- Email: [email protected]
Cavernous Hemangioma of the Orbit
CAVERNOUS HEMANGIOMA OF T H E ORBIT Case report ABRAM B. BRUNER, M.D., F.A.C.S. CLEVELAND
The preoperative notations included extreme exophthalmos which had been developing for about four months, absence of diplopia, and visual acuity of 6/30. After ineffectual use of x-ray treatment, exploratory operation was undertaken, and, with external canthotomy and horizontal incision in the conjunctiva, it was found possible to shell out a large encapsulated mass which extended well back in the lower half of the orbit. The tumor proved to be a spongy structure consisting of endothelial spaces filled with blood. Vision pf 5/4 was fin ally recovered. From the eye dispensary of Lakeside hospital, Cleveland.
R. L., white, male, aged forty-five years, first came to the dispensary Jan uary 21, 1929. He was a tall well devel oped man, apparently of robust health. H e stated that for a period of about four months he had noticed gradual bulging and increasing prominence of the left eyeball. Associated with this was gradually increasing loss of vision in the left eye. Lately the exophthal mos had become extreme, and on two recent occasions the eyeball had proptosed between the lids, the patient himself having replaced the eye into the socket by traction on the upper lid and gentle pressure on the ball. Except for the exophthalmos and failing vision, the subjective symptoms had not been marked. At no time was there pain, and he had never had di plopia. Occasionally there had been a left frontoparietal headache, and there was a "peculiar feeling" when he looked down to the left. There was no history of any preceding illness, no symptom suggestive of infection of the acces sory sinuses. On his second visit he stated that twenty-seven years ago he had had a small splinter in the left eye, which had been removed by operation. H e was quite certain this accident had produced no permanent injury.
ments normal. Vision without glass 6/6 — 2. Exopthalmometer measure ment 23 mm. Left eye: This eye was unusually prominent, all of the cornea and part of the sclera being exposed. On closure of the eyes, however, the entire cornea was covered by the upper lid. There was a moderate chronic conjunctival hyperemia and a small congested pin guecula. The sclera was not injected and the cornea was perfectly transpar ent except for a faint arcus senilis. Anterior chamber normal; iris healthy; pupil same size as in right eye, and prompt to light and accommodation. There was no ciliary tenderness, and the tension felt normal to palpation. T h e eyeball as a whole appeared pushed directly forward and a little up ward. On first examination, however, only very slight limitation of motion down and to the left could be made out. Palpation of the bony orbit revealed nothing. Palpation around the globe gave only a doubtful sense of slight re sistance far back in the lower outer quadrant of the orbit. Diplopia was not present in any position of the gaze, and could not be induced by the usual di plopia tests. Form field of normal limits. Vision without glass 6/30. No Examination of the eyes showed as improvement with any glass. Exophthalmometer measurement 32 mm. follows: Right eye: Lids and conjunctiva Ophthalmoscopic examination: Right normal. There was a small pinguecula. eye: no pathology. Left eye: General Cornea transparent except for a narrow condition normal. No definite pathol arcus senilis. Anterior chamber of ogy made out, although the nerve head normal depth; iris of good color; pupil in this eye was perhaps a trifle hyper round, of average size, and prompt to e m i a light and accommodation. Tension Clinical examinations revealed noth normal to palpation. All muscle move ing. A general physical examination 737
738
ABRAM B. BRUNER
was entirely negative. The blood Wassermann was repeated twice and was negative on both occasions. Rhino-
Fig. 1 (Bruner). Appearance of patient, March 4, 1929, before operation. logical examination revealed only a moderately hypertrophic mucous membrane on all the turbinates and a septum deflected somewhat to the right. There were no signs of definite pathol ogy in nose, throat, or ears, and all sin uses and both orbits were clear on transillumination. Repeated x-ray plates were taken, and revealed no trouble in sinuses, orbits, or cranium. and no bone changes. The patient saw Dr. E. C. Cutler several times in consultation, and the latter reported the neurological examin ation entirely negative. T h e patient was seen several times between the date of first examination and February 1, 1929. On this date the local condition was apparently unchanged, and the exophthaknometer reading was, right eye, 22, left eye, 31 mm. A tentative dianosis of sarcoma of the orbit was made. T h e patient was told the probable seri ousness of the condition, and a course of x-ray therapy was advised before resorting to surgery. X-ray treatments were administered every fourth day. After treatment for
a period of two weeks, the patient thought there was some improvement, and the vision had improved to 5/15, but the exophthalmos did not change. One week later the vision had again dropped to 5/60, the exophthalmos was unchanged but there was now more marked conjunctival irritation, with considerable epiphora. At this time it seemed there was slightly more lim itation of movement down and to the left. On March fourth the exophthalmometer read, right eye, 23, left eye, 31 mm. Left vision was 5/60. There was now evidently a slight resistance deep in the orbit when pressure was made with the finger backward and upward in the lower outer portion of the orbit. One had to be very careful of exerting much pressure, because of the danger of proptosing the globe through the lids. An exploratory operation was ad vised, and the patient entered the hos pital. The following day, under gen eral anesthesia, a horizontal incision in the mid-line was made through the con-
Fig. 2 (Bruner). Appearance of patient, June 10, 1929, three months after operation. junctiva, beginning just beyond the limbus and extending outward to the external canthus. External canthotomy
;
METRIC "SYSTFM *■■
«»
**
Fig. 4 (Bruner). Appearance of tumor (cavernous hemangioma) on gross section.
Fig. 5 (Bruner).
Microscopic section of tumor (cavernous hemangioma).
740
ABRAM B. BRUNER
was then performed. With the lids retracted fully and the eyeball pushed gently upward and inward, good illu mination of the orbit was secured. Immediately a large walnut-shaped mass of bluish color, and apparently encapsulated, could be seen far back in the lower half of the orbit lying as tride Tenon's capsule. It offered only moderate resistance to palpation. A thin layer of fascia over the mass was divided, and it was possible to in troduce a blunt spatula between the fas cia and the capsule. Then the little finger was introduced, and without dif ficulty the entire mass was shelled out and delivered through the wound. There was practically no bleeding. The canthotomy and conjunctival wound were sutured and a firm pressure band age applied. The patient made an un eventful recovery, and left the hospital on the eighth day. H e was seen several times after dis charge from the hospital. On his last visit to the dispensary, June 10, 1929, vision without glass w a s : right eye 5/4, left eye 5/5, and with 0.50 sphere be fore the left eye its vision was 5/4. There was still a very slight ptosis of the left upper lid and a little hyperemia of the conjunctiva at the outer canthus. There still remained slight limitation of movement of the left eye down and to the left. Ophthalmoscopic examina tion was negative. The exophthalmometer reading was right eye 22, left eye 23 mm. Pathological examination (Dr. A. R. Moritz) The specimen consists of a dark red, encapsulated, spongy tumor mass measuring 3.5 by 2.4 by 1.8 cm. T h e capsule is intact and consists of a thin, smooth, translucent membrane beneath which small blood-filled spaces may be
seen. These spaces give the speci men the appearance of a coiled mass of small, tortuous veins. On section, the entire tumor is seen to be made up of blood-filled spaces separated from one another by a delicate fibrous stroma.
Fig. 3 (Bruner). Gross appearance of tumor (cavernous hemangioma). Microscopically, the tissue is seen to be a sponge-like structure of endothelial-lined spaces which are filled with blood. The spaces are irregular in out line and there are frequent spur-like projections from the walls. They are separated from one another by a moder ate amount of fibrous connective tissue which is the seat of myxomatous degen eration in places. Diagnosis: Cavernous hemangioma. N O T E : The author wishes to acknowl edge the assistance rendered by Dr. A. R. Moritz, resident pathologist at Lake side Hospital. Guardian building.
The preoperative notations included extreme exophthalmos which had been developing for about four months, absence of diplopia, and visual acuity of 6/30. After ineffectual use of x-ray treatment, exploratory operation was undertaken, and, with external canthotomy and horizontal incision in the conjunctiva, it was found possible to shell out a large encapsulated mass which extended well back in the lower half of the orbit. The tumor proved to be a spongy structure consisting of endothelial spaces filled with blood. Vision pf 5/4 was fin ally recovered. From the eye dispensary of Lakeside hospital, Cleveland.
R. L., white, male, aged forty-five years, first came to the dispensary Jan uary 21, 1929. He was a tall well devel oped man, apparently of robust health. H e stated that for a period of about four months he had noticed gradual bulging and increasing prominence of the left eyeball. Associated with this was gradually increasing loss of vision in the left eye. Lately the exophthal mos had become extreme, and on two recent occasions the eyeball had proptosed between the lids, the patient himself having replaced the eye into the socket by traction on the upper lid and gentle pressure on the ball. Except for the exophthalmos and failing vision, the subjective symptoms had not been marked. At no time was there pain, and he had never had di plopia. Occasionally there had been a left frontoparietal headache, and there was a "peculiar feeling" when he looked down to the left. There was no history of any preceding illness, no symptom suggestive of infection of the acces sory sinuses. On his second visit he stated that twenty-seven years ago he had had a small splinter in the left eye, which had been removed by operation. H e was quite certain this accident had produced no permanent injury.
ments normal. Vision without glass 6/6 — 2. Exopthalmometer measure ment 23 mm. Left eye: This eye was unusually prominent, all of the cornea and part of the sclera being exposed. On closure of the eyes, however, the entire cornea was covered by the upper lid. There was a moderate chronic conjunctival hyperemia and a small congested pin guecula. The sclera was not injected and the cornea was perfectly transpar ent except for a faint arcus senilis. Anterior chamber normal; iris healthy; pupil same size as in right eye, and prompt to light and accommodation. There was no ciliary tenderness, and the tension felt normal to palpation. T h e eyeball as a whole appeared pushed directly forward and a little up ward. On first examination, however, only very slight limitation of motion down and to the left could be made out. Palpation of the bony orbit revealed nothing. Palpation around the globe gave only a doubtful sense of slight re sistance far back in the lower outer quadrant of the orbit. Diplopia was not present in any position of the gaze, and could not be induced by the usual di plopia tests. Form field of normal limits. Vision without glass 6/30. No Examination of the eyes showed as improvement with any glass. Exophthalmometer measurement 32 mm. follows: Right eye: Lids and conjunctiva Ophthalmoscopic examination: Right normal. There was a small pinguecula. eye: no pathology. Left eye: General Cornea transparent except for a narrow condition normal. No definite pathol arcus senilis. Anterior chamber of ogy made out, although the nerve head normal depth; iris of good color; pupil in this eye was perhaps a trifle hyper round, of average size, and prompt to e m i a light and accommodation. Tension Clinical examinations revealed noth normal to palpation. All muscle move ing. A general physical examination 737
738
ABRAM B. BRUNER
was entirely negative. The blood Wassermann was repeated twice and was negative on both occasions. Rhino-
Fig. 1 (Bruner). Appearance of patient, March 4, 1929, before operation. logical examination revealed only a moderately hypertrophic mucous membrane on all the turbinates and a septum deflected somewhat to the right. There were no signs of definite pathol ogy in nose, throat, or ears, and all sin uses and both orbits were clear on transillumination. Repeated x-ray plates were taken, and revealed no trouble in sinuses, orbits, or cranium. and no bone changes. The patient saw Dr. E. C. Cutler several times in consultation, and the latter reported the neurological examin ation entirely negative. T h e patient was seen several times between the date of first examination and February 1, 1929. On this date the local condition was apparently unchanged, and the exophthaknometer reading was, right eye, 22, left eye, 31 mm. A tentative dianosis of sarcoma of the orbit was made. T h e patient was told the probable seri ousness of the condition, and a course of x-ray therapy was advised before resorting to surgery. X-ray treatments were administered every fourth day. After treatment for
a period of two weeks, the patient thought there was some improvement, and the vision had improved to 5/15, but the exophthalmos did not change. One week later the vision had again dropped to 5/60, the exophthalmos was unchanged but there was now more marked conjunctival irritation, with considerable epiphora. At this time it seemed there was slightly more lim itation of movement down and to the left. On March fourth the exophthalmometer read, right eye, 23, left eye, 31 mm. Left vision was 5/60. There was now evidently a slight resistance deep in the orbit when pressure was made with the finger backward and upward in the lower outer portion of the orbit. One had to be very careful of exerting much pressure, because of the danger of proptosing the globe through the lids. An exploratory operation was ad vised, and the patient entered the hos pital. The following day, under gen eral anesthesia, a horizontal incision in the mid-line was made through the con-
Fig. 2 (Bruner). Appearance of patient, June 10, 1929, three months after operation. junctiva, beginning just beyond the limbus and extending outward to the external canthus. External canthotomy
;
METRIC "SYSTFM *■■
«»
**
Fig. 4 (Bruner). Appearance of tumor (cavernous hemangioma) on gross section.
Fig. 5 (Bruner).
Microscopic section of tumor (cavernous hemangioma).
740
ABRAM B. BRUNER
was then performed. With the lids retracted fully and the eyeball pushed gently upward and inward, good illu mination of the orbit was secured. Immediately a large walnut-shaped mass of bluish color, and apparently encapsulated, could be seen far back in the lower half of the orbit lying as tride Tenon's capsule. It offered only moderate resistance to palpation. A thin layer of fascia over the mass was divided, and it was possible to in troduce a blunt spatula between the fas cia and the capsule. Then the little finger was introduced, and without dif ficulty the entire mass was shelled out and delivered through the wound. There was practically no bleeding. The canthotomy and conjunctival wound were sutured and a firm pressure band age applied. The patient made an un eventful recovery, and left the hospital on the eighth day. H e was seen several times after dis charge from the hospital. On his last visit to the dispensary, June 10, 1929, vision without glass w a s : right eye 5/4, left eye 5/5, and with 0.50 sphere be fore the left eye its vision was 5/4. There was still a very slight ptosis of the left upper lid and a little hyperemia of the conjunctiva at the outer canthus. There still remained slight limitation of movement of the left eye down and to the left. Ophthalmoscopic examina tion was negative. The exophthalmometer reading was right eye 22, left eye 23 mm. Pathological examination (Dr. A. R. Moritz) The specimen consists of a dark red, encapsulated, spongy tumor mass measuring 3.5 by 2.4 by 1.8 cm. T h e capsule is intact and consists of a thin, smooth, translucent membrane beneath which small blood-filled spaces may be
seen. These spaces give the speci men the appearance of a coiled mass of small, tortuous veins. On section, the entire tumor is seen to be made up of blood-filled spaces separated from one another by a delicate fibrous stroma.
Fig. 3 (Bruner). Gross appearance of tumor (cavernous hemangioma). Microscopically, the tissue is seen to be a sponge-like structure of endothelial-lined spaces which are filled with blood. The spaces are irregular in out line and there are frequent spur-like projections from the walls. They are separated from one another by a moder ate amount of fibrous connective tissue which is the seat of myxomatous degen eration in places. Diagnosis: Cavernous hemangioma. N O T E : The author wishes to acknowl edge the assistance rendered by Dr. A. R. Moritz, resident pathologist at Lake side Hospital. Guardian building.