- Email: [email protected]
Percutaneous treatment of an orbital hydatid cyst: a new therapeutic approach
Percutaneous Treatment of an Orbital Hydatid Cyst: A New Therapeutic Approach Okan Akhan, MD, Sevgu¨l Bilgic¸, MD, Deniz Akata, MD, Hayyam Kiratli, MD, ¨ zmen, MD and Mustafa N. O To describe the percutaneous treatment of an orbital hydatid cyst as an alternative approach to conventional surgery. METHODS: In a 21-year-old man with diplopia and right proptosis, radiologic studies disclosed a 25 3 25 3 20-mm purely cystic mass in the right retrobulbar area. Based on the presumptive diagnosis of hydatid cyst, the cyst was treated percutaneously under ultrasonographic guidance with aspiration, 15% hypertonic saline injection, and reaspiration without any complication. RESULTS: A substantial decrease in the size of the cyst was observed in the 3 months after treatment. Nine months after treatment, the shrunken cyst had a volume of only 0.5 ml, and the patient was asymptomatic. Twenty-one months after the procedure, the findings were consistent with those at 9 months of follow-up. CONCLUSION: Percutaneous treatment of orbital hydatid cysts, which is more satisfactory to both the patient and the physician, may be a safe and effective alternative to surgical extirpation. (Am J Ophthalmol 1998;125:877– 879. © 1998 by Elsevier Science Inc. All rights reserved.) PURPOSE:
H
YDATID CYSTS MAY BE ENCOUNTERED IN ALMOST
every organ in the body, but for unknown reasons, hydatid cysts rarely involve the orbit.1 Surgical extirpation is still the most favored treatment for orbital cyst; however, intraoperative and postoperative complications are not infrequent.2,3 Recently, successful percutaneous treatment of hydatid cysts in the abdominal and thoracic cavities has been reported.4,5 We describe a patient with an
Accepted for publication Dec 15, 1997. ¨ ) and Ophthalmology Departments of Radiology (O.A., D.A., M.N.O (S.B., H.K.), Hacettepe University School of Medicine. Inquiries to Okan Akhan, MD, Department of Radiology, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey 06100; fax: 0-312-3112145; e-mail: [email protected]
VOL. 125, NO. 6
orbital hydatid cyst treated by percutaneous route under ultrasonographic guidance. A 21-year-old man with diplopia of recent onset was admitted to the hospital for further evaluation of his right-sided proptosis. His best-corrected visual acuity was RE, 20/30 and LE, 20/20. There was 4 mm of right proptosis measured by Hertel exophthalmometer. The right eye was displaced superiorly. The right fundus examination disclosed optic disk edema. The rest of the ocular examination was unremarkable. His orbital ultrasonography (Figure 1, top) and magnetic resonance imaging studies (Figure 1, bottom left) disclosed a 25 3 25 3 20-mm (6.25 cc) purely cystic mass at the right retrobulbar area. The mass was intraconally located and displaced the bulbus oculi anteriorly and the optic nerve superiorly. A hypointense rim was surrounding the mass on T2-weighted images, which may represent a capsule. No apparent contrast enhancement was noted. Radiologic studies of the cranium, thorax, and abdomen did not disclose any further cysts. Based on the presumptive diagnosis of hydatid cyst of the orbit, we decided to treat the cyst percutaneously under ultrasonographic guidance. The procedure was carried out using the PAIR (puncture-aspiration-injection-reaspiration) technique.4 The content of the cystic cavity was aspirated percutaneously with a 21-gauge needle under ultrasonographic guidance. To devitalize the cyst, the aspirated 7 ml of transparent clear fluid, which was characteristic for hydatid cyst, was replaced by 3 ml of 15% hypertonic saline solution and reaspirated 10 minutes later. There was no complication after the procedure. Notable decrease in the size and the volume of the lesion and the disappearance of the fluid component of the cyst on imaging studies were taken as healing criteria for satisfactory therapeutic outcome.4,5 A gradual decrease in size was observed at the periodic follow-up of the patient. By 3 months after the treatment, the mass lost 60% of its volume, and by 9 months after the treatment, the lesion was entirely solid and shrunken, and its volume was only 0.5 cc (Figure 1, bottom right). The patient’s visual acuity returned to RE, 20/20, and diplopia resolved completely. He remained asymptomatic for the 21 months after the treatment (Figure 2, top left and top right).
BRIEF REPORTS
877
FIGURE 1. (Top) A lobulated cystic lesion (arrowheads) with a volume of 6.25 cc is seen behind the bulbus oculi in axial (left) and sagittal (right) ultrasonographic scans. T1-weighted axial magnetic resonance imaging scan of the orbit before the treatment showed a well-circumscribed, oval, lobulated, hypointense mass in the right orbit (bottom left). At 9 months of follow-up, the lesion (arrowheads) was entirely solid and shrunken, and its volume was only 0.5 cc (bottom right).
Hydatid disease caused by Echinococcus granulosus is endemic in the Middle East, the Mediterranean Basin, South America, New Zealand, and Australia. The orbit is one of the unusual locations for hydatid disease, even in endemic areas, and is reported to be involved in 0.63% to 2.9% of all cases.1,3 Unilateral proptosis is the most common feature of orbital disease. Other possible findings include mechanical restriction of ocular movements and visual impair878
AMERICAN JOURNAL
ment, chemosis, eyelid edema, hypopyon, and conjunctivitis.2,3 Orbital hydatid cyst is seen as a wellcircumscribed cystic mass on imaging modalities such as ultrasonography and magnetic resonance imaging. Traditionally, the treatment of orbital hydatid cysts consists of surgical removal of the lesion as is done in other parts of the body. However, surgery is often complicated by the rupture of the cyst, which may lead to severe anaphylactic OF
OPHTHALMOLOGY
JUNE 1998
FIGURE 2. The patient is shown before (left) and 6 months after (right) the procedure. The proptosis and elevation of the right eye disappeared after the percutaneous treatment.
reaction, incomplete removal, or secondary implantation cysts.2 To reduce the probability of these complications, Nahri2 developed a simplified technique that reduces extensive dissection, which is a major cause of cyst rupture. Puncture of hydatid cyst was considered contraindicated because of potential risks of anaphylaxis and spillage of scolices. More recent clinical and experimental studies on percutaneous treatment of liver and pulmonary hydatid cysts did not show any evidence of anaphylaxis or dissemination. Published studies on abdominal and thoracic hydatid cysts suggest that percutaneous treatment of hydatid cysts is a safe and effective method and a good working alternative to surgery.4,5 We propose that percutaneous treatment of orbital hydatid cyst, which is more satisfactory to both the patient and the physician, may be a safe and effective alternative to surgical extirpation.
R
REFERENCES
1. Alpaslan L, Kanberogˇlu K, Peksayar G, C ¸ okyu¨ksel O. Orbital hydatid cyst: assessment of two cases. Neuroradiology 1990;32:163–165. 2. Nahri GE. A simplified technique for removal of orbital hydatid cysts. Br J Ophthalmol 1991;75:743–745. 3. Talib H. Orbital hydatid disease in Iraq. Br J Surg 1972;59: 391–394. ¨ zmen MN, Dinc¸er A, Sayek I, Go¨c¸men A. Liver 4. Akhan O, O hydatid disease: long term results of percutaneous treatment. Radiology 1996;198:259 –264. ¨ zmen MN, Dinc¸er A, Go¨c¸men A, Kalyoncu F. 5. Akhan O, O Percutaneous treatment of pulmonary hydatid cysts. Cardiovasc Intervent Radiol 1994;17:271–275.
Pneumo-orbital Cyst After Orbital Fracture Repair Robert B. Neves, MD, R. Patrick Yeatts, MD, FACS, and Timothy J. Martin, MD VOL. 125, NO. 6
PURPOSE: To report a case of a respiratory epithelial-lined, air-filled orbital cyst as a late complication of orbital fracture repair. METHOD: Case report. RESULTS: Recurrent episodes of diplopia and hyperophthalmia developed secondary to pneumatic inflation of a respiratory epithelial-lined orbital cyst 6 months after orbital fracture repair. This cyst remained in communication with an ethmoidal air cell and became inflated during pressurization of the ethmoid sinus. Removal of the cyst and orbital implant was curative. CONCLUSION: Air-filled, respiratory epithelial-lined orbital cyst is a rare cause of episodic diplopia and globe displacement after orbital trauma. (Am J Ophthalmol 1998;125:879 – 880. © 1998 by Elsevier Science Inc. All rights reserved.) ESPIRATORY EPITHELIAL-LINED CYSTS OF THE OR-
bit are usually seen in the fourth and fifth decades, secondary to chronic sinus disease and mucocele formation. Orbital cysts unrelated to mucocele formation are thought to develop secondary to choristomatous rests of respiratory epithelium in the orbit or to previous orbital trauma.1,2 Traumarelated cysts are formed by the proliferation of respiratory epithelium deposited into the orbit through a fracture. These cells generate a cyst with no communication to the nasal cavity and are filled with a brown oily fluid.2 Orbital emphysema is encountered acutely in up to 50% of orbital fractures, most commonly after Accepted for publication Dec 9, 1997. Department of Ophthalmology, Wake Forest University School of Medicine. Inquiries to R. Patrick Yeatts, MD, FACS, Wake Forest University Eye Center, Medical Center Blvd, Winston-Salem, NC 27157-1033; fax: (910) 716-7994; e-mail: [email protected]
BRIEF REPORTS
879
H
YDATID CYSTS MAY BE ENCOUNTERED IN ALMOST
every organ in the body, but for unknown reasons, hydatid cysts rarely involve the orbit.1 Surgical extirpation is still the most favored treatment for orbital cyst; however, intraoperative and postoperative complications are not infrequent.2,3 Recently, successful percutaneous treatment of hydatid cysts in the abdominal and thoracic cavities has been reported.4,5 We describe a patient with an
Accepted for publication Dec 15, 1997. ¨ ) and Ophthalmology Departments of Radiology (O.A., D.A., M.N.O (S.B., H.K.), Hacettepe University School of Medicine. Inquiries to Okan Akhan, MD, Department of Radiology, Hacettepe University School of Medicine, Sihhiye, Ankara, Turkey 06100; fax: 0-312-3112145; e-mail: [email protected]
VOL. 125, NO. 6
orbital hydatid cyst treated by percutaneous route under ultrasonographic guidance. A 21-year-old man with diplopia of recent onset was admitted to the hospital for further evaluation of his right-sided proptosis. His best-corrected visual acuity was RE, 20/30 and LE, 20/20. There was 4 mm of right proptosis measured by Hertel exophthalmometer. The right eye was displaced superiorly. The right fundus examination disclosed optic disk edema. The rest of the ocular examination was unremarkable. His orbital ultrasonography (Figure 1, top) and magnetic resonance imaging studies (Figure 1, bottom left) disclosed a 25 3 25 3 20-mm (6.25 cc) purely cystic mass at the right retrobulbar area. The mass was intraconally located and displaced the bulbus oculi anteriorly and the optic nerve superiorly. A hypointense rim was surrounding the mass on T2-weighted images, which may represent a capsule. No apparent contrast enhancement was noted. Radiologic studies of the cranium, thorax, and abdomen did not disclose any further cysts. Based on the presumptive diagnosis of hydatid cyst of the orbit, we decided to treat the cyst percutaneously under ultrasonographic guidance. The procedure was carried out using the PAIR (puncture-aspiration-injection-reaspiration) technique.4 The content of the cystic cavity was aspirated percutaneously with a 21-gauge needle under ultrasonographic guidance. To devitalize the cyst, the aspirated 7 ml of transparent clear fluid, which was characteristic for hydatid cyst, was replaced by 3 ml of 15% hypertonic saline solution and reaspirated 10 minutes later. There was no complication after the procedure. Notable decrease in the size and the volume of the lesion and the disappearance of the fluid component of the cyst on imaging studies were taken as healing criteria for satisfactory therapeutic outcome.4,5 A gradual decrease in size was observed at the periodic follow-up of the patient. By 3 months after the treatment, the mass lost 60% of its volume, and by 9 months after the treatment, the lesion was entirely solid and shrunken, and its volume was only 0.5 cc (Figure 1, bottom right). The patient’s visual acuity returned to RE, 20/20, and diplopia resolved completely. He remained asymptomatic for the 21 months after the treatment (Figure 2, top left and top right).
BRIEF REPORTS
877
FIGURE 1. (Top) A lobulated cystic lesion (arrowheads) with a volume of 6.25 cc is seen behind the bulbus oculi in axial (left) and sagittal (right) ultrasonographic scans. T1-weighted axial magnetic resonance imaging scan of the orbit before the treatment showed a well-circumscribed, oval, lobulated, hypointense mass in the right orbit (bottom left). At 9 months of follow-up, the lesion (arrowheads) was entirely solid and shrunken, and its volume was only 0.5 cc (bottom right).
Hydatid disease caused by Echinococcus granulosus is endemic in the Middle East, the Mediterranean Basin, South America, New Zealand, and Australia. The orbit is one of the unusual locations for hydatid disease, even in endemic areas, and is reported to be involved in 0.63% to 2.9% of all cases.1,3 Unilateral proptosis is the most common feature of orbital disease. Other possible findings include mechanical restriction of ocular movements and visual impair878
AMERICAN JOURNAL
ment, chemosis, eyelid edema, hypopyon, and conjunctivitis.2,3 Orbital hydatid cyst is seen as a wellcircumscribed cystic mass on imaging modalities such as ultrasonography and magnetic resonance imaging. Traditionally, the treatment of orbital hydatid cysts consists of surgical removal of the lesion as is done in other parts of the body. However, surgery is often complicated by the rupture of the cyst, which may lead to severe anaphylactic OF
OPHTHALMOLOGY
JUNE 1998
FIGURE 2. The patient is shown before (left) and 6 months after (right) the procedure. The proptosis and elevation of the right eye disappeared after the percutaneous treatment.
reaction, incomplete removal, or secondary implantation cysts.2 To reduce the probability of these complications, Nahri2 developed a simplified technique that reduces extensive dissection, which is a major cause of cyst rupture. Puncture of hydatid cyst was considered contraindicated because of potential risks of anaphylaxis and spillage of scolices. More recent clinical and experimental studies on percutaneous treatment of liver and pulmonary hydatid cysts did not show any evidence of anaphylaxis or dissemination. Published studies on abdominal and thoracic hydatid cysts suggest that percutaneous treatment of hydatid cysts is a safe and effective method and a good working alternative to surgery.4,5 We propose that percutaneous treatment of orbital hydatid cyst, which is more satisfactory to both the patient and the physician, may be a safe and effective alternative to surgical extirpation.
R
REFERENCES
1. Alpaslan L, Kanberogˇlu K, Peksayar G, C ¸ okyu¨ksel O. Orbital hydatid cyst: assessment of two cases. Neuroradiology 1990;32:163–165. 2. Nahri GE. A simplified technique for removal of orbital hydatid cysts. Br J Ophthalmol 1991;75:743–745. 3. Talib H. Orbital hydatid disease in Iraq. Br J Surg 1972;59: 391–394. ¨ zmen MN, Dinc¸er A, Sayek I, Go¨c¸men A. Liver 4. Akhan O, O hydatid disease: long term results of percutaneous treatment. Radiology 1996;198:259 –264. ¨ zmen MN, Dinc¸er A, Go¨c¸men A, Kalyoncu F. 5. Akhan O, O Percutaneous treatment of pulmonary hydatid cysts. Cardiovasc Intervent Radiol 1994;17:271–275.
Pneumo-orbital Cyst After Orbital Fracture Repair Robert B. Neves, MD, R. Patrick Yeatts, MD, FACS, and Timothy J. Martin, MD VOL. 125, NO. 6
PURPOSE: To report a case of a respiratory epithelial-lined, air-filled orbital cyst as a late complication of orbital fracture repair. METHOD: Case report. RESULTS: Recurrent episodes of diplopia and hyperophthalmia developed secondary to pneumatic inflation of a respiratory epithelial-lined orbital cyst 6 months after orbital fracture repair. This cyst remained in communication with an ethmoidal air cell and became inflated during pressurization of the ethmoid sinus. Removal of the cyst and orbital implant was curative. CONCLUSION: Air-filled, respiratory epithelial-lined orbital cyst is a rare cause of episodic diplopia and globe displacement after orbital trauma. (Am J Ophthalmol 1998;125:879 – 880. © 1998 by Elsevier Science Inc. All rights reserved.) ESPIRATORY EPITHELIAL-LINED CYSTS OF THE OR-
bit are usually seen in the fourth and fifth decades, secondary to chronic sinus disease and mucocele formation. Orbital cysts unrelated to mucocele formation are thought to develop secondary to choristomatous rests of respiratory epithelium in the orbit or to previous orbital trauma.1,2 Traumarelated cysts are formed by the proliferation of respiratory epithelium deposited into the orbit through a fracture. These cells generate a cyst with no communication to the nasal cavity and are filled with a brown oily fluid.2 Orbital emphysema is encountered acutely in up to 50% of orbital fractures, most commonly after Accepted for publication Dec 9, 1997. Department of Ophthalmology, Wake Forest University School of Medicine. Inquiries to R. Patrick Yeatts, MD, FACS, Wake Forest University Eye Center, Medical Center Blvd, Winston-Salem, NC 27157-1033; fax: (910) 716-7994; e-mail: [email protected]
BRIEF REPORTS
879