Cavernous haemangioma is the most common primary benign vascular
orbital tumour.1 It presents with painless unilateral proptosis that is
reducible and associated with hyperopia.2 Most cavernous
haemangiomas are intraconal and lateral in location. They result from new
vessel formation, proliferation of tissue components of the vessel wall, and
hyperplasia of cellular elements of vascular origin.3 Computed
tomography (CT) and magnetic resonance imaging (MRI) are of particular
importance in the diagnosis of orbital vascular lesions.
Surgical access to posterior orbit is difficult because of
the presence of delicate structures including optic nerve, ophthalmic artery
and veins, extra-ocular muscles and nerves. Surgical approaches to treat
orbital disease should provide a good exposure of intra-orbital anatomical
structures, and provide good cosmetic results. Different approaches to the
intra-orbital space have been described in the literature.4
In
an attempt to maintain this philosophy and to avoid large incisions still
providing an increased operative exposure, we describe cryo-assisted minimally
invasive approach which mostly avoids bone removal or intraconal muscle
sectioning. It provides access to the superior, medial, lateral, and inferior
quadrants of the orbit, depending on the extent of the conjunctival and eyebrow
incisions. Thus, complete exposure and resection of very large intra-orbital
lesions is feasible with reduced morbidity.
MATERIAL AND
METHODS
We
describe the outcome of 6 patients with cavernous haemangioma of the orbit
treated in our department between April 2008 and Feb 2010. Study Design was
interventional case series. Patients underwent minimally invasive surgery
through different approaches, completely removing the angiomas. All patients
with intraconal mass and a strong clinical suspicion of cavernous hemangiomas
underwent minimally invasive cryosurgical extraction. Patients having any
surgical intervention in the past were excluded from the study. The presenting
features of all six cases in given in table-1. Pre-op marking of site of
incision and tumor was carried out. The tumor was reached either by lateral
orbitotomy, a lid crease incision, or via trans- conjunctival approach
depending upon location of tumor (table 2). After securing the vascular
connections, lesion was extracted en bloc with the help of cryo-probe and blunt
dissection. Wound was closed in layers. Histopathology was carried out in the
end to confirm the diagnosis.
RESULTS
The mean age of patients was 32 years with a range of 16- 55
years. All the tumours were successfully removed en bloc with the help cryo
extraction. The vision improved in all but one cases, and table-3 shows the
comparison of pre-op and post-op visual acuity of the selected cases. The
recovery was uneventful and histopathological reports confirmed the diagnosis
of cavernous hemangioma. After a mean follow-up of nine months, no recurrence
was observed in any of the operated eyes.
CASE 1
A 32 year old female presented with a 07 years history of
painless progressive proptosis and impaired visual acuity of her right eye. She
denied history of trauma. In the past, she was given a course of systemic
steroids and biopsy was attempted elsewhere. Her systemic and medical history
was not contributory. She was admitted in another institute where she was given
a course of systemic steroids and biopsy was taken which was non diagnostic
because the sample was inadequate. She was using only lubricants on admission
to our hospital. On examination the best corrected visual acuity (BCVA) was
6/36 in right eye and 6/6 in left eye. Right eye showed proptosis, diplopia in
primary gaze, chemosis and restriction of extraocular movements in all gaze
positions. Examination of right fundus showed choroidal folds. CT scan orbit
and brain with coronal sections showed a well circumscribed intraconal lesion
in right orbit. A plan for excisional biopsy was made.
The mass in her right orbit was approached via a subciliary
incision. Extensive adhesions were encountered after opening the orbital
septum, probably from her previous biopsy. These were lysed and the rest of the
mass was extracted en masse using a cryoprobe and blunt dissection. The
recovery was uneventful. Histopathology revealed an encapsulated cavernous
haemangioma. Her vision improved to 6/9, the choroidal folds resolved and
ocular movements recovered in all gaze positions (Fig. 1 and 2).
Fig. 1: 7th
Post-op Day in OPD in primary position.
Fig.
2: Subciliary incision sutured with 7/0
Vicryl with mild lower lid post op. edema.
CASE 2
A 37 years old man presented with gradual painless proptosis
with gradual loss of vision in his left eye for the last 08 years. BCVA in
right eye was 6/6, while in the left eye was 6/60. Left eye showed axial
proptosis of 35 mm and supero-temporal dystopia of 5 mm (Fig. 3). Extra-ocular
movements were restricted in all gaze positions. There was no retropulsion or
bruit. Fundus showed choroidal folds. Examination of right eye was unremarkable.
CT scan showed a large well circumscribed intraconal lesion in left orbit (Fig.
4).
Fig. 3: Proptosis and suprotemporal dystopia of left eye.
Fig. 4: CT scan axial view showing large well circumscribed intraconal
lesion in left orbit.
Fig. 5: Three weeks after the surgery showing resolved proptosis
and dystopia.
The
patient was planned for orbitotomy under general anesthesia. After marking an
extended lazy S incision till zygomatic arch, lateral orbital margin was
removed and the lesion approached through blunt dissection. On opening the
periorbita, a plump, nodular, encapsulated mass with vascular channels on its
well defined surfaces was found. An apical vascular tag was identified and
cauterized; to prevent the gush of blood. A cryoprobe assisted extraction was
done. The lesion was completely excised. Wound was closed in layers. Visual
acuity of patient was checked in the evening to exclude optic nerve
compression. Histopathology confirmed the diagnosis of multi-lobulated, well
encapsulated left cavernous haeman-gioma. Vision in the left eye improved to
6/24 six weeks after the surgery (Fig. 5).
Fig. 6: Right eye with inferior dystopia and proptosis.
Fig. 7: CT Scan revealed a large extraconal, well
circumscribed lesion in supero-nasal region of right orbit.
CASE 3
A 35 years old female presented to our
hospital with inferior displacement of right eye for last 04 years associated
with gradual deterioration of vision. There was no history of trauma or any
systemic illness. On ocular examination BCVA in right eye was 6/36 while that
in left eye was 6/6. Right eye showed 6 mm inferior dystopia, 2 mm of proptosis
compared to left eye and restriction of ocular motility more marked in vertical
than in horizontal gaze (Fig. 6). There was no retropulsion or bruit. Fundus
showed choroidal folds. Examination of left eye was unremarkable. CT-Scan
revealed a large extraconal, well circumscribed lesion in supero-nasal region
of orbit (Fig. 7).
Patient
was planned for orbitotomy under general anesthesia. Pre op. marking was made
(Fig. 8). Lid crease incision extending temporally 15 mm lateral to temporal
orbital margin was made. After penetrating the septum, the lesion was
approached through blunt dissection which revealed a well encapsulated nodular
mass. Vascular connections were secured
and the lesion was removed en bloc with the help of cryoprobe (Fig. 9). It
measured 35 x 22 mm. Wound was closed in layers. Histopathology confirmed the
diagnosis of multi-lobulated, well encapsulated cavernous hemangioma. Vision in
the left eye improved to 6/12 two weeks after surgery.
Fig. 8: Right upper lid crease marking extending temporally.
Fig. 9: Lesion being removed en bloc with the help of
cryoprobe.
CASE 4
A 16 years old male presented to our
hospital with inferior displacement of right eye for last 3 years associated
with gradual deterioration of vision (Fig. 10). There was no history of trauma
or any systemic illness. On ocular examination BCVA in right eye was 5/60 while
visual acuity in left eye was 6/6. Right eye showed 07 mm inferior dystopia, 04
mm of proptosis compared to left eye and restriction of ocular motility more
marked in vertical than in horizontal gaze. There was no retropulsion or bruit.
Fundus showed choroidal folds. Examination of left eye was unremarkable. CT Scan
revealed a large extraconal, well circumscribed and encapsulated lesion in
supero-nasal region of orbit.
Patient
was planned for orbitotomy under general anesthesia. Lid crease incision
extending temporally 13 mm lateral to temporal orbital margin was made. The
lesion was reached through blunt dissection. The tumour was found to be plum
coloured well encapsulated nodular mass. After securing the vascular
connections, lesion was extracted en bloc with the help of cryoprobe. It
measured 30 X 20 mm. Wound was closed in layers. Histopathology
confirmed the diagnosis of multi-lobulated, well encapsulated left cavernous
hemangioma. BCVA in the right eye improved to 6/12 six weeks after the surgery
(Fig. 10).
Fig. 10: Inferior dystopia and proptosis of right eye.
CASE 5
A 65
years old man presented with gradually enlarging mass below right eye for last
3 years. On examination visual acuity in right eye was hand movement (HM)
positive. He had relative afferent pupillary defect in the same eye.
Extraocular
Fig. 11: Six
weeks after the surgery.
Fig. 12: Mass bulging through inferior fornix causing mechanical
ectropion.
Fig. 13: Well demarcated
homogenous hyper dense mass involving inferonasal aspect of right orbit.
Fig. 14: Lesion below right eye ball visible under conjunctiva and with
bluish discoloration of lower lid.
Fig. 15: Brownish well encapsulated mass measuring 3.0 X
2.8 cm was extracted en bloc.
![DSCN8749[1]](11.%20CR-%20M%20Amir%20Yaqoob_files/image052.jpg)
Fig. 16: Cosmetic improvement three weeks post operatively.
