Georgina Kourt

Orbital exenteration: a 15-year study of 38 cases.

Purpose: To determine the clinical indications and outcomes after orbital exenteration when histologic margins were reported as “clear,” examining factors affecting local and systemic recurrences and mortality. Methods: Retrospective case review of exenterations performed in Sydney Eye Hospital in Sydney, Australia, between 1990 and 2004. Reviewed data indications for exenteration, histopathologic diagnosis, and recurrences on follow-up. Results: Secondary intraorbital spread of malignant adnexal tumors was the most common indication for exenteration (34 of 38). Among these, the site of the primary neoplasm was the eyelid in 19 cases and the ocular surface in 12 cases. Exenteration was total in 26 cases, subtotal in 8 cases, and extended in 4 cases. In 11 cases, a dermis-fat graft was used for socket reconstruction; 24 cases were allowed to granulate spontaneously. The average healing time was 5 months (range, 4–6 months) for spontaneous granulation, and 6 weeks (range, 4–8 weeks) for dermis-fat grafts. Perineural spread was demonstrated histopathologically in 7 specimens. During follow-up (median, 48 months), there were 9 recurrences (23.7%): 3 local and 6 systemic. Seven patients (18.4%) died of the disease during the follow-up period. Conclusions: Dermis-fat grafts for reconstruction of the exenterated socket seem to optimize the aesthetic results. The first year is the most important period for follow-up of local recurrences, but systemic examination is needed for the longer follow-up. This may have implications in terms of reconstruction and adjunctive treatment following exenteration surgery.

Orbital metastasis from transitional cell carcinoma of the bladder.

Transitional cell carcinoma (TCC) is a common bladder tumour, 10−15% of which will exhibit invasive behaviour. About 50% of patients with invasive TCC will eventually develop distant metastases, usually to lymph nodes, lung or bones. The case is reported of bladder TCC metastasizing to the orbit.

Orbital invasion of frontal sinus lymphoma.

Paranasal sinus lymphoma is an uncommon malignancy and is often difficult to diagnose. Early diagnosis is essential for effective treatment. The tumour generally has poor prognosis. Ophthalmological symptoms and signs occur early in the disease process due to the close proximity of the orbit to the paranasal sinuses. Common presenting features include eye pain, proptosis, visual loss and diplopia. We report a case of frontal sinus lymphoma that presented as a superior-nasal orbital mass in an 84 year old man. CT scan demonstrated a mass occupying the frontal sinuses, with destruction of the anterior bony wall of the frontal sinus and extending to the right orbit. Histology revealed diffuse large B cell non Hodgkins lymphoma. The tumor was treated with radiotherapy and showed regression; however the patient died 9 months later. Sinus tumours are encountered by ophthalmologists and should be considered in patients presenting with an orbital mass.

Repair of isolated abortive cryptophthalmos with lower eyelid switch flap and amniotic membrane graft.

The surgical correction of a case of bilateral isolated abortive cryptophthalmos is described. An upper eyelid and superior fornix were successfully created in a 2-stage procedure using a switch flap from the patients normal lower eyelid and an amniotic membrane graft. Exposure keratopathy was significantly reduced with resultant visual improvement.

Eyelid and Periocular Skin Tumors

Skin cancers commonly affect the eyelids and periocular region. Orbital invasion is a serious and potentially fatal complication of cutaneous neoplasia. The most frequent skin cancers resulting in orbital invasion are basal cell carcinoma, squamous cell carcinoma, sebaceous gland carcinoma, and malignant melanomas. Orbital invasion from eyelid tumors usually results from a delayed presentation, incomplete excision with subsequent recurrences, and highly aggressive invasive tumors. Basal cell carcinomas represent 90% of periocular tumours with orbital invasion and occur predominantly from the medial and lateral canthal regions by direct extension. Medial canthal basal cell carcinomas that invade the orbit via contiguous spread often have minimal external changes and are known as an iceberg type. Squamous cell carcinomas may invade the orbit by direct extension, by metastatic spread, or by perineural spread. The most important external cause of basal cell carcinomas, squamous cell carcinomas, and malignant melanomas is exposure of fair-skinned people to sunlight, in particular, to wavelengths in the ultraviolet B (UV-B) range. The amount of UV-B in sunlight increases with increasing proximity to the equator, posing a particular risk for nonindigenous populations who migrate from temperate to tropical and subtropical zones. Ultraviolet irradiation damages DNA in the skin either by direct absorption or via damage to chemical mechanisms.1 Australia has the highest incidence of skin cancers in the world, ranging from 650 to 1560 cases per 100,000 persons compared with 300 cases per 100,000 persons in Texas and Arizona. In the United States, basal cell carcinomas and squamous cell carcinomas are classified as non-melanoma skin cancers; their incidence decreases with increasing latitude. The high incidence of skin cancers in Australia has been partly attributed to holes in the ozone layer.2 The morbidity and mortality of patients with nonmelanoma skin cancers is significant, particularly in patients with a late presentation. Patients with basal cell carcinoma rarely die from the disease, but morbidity increases with advanced cases, particularly those with orbital invasion. Metastases from squamous cell carcinoma occur in 2 to 6% of cases. BASAL CELL CARCINOMA

Unusual presentation of metastatic neuroendocrine (carcinoid) tumor in the orbit

Purpose: To report a rare presentation of metastatic neuroendocrine tumor in the orbit. Case report: A 43-year-old female presented with a left painful proptosis of 4 days duration associated with nausea and vomiting. There was a history of multiple liver metastases from an unknown primary carcinoid tumor for 7 years. Ocular examination revealed severe eyelid swelling associated with conjunctival injection, chemosis and complete external ophthalmoplegia. The visual acuity was 20/20 in right eye and no light perception in left eye. The initial clinical diagnosis was orbital cellulitis with optic nerve compression. Orbital imaging showed gross enlargement of left lateral rectus muscle with optic nerve compression consistent with a carcinoid metastasis. Surgical resection of the tumor mass along with the involved muscle was performed. Histopathology confirmed the diagnosis of neuroendocrine (carcinoid) tumor infiltrating fibro fatty tissue and skeletal muscle with widespread necrosis. On Immunohistochemical staining the tumor cells were positive for chromogranin A, synaptophysin and cytokeratin. Post-operative external beam radiotherapy (EBRT) and systemic chemotherapy were given. Conclusion: Acute necrosis in metastatic orbital carcinoid tumor can lead to orbital inflammation which could mimic orbital cellulitis. Systemic history and orbital imaging play an important role in differentiating the infective etiology from metastasis.