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Orbital Pseudotumor
Micah Kinney, OD, FAAO
655 Bluff Park Rd
Hoover, AL 35226
Tel: (205)739-1541
[email protected]
I. Case History
A. Patient demographics: 31- year old Caucasian Male
B. Chief complaint: Bump on left lower eyelid for the past four months. The
patient was seen by his flight surgeon four months prior and started a tenday course of Septra DS (160 mg trimethoprim/800 mg sulfamethoxazole)
without any improvement. There was no follow-up by the patient; so further
investigation did not take place at that time. Mild pain and tenderness upon
palpation, warm compresses used at least BID. Diplopia in left gaze.
C. Ocular, medical history: Negative Ocular History. History of Kidney
stones x 8 years ago
D. Medications: None
E. Other salient information: None
II. Pertinent findings
A. Preliminary Testing:
DVA sc 20/20 OD/OS
EOMs: FROM, diplopia in left gaze
Red Lens test: 5ΔBI OS Left Gaze
CT: Ortho in Primary gaze (6m and 40cm)
PERRL (-) APD
IOP (app) OD: 10 mmHg
OS: 11 mm Hg
B. Physical:
OD anterior segment unremarkable
OS 1x1 cm palpable HARD mass superior to the inferior orbital rim. Not
warm to touch, mild pain with palpation, no visible elevation with lower lid
eversion.
OU Posterior segment findings unremarkable
C. Radiology studies:
i. CT ordered with 1mm cuts revealed Left orbit inferiolateral aspect
mass measuring 1.8 x 1.9 x 1.7 cm. Well defined. No significant
infiltration of the intraorbital fat. No infiltration of the globe. Loss of
clarity of the margins of the inferior rectus muscle.
ii. MRI (with and without contrast) ordered per request of radiology.
Enhancing mass within left orbit inferolateral aspect measuring 1.9 x
2 x 1.7 cm. Left intraorbital fat, bony orbit, extra ocular muscles, and
optic nerve appear normal without infiltration
III. Differential diagnosis
A. Orbital Pesudotumor
B. Dermoid
C. Lymphoma
D. Metastasis
E. Bacterial Orbital Cellulitis
IV. Diagnosis and discussion
A. Orbital pseudotumor accounts for approximately 6-11% of all orbital
lesions.5-6 It is the third most common orbital disorder.2 Diagnosis is based
on clinical findings, imaging studies, response to steroids, and/or biopsy.16 Biopsy is indicated to aid in differentiation from neoplasia, provided the
risk is minimal to surrounding structures. Unlike a true tumor or neoplasia,
IOID does not indent the globe, cause tissue necrosis, or give rise to bone
deformities.5
B. Symptoms of IOID1,3: Orbital Pain, Proptosis, Lid Swelling, Chemosis,
Limited Ocular Motility, Pain on Palpation, Diplopia, Unilateral (although
children are more likely to have bilateral symptoms)
C. Types based on location1,2,4:
i. Dacryoadenitis- inflammation of the lacrimal gland occurs in
approximately 25% of IOID patients, making the most common
form. Patients complaint of acute pain/discomfort in area of the
lacrimal gland.
ii. Orbital Myositis- inflammation of one or more extra ocular
muscles. Symptoms include pain especially with eye movement, and
diplopia. Signs include ptosis, lid edema, and chemosis.
iii. Tolosa-Hunt Syndrome- a rare form of IOID in which the
cavernous sinus, superior orbital fissure, and/or the orbital apex are
inflamed. Patients present complaining of doubled vision with
periorbial pain. Cranial nerve palsies including CN3, CN4, CN6, and a
loss of sensation along the first and second divisions of CN5.
iv. Optic Perineuritis- inflammation of the optic nerve
causing decreased vision, occurring in less than 15% of IOID
cases. MRI helps to differentiate from idiopathic optic neuritis as this
can be an early sign of Multiple Sclerosis.
v. Localized Inflammation- may not be defined to a specific tissue
and may appear tumor-like, as is described in this case.
V. Treatment, management
A. Labs: CBC, Thyroid Panel, ACE with Chest X-ray, c-ANCA/p-ANCA
B. Imaging: CT v/s MRI
C. Oral/Injected Steroids
D. NSAIDS, Cyclosporine A
E. Surgery
VI. Conclusion
A. Non typical presentation and no response to antibiotic
B. Management of orbital mass removal and post surgical diplopia
References:
1. Kanski J. Clinical Ophthalmology a Systemic Approach. 6th ed. Edinburgh,
England: Butterworth Heinemann Elsevier, 2007.
2. Weber A, Romo L, Sabates N. Pseudotumor of the orbit: Clinical, pathologic,
and radiologic evaluation. Radiologic Clinics of North America. 1999; 1: 151168.
3. Espinoza G. Orbital inflammatory pseudotumors: etiology, differential
diagnosis, and management. Curr Rheumatology Rep. 2010; 12:443-447.
4. Jacobs D, Galetta S. Diagnosis and management of orbital pseudotumor. Curr
Opinion in Ophthal. 2002; 13:347-351.
5. Martin C. Orbital pseudotumor: case report and overview. JAOA. 2007;
12:775-781.
6. Mendenhall W, Lessner A. Orbital pseudotumor. Am J of Clinical
Oncology. 2010; 33:304-306.