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Deep orbital haemangioma

  • 1.  Deep orbital haemangioma

    Posted 3 hours ago
    This is a 43-year-old female known to have a left orbital haemangioma since 2013, but it was left untreated.  She now came to our hospital for second opinion.
    The haemangioma is too deep for the orbital surgeon and in an uncommon place for the neurosurgeon.
    The right eye has a Snellen visual acuity of 0.9 (18/20). The left eye sees 0.7 (14/20).
    There is a left optic atrophy (GCL more affected than RNFL) and associated visual field loss. However, there is still vision to be saved.
    What would you recommend?
    Thank you,
    Michel
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  • 2.  RE: Deep orbital haemangioma

    Posted 2 hours ago
    Coronal views?

    Russ Edwards





  • 3.  RE: Deep orbital haemangioma

    Posted 2 hours ago
    Also, do you have older fields? is the vision loss progressing, or has it been stable for the past 13+ years?

    --
    Russ Edwards





  • 4.  RE: Deep orbital haemangioma

    Posted 2 hours ago
    Steretotactic radiosurgery (Cyberknife or Gammaknife) can be an alternative to surgery in these cases. If there is severe neuro-axonal loss already then the risk of more post-op visual loss risk is higher.


    RB




  • 5.  RE: Deep orbital haemangioma

    Posted 2 hours ago
    These are always tough calls. Depending on the exact location, endoscopic surgery can be done to decompress or take the lateral wall off all the way back to get at it from superior or inferior laterally. Another option would be to inject an anti-VEGF agent into the lesion. Finally, radiosurgery may be appropriate but will take a long time to reduce the lesion size.

    N



    Original Message


  • 6.  RE: Deep orbital haemangioma

    Posted 2 hours ago
    It doesn't have to be radiosurgery, they can do fractionated radiotherapy (~50 gy in  in 26 fractions) similar to what is used for meningiomas which will likely be lower risk optic nerve toxicity as the dose per fraction is lower and better tolerated by the optic nerve. 

    I think orbital decompression without resection is likely just kicking the can down the road.

    In the orbital apex, there is high risk of vision loss (60-80%) with surgery from a variety of mechanisms including traction on the nerve of the tumor is adherent, retrobulbar inflammation / hemorrhage.

    Best, 

    Drew




    Original Message


  • 7.  RE: Deep orbital haemangioma

    Posted 2 hours ago

    Michel,

     

    I operated on a similar case many years ago.  I used a transantral approach to the medial wall at the apex.  Once the bone was removed and the periorbital opened, the mass presented itself into the posterior ethmoidal space an was easily dissected free from the orbital tissues.

     

    Steve

     






  • 8.  RE: Deep orbital haemangioma

    Posted an hour ago

    Many years ago when I was JSKs fellow and we were operating on optic nerve sheath meningiomas. our exposure with neurosurgical help was to remove the lateral wall back to the temporal dura.  

    that is not too difficult and then open the periorbita and hope that you decomopress the optic nerve

    but my question is (and remember I was a very aggressive optic nerve and orbital surgeon) what is the patient to Gain

    this goes back to my residency when I wanted to do a glaucoma procedure on an only eye (glaucoma surgery was frowned upon in NYC in those days) and my attending in a fatherly manner said "let 

    God blind him Tom not us" best to al and stay well

    tcs



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    tsapoor md
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    Original Message


  • 9.  RE: Deep orbital haemangioma

    Posted 28 minutes ago
    The tumor appears to lie lateral to the optic nerve. A trans ethmoidal approach might take some pressure off the nerve but would not provide safe access to it. Lateral orbitotomy combined with a frontal craniotomy would give access. 

    But - this is based on the few cuts provided; any surgeon would want to review the whole series of scans before making any recommendations. 

    If this is in fact a cavernous hemangioma, it and the option neuropathy may be stable. I had a patient with mild optic neuropathy from a much larger cavernous hemangioma who declined surgery. I followed her for 20 years without change. I still recommend chasing down old records.

    Russ Edwards




    Original Message


  • 10.  RE: Deep orbital haemangioma

    Posted 19 minutes ago
    If the tumor is lateral to the optic nerve, then a far posterior superolateral approach would be best, hopefully between the lateral rectus and the superior rectus/levator complex. The farther posterior the lesion, the more it tends to be stuck to surrounding tissue so a piecemeal approach with focal bipolar cautery to shrink might be ideal.



    Original Message


  • 11.  RE: Deep orbital haemangioma

    Posted 9 minutes ago

    At the orbital apex, there is enough pressure build-up to affect optic nerve function.  Also, lmost all of the tissue is fixed in position except for that slippery hemangioma that will follow path of least resistance.  Just an N of 1, but a very satisfying result.

    Steve

     




    Original Message


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