalmology The Quick-Reference Manual for Diagnosis and Treatment
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3 Orbital Infections, In
am m ation, and Neoplasm s 91
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Fig. 3.10 (A) Young adult presenting with proptosis, a case of cavernous hemangioma. (B) Coronal section computed tomographic (CT) scan, cavernous hemangioma. (C) CT scan, cavernous hemangioma.
92 Color Atlas of Ophthalm ology
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Fig. 3.11 (A) Carotid cavernous fistula with left eye proptosis conjunctival congestion. (B) Restricted movements in the left eye. (C) Computed tomographic scan showing cavernous sinus involvement. Arrow marks cavernous sinus and also note prominent superior ophthalmic vein.
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Differential Diagnosis
Cavern ou s sin u s th rom bosis, pseudot um or, thyroid orbitopathy
Management
Com puted tom ograph ic scan w ith con t rast rem ain s th e in it ial procedu re of ch oice. It sh ow s dilated su perior oph th alm ic vein w ith en largem en t of th e superior orbital fissure an d erosion of th e an terior clin oid process. Ult rason ography of th e orbit sh ow s a dilated superior oph th alm ic vein , m ild th icken ing of th e EOMs, an d m e- diu m to h igh in tern al reflect ivit y from edem a. MRI w ith gadolin iu m or m agn et ic reson an ce angiography is a u sefu l tool to invest igate fu rth er, su pplem en t ing th e CT scan .
Sm all, spon t an eou s, low -flow fist ulas resolve frequen tly (u p to 40%) from th rom bosis. Em bolizat ion is in dicated on ly w h en vision loss, glaucom a, or severe pain is presen t . Traum at ic h igh -flow fist ulas rarely resolve on th eir ow n . With a h igh rate of visual loss in th ese pat ien ts in ter ven t ion becom es th e ru le. Th e cu r- ren t t ren d involves in ter ven t ion al radiology w ith in t ravascular balloon s or oth er em bolizat ion via cath eter in th e in tern al carot id arter y.
Orbital Varices
Orbit al varices m ay represen t congen ial foci of an abn orm al vessel (th e m ost com - m on site is th e upp er n asal qu adran t , an d it is usu ally un ilateral) or m ay be th e late stage of oth er vascu lar abn orm alit ies.
Presentation
In term it ten t proptosis, w h ich is n onpu lsat ile an d n ot associated w ith bru it . It can affect pat ien t s from early ch ildh ood to late m iddle age.
Differential Diagnosis
Derm oid cyst , lym ph angiom a
Management
Su rger y is difficu lt because th e lesion s are friable an d bleed easily, an d in m ost cases, excision is incom plete. Indications for surgical intervention include repeated episodes of pain , th rom bosis, severe proptosis, an d opt ic n er ve com pression . Con - ser vat ive t reat m en t by CO2 laser, yt t riu m -alum in u m -garn et laser, or cau ter y is recom m en ded . Em bolizat ion is possible if feeder vessels can be iden t ified .
Mucocele
Mu coceles are cyst ic lesion s origin at ing from prim ar y obst ru ct ion of a paran asal sin us (m ost com m on ly fron t al or eth m oid sin uses) follow ing t rau m a, sin usit is, or, rarely, a t um or, th at slow ly en large causing bon e deform it y w ith erosion s of th e orbit . Con sist ing of a cyst ic m ass filled w ith m ucu s, m ucoceles m ay be bou n d by an eggsh ell layer of bon e an d w h en in fected are referred to as pyoceles.
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Presentation
Mu coceles m ost com m on ly arise from th e fron t al an d eth m oidal sin us. Pat ien ts presen t w ith a com bin at ion of proptosis, a palpable flu ct u an t m ass, h eadach e, dip - lopia, ptosis, an d epiph ora or globe displacem en t . Sw elling of th e u pper eyelid m e- dially is com m on . Pain is n ot com m on in th e absen ce of in fect ion (Fig. 3.12A–D).
Differential Diagnosis
Derm oid cyst , osteom a, pseudot um or
Management
Com pu ted tom ograph ic scan sh ow s an op acified fron t al or eth m oidal sin u s, loss of eth m oid septae, an d a bony deh iscen ce. Th e cyst ic con ten t sh ow s variable den - sit y an d is n on en h an cing. Ult rason ography reveals a ver y w ell-defin ed m ass w ith sh arp su rface spikes an d low in tern al reflect ivit y. Mucocele is associated w ith a ver y large bony defect adjacen t to a paran asal sin u s. Treat m en t is su rgical rem oval of th e cyst lin ing an d reestablish m en t of n orm al drain age. Obliterat ion of th e sin u s w ith fat or m u scle m ay be n ecessar y to t reat recu rren ces.
Metastatic Orbital Lesions
Th ese lesion s represen t 2 to 10%of all orbital t um ors. In ch ildren , n euroblastom a, Ew ing sarcom a, an d acute m yeloid leu kem ia are com m on . Th e m ost com m on pri- m ar y sites in adu lt s are th e breast , bron ch u s, p rostate, skin m elan om a, gast roin - test in al t ract , an d kidn ey.
Presentation
A m ass in th e an terior orbit cau sing axial or n on axial displacem en t of th e globe is m ost com m on . In filt rat ion of orbit al t issue ch aracterized by ptosis, diplopia, an d in durated skin su rroun ding th e orbit is com m on . In flam m ator y react ion is seen . It m ay be seen presen t ing eith er as proptosis w ith decreased visual acuit y, diplopia, pain , paresth esia, in creased in t raocular pressure, an d exp osure keratopathy, or in cases of cicat rizing carcin om as su ch as cer t ain secon daries from th e breast , as en - oph th alm os (Fig. 3.13A–D).
Differential Diagnosis
Orbit al pseudot um or, rh abdom yosarcom a, leukem ias
Management
Treat m en t is aim ed at preser ving vision an d relieving p ain . Th e m ain opt ion s are radioth erapy an d h orm on al th erapy (th e lat ter in cases of breast an d prost at ic m e- t ast asis). Ch em oth erapy is often useful in con t rolling th e system ic disease. A biopsy m ay som et im es be requ ired to est ablish th e n at u re of th e prim ar y. Gen erally, on ly palliat ive th erapy can be offered .
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Fig. 3.12 (A) Orbital abscess from frontal sinus with pansinusitis. (B) CT scan axial section showing the orbital abscess. (C) CT scan sagit tal section showing spread of infection behind the orbital septum . (D) The patient also has ethmoidal and maxillary sinusitis.
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Fig . 3.13 (A) Eight-year-old girl suffering from leukemia.
(B) Computed tomographic scan, leukemia involving the orbit. (C) Neuroblastoma. (D) Secondaries in orbit.
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Lacrimal Gland Enlargement
Lacrimal Gland Inflammation
In flam m ator y cau ses, w h ich are n ot u n com m on , in clude dacr yoaden it is, sarcoid - osis, an d orbital in flam m ator y pseudot u m or. A decreased Sch irm er test suggest s an in flam m ator y lesion .
Lacrimal Gland Tumors
Benign Mixed Tumor (Pleomorphic Adenoma)
Th ese are slow ly grow ing lesion s u su ally seen in th e fou r th to fifth decades of life.
Presentation
A long h istor y of m ore th an 1 to 2 years is gen erally obtain ed, an d it u su ally presen ts as a n on in filt rat ing lesion in th e lacrim al glan d area w ith fulln ess of th e su perotem poral lid an d orbit an d pain less in feron asal proptosis. Th e upper lid con - tour m ay t ake an ̴ sh ape (Fig. 3.14).
Differential Diagnosis
In flam m ator y lesion s, t u m ors of th e lacrim al glan d, derm oids
Management
Com pu ted tom ograp h ic scan sh ow s a w ell-circum scribed, pseu doen capsu lated lesion in th e lacrim al fossa.
Pat ien ts w ith a long-st an ding, pain less, slow ly grow ing m ass w ith a w ellcircum scribed appearan ce on im aging st u dies are presu m ed to h ave a pleo- m orph ic aden om a.
Treat m en t is ext irpat ion , con sist ing of a lateral orbitotom y w ith in t racapsular rem oval of all lesion al t issue w ith carefu l at ten t ion to preven t violat ion of th e pseu docapsu le.
Fig. 3.14 Mass in upper orbital region in young girl.
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In cision al biopsy of th ese lesion s is con t rain dicated becau se, alth ough h istologically ben ign , in com plete excision often leads to repeated recu rren ces (as h igh as 30%in som e st udies) an d m align an t t ran sform at ion .
Sm all, fingerlike prot u beran ces ou tside th e m ain t u m or bu lk w ith su bsequen t seeding of th e residu al t u m or are believed to be respon sible for th is ph en om - en on .
For pleom orph ic aden om as, long-term st u dies reveal an in creased in ciden ce of m align an t t ran sform at ion (10% at 20 years an d 20% at 30 years) associated w ith m ult ip le recu rren ces for lesion s th at h ad frequen t in cision al biopsies an d in com p lete rem oval of th e prim ar y t u m or.
Adenoid Cystic Carcinoma
Aden oid cyst ic carcin om a is th e m ost com m on m align an t lacrim al glan d t u m or, represen t ing 50%of m align an t t um ors of th e lacrim al glan d an d 25%of all lacrim al glan d t u m ors.
Presentation
Most cases are seen in th e th ird decade of life w ith a secon d bim odal peak in th e teen age years. Aden oid cyst ic carcin om as an d oth er m align an cies can also presen t w ith pain secon dar y to perin eu ral or bony involvem en t . Dip lopia an d dim in ish ed visu al acuit y can be seen w ith rapidly progressive lesion s. Aden oid cyst ic carci- n om a u su ally p resen t s as an irregular m ass, produ cing bony erosion (70%) an d occasion al calcificat ion (20%).
Differential Diagnosis
In flam m ator y lesion s, t u m ors of th e lacrim al glan d, derm oids
Management
Aden oid cyst ic carcin om as carr y a poorer progn osis becau se of bony exten sion an d perin eu ral in filt rat ion . Th ese pat ien t s h ave a 50%at 5-year an d 75%at 15-year m ort alit y rate. Death is com m on ly due to in t racran ial spread an d pu lm on ar y m e- tast asis. Histological pat tern is also of progn ost ic sign ifican ce, w ith a cribriform pat tern h aving a 70% at 5-year sur vival com pared w ith a 20% at 5-year su r vival w ith a basaloid pat tern . CT scan , along w ith clin ical appearan ce, h elps in preopera- t ive diagn osis. Treat m en t con sist s of en bloc com plete su rgical excision of th e orbit an d its con ten t s (Fig. 3.15A–D).
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Fig. 3.15 (A) Exenteration done in a 35-year-old woman with adenoid cystic carcinoma. (B) Spectacle prosthesis. (C) Exenteration done in a 35-year-old wom an with adenoid cystic carcinoma. (D) Same patient, spectacle prosthesis.
4 External Diseases
Guillerm o Sim ónCastellví, Pablo Gili-Manzanaro, Sarabel Sim ónCastellví, José María Sim ónCastellví, Crist ina Sim ónCastellví, and
José María Sim ón-Tor
Blepharitis and Ocular Rosacea
Anterior blepharitis is a bilateral chronic inflam m atory process of the eyelids, w hich m ay secondarily result in corneal and conjunctival changes, w ith severe dry eye. It m ay result in corneal and conjunctival irritation due to the secretion into the eye of inflam m ator y substances and alteration of the oily layer of the tear film .
St aphylococcal bleph arit is, seborrh eic bleph arit is, an d acn e rosacea w ith lid an d ocu lar involvem en t are com m on ly foun d in pat ien ts w ith bleph arit is. Hordeolum an d ch alazion form at ion is also com m on ly seen .
Presentation
Presen tat ion in clu des itch ing, irritat ion , tearing, foreign body sen sat ion , crust ing on th e lid m argin s, lash loss (m adarosis) or lash m isdirect ion (t rich iasis), u lcerat ion of th e lid m argin (t ilosis), red an d th icken ed eyelids, an d ch ron ic conju n ct ivi- t is. Meibom it is (sebaceou s glan d dysfu n ct ion ) m ay also be presen t (Fig. 4.1A–D).
Infect ious: Fibrin collaret tes on th e lash es
Seborrheic: Seborrh eic derm at it is, tear film in st abilit y
Ocular rosacea: Greasy skin ; facial telangiect asia; er yth em a of th e ch eeks, fore- h ead; an d n ose; rh in ophym a. Com m on ly, p eriph eral corn eal im m un e in filt rates (asept ic, du e to staphylococcal t ype IV hypersen sit ivit y)
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Fig. 4.1 (A) Fibrin collaret tes; (B,C) lid margin telangiectasia; (D) erythem a of the cheeks in a patient with ocular rosacea.
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