Tumours of the orbit

CLINICAL SYMPTOMS AND SIGNS

Orbital pain: prominent in rapidly growing malignant tumours, but also a characteristic feature of orbital granuloma and carotid-cavernous fistula.

Proptosis: forward displacement of the globe is a common feature, progressing gradually and painlessly over months or years (benign tumours) or rapidly (malignant lesions). Lid swelling: may be pronounced in orbital granuloma, dysthyroid exophthalmos or carotid-cavernous fistula.

Palpation: may reveal a mass causing globe or lid distortion - especially with lacrimal gland tumours or with a mucocele. Pulsation indicates a vascular lesion - carotid-cavernous fistula or arteriovenous malformation - listen for a bruit.

Eye movements: often limited for mechanical reasons, but if marked, may result from a dysthyroid ophthalmoplegia or from III, IV or VI nerve lesions in the orbital fissure (e.g. Tolosa Hunt syndrome) or cavernous sinus.

Visual acuity: may diminish due to direct involvement of the optic nerve or retina, or indirectly from occlusion of vascular structures.

INVESTIGATIONS

X-ray of the orbit: may reveal local erosion (malignancy), dilatation of the optic foramen (meningioma, optic nerve glioma) and occasionally calcification (retinoblastoma, lacrimal gland tumours). A meningioma often causes local sclerosis. CT scan of the orbits demonstrates the precise site of intraorbital pathology and shows the presence of any intracranial extension.

Axial view showing an optic nerve glioma. _

Coronal views are of value in assessing the size of the optic nerve and extraocular muscles and the floor and roof of the orbit

MRI may provide more information in certain conditions, e.g. meningioma of the optic nerve sheath.

MANAGEMENT

benigk tumours: require excision, but if visual loss would inevitably result, the clinician may adopt a conservative approach.

malignant tumours: require biopsy plus radiotherapy. Lymphomas may also benefit from chemotherapy. Occasionally localised lesions (e.g. carcinoma of the lacrimal gland) require radical resection. Operative approach

Ethmoidal: for anterior tumours, — lying medial to the optic nerve radical resection. Operative approach

Ethmoidal: for anterior tumours, — lying medial to the optic nerve

___|___Frontal-transcranial: for tumours with intracranial extension or lying posterior and medial to the optic nerve

- Lateral: for tumours lying superior, lateral or inferior to the optic nerve

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