Interventions for orbital lymphangioma

Orbital Lymphangioma in an Adolescent Male: A Case Report and Review of Literature

Lymphangiomas are localized multi-cystic malformations of the lymphatic and vascular system, primarily affecting the head and neck regions in children. Orbital lymphangiomas are not considered hamartomas because the orbit does not commonly display lymphatic vessels. In this case report, we describe a male patient who was 15 years old and presented to our medical facility with the primary complaints of having a bulging left eye, sudden chemosis of the lower conjunctiva, and pain in the left eye. During the examination of the left eye by the ophthalmologist, proptosis, hyperlacrimation, conjunctival hyperemia, keratopathy, and pain on probing were found. A magnetic resonance imaging (MRI) of both orbits was recommended, which revealed an ill-defined, multi-locular heterogeneous solid-cystic mass in the left retrobulbar space. He was subsequently admitted to the healthcare facility for a biopsy of the orbital lesion. The examination of the specimen, both at the macroscopic and microscopic levels, was consistent with the diagnosis of lymphangioma. Given the potential risk of damage to adjacent structures, the patient was initially scheduled for sclerotherapy rather than a surgical excision. A total of three sessions of bleomycin-based sclerotherapy were administered to the patient. The patient gradually improved in the follow-up period, achieving complete remission of pain, proptosis, and chemosis. However, considering the possibility of new episodes arising, it was recommended that he attend regular follow-up appointments. The purpose of this case report is to present a rare case of orbital lymphangioma and emphasize the clinical and radiological features and management of orbital lymphangiomas.

A Simple Orbital Lymphatic Malformation Clinically Mimics Primary Conjunctival Cyst

Introduction

A simple orbital lymphatic malformation usually presents with acute proptosis with ophthalmoplegia after an upper respiratory tract infection. Various treatments have been described but the lesions often recur after treatment due to their infiltrative nature.

Case Presentations

A 6-year-old girl presented with a 5 × 10 mm translucent mass in the left inferior fornix for 3 years but she denied diplopia and visual disturbance. Orbital computed tomography with contrast emphasized the clinical findings, a nonseptated cystic lesion without enhancement in the anterior orbit. The lesion was surgically totally excised. Histopathological findings revealed an endothelial lining cyst without intraluminal cells consistent with a lymphatic malformation. In a 1-year follow-up, the lesion does not recur.

Conclusion

The simple orbital lymphatic malformation can present as a single nonseptate cystic lesion. Pathological study should be done for the definitive diagnosis. Surgical excision can achieve a favorable outcome.

Histopathological changes of lymphatic malformation after bleomycin injection

Lymphatic malformation is a rare orbital tumor that used to be treated surgically, with high complication rates, or recently with intralesional bleomycin injection. We report for the first time the histopathological changes of eyelid lymphatic malformation after water-soluble intralesional bleomycin injection in a 20-year-old woman who had unsuccessful orbital surgical debulking during childhood. The changes confirmed the assumption of fibrosis induced by intralesional bleomycin injection. The minimal bleeding during surgical intervention made it much easier than the usual lymphatic malformation bloody procedure, without postoperative recurrences and with favorable aesthetic outcomes.

Acute Unilateral Proptosis After Blunt Orbital Trauma in an Adolescent Patient

A male patient aged 16 years with a recent history of blunt trauma to the periorbita presented with blurred vision, pain, and proptosis of the right eye. MRI imaging revealed an intraconal mass. What would you do next?

Long term outcomes of transcutaneous non-image guided bleomycin sclerotherapy in orbital/adnexal lymphatic malformations: a protocol-based management in 69 eyes

OBJECTIVES

To study the efficacy and the long-term outcomes of treating micro and macrocystic orbital and/or adnexal lymphatic malformations (OA-LM) with protocol-based bleomycin sclerotherapy.

METHODS

A retrospective interventional study of 69 eyes having OA-LM treated with non-image guided transcutaneous or transconjunctival bleomycin sclerotherapy (1IU/ml aqueous solution) between December 2014 and December 2018. Based on clinical regression, the outcomes were classified as excellent, good, fair and poor.

RESULTS

The mean age at presentation was 20 ± 16 years (median 16; range 1 month to 70 years). The orbital-palpebral variant was the most common presentation, seen in 29 patients (42%). Microcystic morphology was seen in 34(49%), macrocystic in 22 (32%) and mixed cyst in 13 (19%) patients. Mean units of bleomycin injected per patient were 9 ± 8 IU (median 5.5 IU, range 1-38 IU). Mean number of treatment sessions required were 2 ± 1 (median 2, range 1-6). The response was excellent in 43 (62%), good in 12 (17%), fair in 9 (13%) and poor in 5 (7%) patients. These responses were comparable across the morphological subgroups (p = 0.24, chi-square test). Adverse reactions noted were inflammation in 11 eyes (16%) and peri-ocular pigmentation in 15 (22%). There was a sustained tumour regression over a mean follow-up duration of 3.5 years (median 3; range 1.5-5 years).

CONCLUSIONS

Seventy-nine percent of eyes with OA-LM showed a good outcome with transcutaneous and/or transconjunctival non-image guided bleomycin sclerotherapy with no serious adverse events. The results were promising over long-term follow-up.

Novel treatment of recurrent orbital venolymphatic malformation with sirolimus and rivaroxaban

Orbital venolymphatic malformations are rare vascular malformations that typically appear early in life and harbor acute and chronic threats to vision. Historically, there are four categories of management: observation, medication, sclerotherapy, and surgery. Currently, there is neither a gold standard for treatment nor randomized control trials comparing treatments.The authors present a 20-year-old male who presented with spontaneous hemorrhage of an orbital venolymphatic malformation occurring with increased frequency and involving more of the posterior orbit. Surgery and sclerotherapy were not feasible options due to the extensive intraorbital and intracranial involvement of the venolymphatic malformation. Systemic steroids treated symptoms but was not curative. To this end, a combination of sirolimus, an mTOR inhibitor, and rivaroxaban, a factor Xa inhibitor, were used to reduce the size of the lesion and minimize the risk of thromboembolic events. This treatment has successfully kept the patient's symptoms in remission for greater than 2 years.