Clinicopathological study of parasitic lesions of the eye and ocular adnexa in a tertiary care ophthalmic center in South India

Purpose: To study clinical and pathological features of parasitic lesions in the ocular adnexa in a tertiary care ophthalmic center in south India. Methods: 43 cases of ocular parasitosis were analysed clinically and correlated with the pathological findings (gross morphology and histopathology) over a period of five years (2015–2020). Results: Among the 43 cases, the age group ranged from 9 months to 78 years (mean age of 41.6 years). Female patients were more common than male patients, with a percentage of 63% (27) and 37% (16) respectively. Cystic lesion in the lid or orbit was seen in 23 cases (53.4%); solid mass lesions were seen in 17 cases (39.5%); subconjunctival worms in three cases; and subretinal parasite in one. Gross examination and histopathologic study showed Dirofilaria in 23 cases (53.5%), followed by Cysticercus in six cases (14%) and Microfilariae in four cases (9.3%). Exact species identification was not possible in ten cases (23.25%). Correlation between the type of lesion and type of inflammatory cells with the specific parasite was done. Conclusion: Our study showed that important clinicopathological correlations can be made from the parasitic lesions in the eye and adnexa, which can aid in definitive diagnosis and prompt identification of the parasite for patient management

A Case of Orbital Lymph Node Misdiagnosed as a Dermoid

PURPOSE: We report our experience with a case of orbital lymph node which has not been previously reported in the Republic of Korea. CASE SUMMARY: A 24-year-old female patient with no underlying disease visited our hospital with a 2-month history of a mass at the lateral side of the left upper eyelid. On physical examination, a round, well-defined subcutaneous mass was palpable, and pain, swelling or a skin change were not reported or seen. The appearance, location, and imaging findings of the mass were suspected to be dermoid, and excisional biopsy was performed for accurate diagnosis and treatment. The 1.0 × 0.7 cm-sized, round-shaped and brown-colored mass was excised. The mass was well-defined but in the posterior part; it was attached to the periosteum. The mass was finally diagnosed as a lymph node with lymphadenitis by histopathological examination. No recurrence or new lesion was observed after surgery, and the patient did not complain of abnormal symptoms. CONCLUSIONS: A Complete orbital lymphoid tissue has not yet been found in the orbit, and lymph nodes are known to be absent. However, as in this case, when an orbital mass is observed, the possibility of lymph node should be considered and histopathological examination should be performed to confirm it.

A Case of Small Cell Lung Cancer Diagnosed via Incisional Biopsy of an Orbital Mass

PURPOSE: To report a case of an orbital mass diagnosed as metastasis from small cell lung cancer and to provide a review of the literature. CASE SUMMARY: A 66-year-old male with a history of diabetes mellitus and hypertension presented with decreased visual acuity and exophthalmos in his left eye. He had been diagnosed with age-related macular degeneration 13 years prior and had a history of pneumonia that was treated for one month. The best corrected visual acuity was hand-motion in the right eye and 0.04 in the left eye. Optic disc swelling and splint hemorrhage of the left eye was observed on fundus examination. The left eye was protruded and eye movement was limited. On orbital magnetic resonance imaging, an irregular mass in the left intraconal space was found. Incisional biopsy was performed, and histopathologic examination revealed a small round tumor. According to the results of immunohistochemical staining, metastatic tumors were suspected. After systemic evaluation, the patient was diagnosed with primary small cell lung cancer with multiple metastases. After 2 months, the visual acuity was hand-motion and proptosis was not resolved. CONCLUSIONS: In patients with orbital masses, the possibility of metastatic tumors should be considered during differential diagnosis and early biopsy should be performed.

Multiple Solitary Plasmacytomas Presenting with Painful Erythematous Swelling of the Upper Eyelid

PURPOSE: To report a case of multiple solitary plasmacytomas that presented with painful erythematous swelling of the upper eyelid. The patient was diagnosed with extramedullary plasmacytoma, and was later found to have multiple metastases of the bone and soft tissue during follow up. CASE SUMMARY: A 55-year-old female patient presented with painful erythematous swelling of the left upper eyelid that persisted for 1 month prior to examination. Under suspicion of lacrimal gland inflammation, anti-inflammatory medication was started but the symptoms worsened. Orbital computed tomography showed that a mass infiltrated the left lacrimal gland. We performed incisional biopsy of the mass via eyelid crease incision. Based on histopathological examination, the mass was diagnosed as extramedullary plasmacytoma and the patient was treated with radiation. After a 10-month follow-up period, multiple metastases on the left parotid gland, thoracic spine, lumbar spine and pelvic bone were observed. Finally, we diagnosed the patient with multiple solitary plasmacytomas. CONCLUSIONS: We report the first case of multiple solitary plasmacytomas presenting with upper eyelid painful erythematous swelling. This condition should be considered for patients presenting with eyelid inflammation. In addition, long term follow up should be conducted to detect metastasis or recurrence.

A Case of Bilateral Orbital Tuberculosis

PURPOSE: Periocular tuberculosis is common in the form of conjunctival tuberculosis or uveitis; however, orbital tuberculosis is very rare. We report a case of tuberculosis diagnosed based on bilateral orbital masses. CASE SUMMARY: A 64-year-old male with a history of diabetes, hypertension, and chronic obstructive pulmonary disease presented with diplopia. His best-corrected visual acuity was 1.0, and intraocular pressure was 16 mmHg in both eyes. Bilateral proptosis was noted, and inferior orbital masses were palpated in both eyes. On orbital computed tomography, irregular masses were surrounding both globes in the extraconal space. Incisional biopsy of the bilateral orbital masses was performed under local anesthesia. Pathologic examination revealed chronic granulomatous inflammation accompanied by caseous necrosis. The patient was diagnosed with bilateral orbital tuberculosis and underwent triple therapy with isoniazid, rifampin, and ethambutol for 12 months. The orbital masses completely resolved, and there was no recurrence or complication through 12 months after treatment. CONCLUSIONS: To our knowledge, bilateral orbital tuberculosis has not been reported yet. Herein, we report a case of orbital tuberculosis presenting as bilateral orbital masses.

A rare case of eyelid sarcoidosis presenting as an orbital mass.

Intraorbital sarcoidosis presenting externally as a solitary eyelid mass has been described in the literature as isolated case reports. We describe a rare case of asymptomatic sarcoidosis with orbital mass as the presenting feature in a young woman. The lesion was excised with the clinical possibility of a thrombosed varix. On histology, the lesion was characterized by numerous nonnecrotizing epithelioid cell granulomas with several multinucleated giant cells containing abundant asteroid bodies and oxalate crystals. No tubercular bacilli were detected. A diagnosis of sarcoidosis was rendered and on further clinical work‑up, she was detected to have hilar lymphadenopathy. Sarcoidosis should be considered in the differential diagnosis of orbital mass as it could be the initial manifestation of the disease process.

A Case of Extra-axial Anaplastic Meningioma with Direct Orbital Extension

PURPOSE: We report the first case of extra-axial anaplastic meningioma with direct orbital extension for differential diagnosis of orbital tumors. CASE SUMMARY: An 83-year-old woman presented with a protruding left eye and a palpable mass on the forehead. A brain computed tomography scan revealed a huge sarcomatous mass that had directly invaded the surrounding tissues. We removed the tumor by craniotomy and found that it involved the extradural and intradural spaces, brain parenchyma, subcutaneous tissue, left temporalis, orbital roof, and the other frontal lobe across the midline. A cranioplasty was performed, and the orbital roof was reconstructed with artificial bone and bone cement. The final histological diagnosis was anaplastic meningioma. The left eyeball was restored to its normal position 1 month after the surgery. Also, visual acuity and eye movement of the left eye were preserved. CONCLUSIONS: Direct orbital extension of originated extra-axial cerebral convexity anaplastic meningioma is rare but should be considered in the differential diagnosis of a rapidly growing orbital mass.

Dermatofibrosarcoma in the Orbit: A Case Report

PURPOSE: Dermatofibrosarcoma in the orbit is a rare malignant neoplasm. We report an extremely rare case of primary dermatofibrosarcoma in the orbit. CASE SUMMARY: A 66-year-old male presented with a slowly progressing periorbital mass on his left upper eyelid which developed 3 weeks earlier. On physical examinations, a palpable firm mass under the skin was observed at the superomedial aspect of the left upper eyelid. However, there was no surface nodule or demarcated line on the eyelid. An approximately 1.2 × 1 × 1 cm sized well defined and clearly demancated mass was observed on orbital computed tomography. Excisional biopsy was performed under local anesthesia and pathological examination revealed dermatofibrosarcoma. There was no metabolic evidence of regional or distant metastasis based on positron emission tomography-computed tomography. Nine months after surgical excision there was no evidence of local recurrence. CONCLUSIONS: This is the first report in South Korea of dermatofibrosarcoma in the orbit. Dermatofibrosarcoma should be considered following differential diagnosis of a periorbital mass.

A Case of Primary Orbital Synovial Sarcoma

PURPOSE: To report a rare case of primary orbital synovial sarcoma. CASE SUMMARY: A 55-year-old male visited our clinic with a 2-month history of decreased visual field in the left eye. The best corrected visual acuity of the left eye was 1.0, and 2.5 mm of proptosis was observed. There was slight limitations in motility and a mild visual field defect in the inferotemporal quadrant of the left eye. Funduscopic examination of the left eye revealed papilledema. Orbital magnetic resonance imaging (MRI) demonstrated the presence of an orbital mass that extended inferotemporally into the left orbit. On magnetic resonance imaging, a well-demarcated and 2.7 x 2.0 x 2.2 cm sized tumor was identified with intermediate signal intensities on T1/T2-weighted scans with slight homogenous enhancement. We approached the orbital mass using a lateral conjunctival incision with left canthotomy and cantholysis and performed partial surgical resection of the mass because the mass encircled the optic nerve. The mass was diagnosed as synovial sarcoma based on the findings of both histopathology and immunohistochemical staining. Postoperatively, the patient underwent radiation therapy to the rest of the tumor site. CONCLUSIONS: Synovial sarcoma should be considered in the differential diagnosis of an orbital mass lesion encircling the optic nerve. Radiation therapy is useful to treat completely unresectable primary synovial sarcoma.

Nonspecific Traumatic Carotid-Cavernous Fistula Presented as Naso-Orbital Mass

Traumatic carotid-cavernous fistulae(TCCF) are rare but can cause potentially lethal complications such as visual loss and subarachnoid hemorrhage after craniomaxillofacial trauma. This represents aberrant vascular communication in skull base between the carotid artery system and the venous channels within the cavernous sinuses of a sphenoid bone. The symptoms are mostly related with ophthalmic problems such as pulsatile proptosis, chemosis, and diplopia. The standard diagnostic method is cerebral angiography. CT and MRI can be also useful. The main current treatment is endovascular detachable balloon occlusion. The clinicians who treat patients with craniofacial injuries should have complete understandings of this pathological entity, so that early diagnosis and urgent intervention can be done to avoid serious complications and to get successful results. We report the experience of treating a 25-year-old female with nonspecific traumatic carotid-cavernous fistula presented as naso-orbital mass using intravascular detachable balloon catheter embolization.

Multiple Myeloma Presented With Unilateral Ptosis: A Case Report

PURPOSE: As orbital involvement in multiple myeloma is rare, the correct diagnosis is usually difficult. We report a case of multiple myeloma which involved the orbit, and which presented with unilateral ptosis. METHODS: A 35-year-old man was referred for the evaluation of ptosis of the left eyelid for 1 month. The levator function was normal, and there was no proptosis. Orbital computerized tomography (CT) revealed an orbital mass lesion involving the superior orbital ridge with intracranial extension. RESULTS: Excisional biopsy was performed through craniotomy and superior orbitotomy. Histopathologic examination and immunostaining result suggested a diagnosis of a plasmacytoma. The diagnosis of multiple myeloma was confirmed through bone marrow aspiration and biopsy showing diffuse infiltration of plasma cells. CONCLUSIONS: We experienced a case of multiple myeloma, which is rare in the orbit presenting unilateral ptosis. In addition, the possibility of orbital mass should be considered as an unusual cause of unilateral, acquired, progressive ptosis.

Erdheim-Chester Disease: Two Cases of Orbital Involvement

PURPOSE: ECD is a rare idiopathic condition characterized by infiltration of the bone, heart, lungs, retroperitoneum, skin, CNS and other tissues by a fibrosing process containing xanthomatous histiocytes and multinucleated giant cells of the Touton type. Orbital involvement of ECD is rare and we report two cases of Erdheim-Chester disease. METHODS: A 46-year-old man with dilated cardiomyopathy and chronic renal failure and a 70-year-old woman with pulmonary disease and intracranial mass visited our clinic because of bilateral proptosis. RESULTS: The systemic evaluation revealed multiple organ involvement, such as bone, heart, lung and retroperitoneum ,while radiography of the tibia showed symmetrical osteosclerosis. The biopsy of tibia revealed a diffuse infiltration of foamy histiocytes and multinucleated giant cells of the Touton type. Based on the diagnosis of ECD, the patients were treated with radiation and steroids. CONCLUSIONS: Although most patients with ECD do not have ocular involvement, the unusual occurrence of bilateral proptosis and diffuse infiltrative orbital masses are suggestive of ECD. These findings should alert the ophthalmologist to this potentially serious systemic disease and prompt an evaluation for systemic manifestations.