Amputation neuroma of the orbit. Report of two cases and review of the literature

A case of eyelid neuroma with recurrent ptosis

Purpose

We report a rare case of eyelid neuroma, discovered nine years after external levator advancement, presenting with recalcitrant ocular foreign body sensation and pain, persistent corneal epithelial defect, followed by corneal scarring, and ptosis.

Observations

An 85-year-old man with a history of multiple skin cancers presented with left ptosis, epiphora and recalcitrant eye pain. Nine years prior to presentation, he underwent excision of melanoma in situ of the left forehead, followed by simultaneous forehead reconstruction and left external ptosis repair. At presentation, he had left ptosis and left superior corneal scarring. Eversion of the eyelid demonstrated the presence of a nodule at the superior border of the tarsus. The patient underwent simultaneous excisional biopsy of the lesion and posterior ptosis repair by Müller muscle conjunctival resection (MMCR). He experienced postoperative resolution of pain, ptosis and epiphora. Histopathologic examination demonstrated the presence of a foreign body granuloma alongside a neuroma.

Conclusions

This case highlights the importance of thorough eyelid exam in individuals with ocular surface disease. We review herein the pathophysiology and histopathology of eyelid neuroma.

Anophthalmic Socket Syndrome: Prevalence, Impact and Management Strategies

Anophthalmic socket syndrome determines functional deficits and facial deformities, and may lead to poor psychological outcomes. This review aims to comprehensively evaluate the features of the syndrome, based on literature review and authors’ clinical and surgical experience. An electronic database (PubMed,MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on anophthalmic socket syndrome was performed. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. Different types of orbital implants were evaluated; the management of implant exposure was examined; different orbital volume enhancement procedures such as secondary implantation, subperiosteal implants and the use of fillers in anophthalmic patients were described; the problems related to socket contraction were outlined; the treatment options for chronic anophthalmic socket pain and phantom eye syndrome were assessed; the most recent advances in the management of congenital anophthalmia were described. Current clinical evidence does not support a specific orbital implant; late exposure of porous implants may be due to pegging, which currently is seldom used; filler absorption in the orbit appears to be faster than in the dermis, and repeated treatments could be a potential source of inflammation; socket contraction results in significant functional and psychological disability, and management is challenging. Patients affected by anophthalmic socket pain and phantom eye syndrome need specific counseling. It is auspicable to use a standardized protocol to treat children affected by clinical congenital anophthalmia; dermis fat graft is a suitable option in these patients as it helps continued socket expansion. Dermis fat graft can also address the volume deficit in case of explantation of exposed implants and in contracted sockets in both children and adults. Appropriate clinical care is essential, as adequate prosthesis wearing improves the quality of life of anophthalmic patients.

Persistent socket pain postenucleation and post evisceration: a systematic review

PURPOSE

To investigate causes, diagnostics and treatment modalities for persistent socket pain (PSP) after enucleation and evisceration.

METHODS

A systematic search was undertaken in accordance with the PRISMA Statement, in PubMed, Embase.com and Thomson Reuters/Web of Science. We searched for relevant papers until the 28th of July 2016. Inclusion criteria were (1) patients with a history of enucleation or evisceration, (2) PSP, (3) report of the cause and/or used diagnostics and/or treatment modality, (4) full text in English, Dutch or Spanish language. Excluded were (1) review articles, (2) comments, and publications concerning, (3) nonhumans, (4) exenterated patients, (5) acute postoperative pain, or (6) periorbital pain without pain in the socket. Given the lack of high quality evidence from randomized controlled trials, we examined all available evidence from primary observational studies and assessed quality within this lower level of evidence.

RESULTS

A total of 32 studies were included. Causes of PSP found were prosthesis-related (n = 5), dry socket (n = 2), trochleitis (n = 3), compression of the trigeminal nerve (n = 2), implant-related (n = unknown), inflammation (n = 5), surgery-related (n = 4), neuromas (n = 8), malignant tumours (n = 3), psychiatric/psychosocial (n = 2), phantom pain (n = 149), rarer entities (n = 3) or unknown (n = 14). Nonsurgical treatments suffice for conditions as trochleitis, prosthesis-related pain, dry socket and for phantom pain. Other causes of pain may require more invasive treatments such as implant removal.

CONCLUSION

Careful history and examination can give some direction in the diagnostic procedure; however, PSP is probably multifactorial and the specific origin(s) may remain uncertain. Implant replacement can be an effective treatment. Studies to identifiy less invasive procedures are required.

A case of traumatic infraorbital neuroma

A 53-year-old Afghan man presented with a 12-month history of left proptosis, diplopia and facial swelling 20 years after a bomb blast injury. Magnetic resonance and computed tomography imaging revealed a well-circumscribed lesion centred within the left inferior orbit/superior maxillary sinus along with left orbital fracture. Histopathology and immunostaining of the debulked lesion were consistent with traumatic neuroma of the infraorbital nerve. Infraorbital neuromas have developed following orbital decompression surgeries but have not been reported previously following non-surgical trauma.

Clinicopathological features of peripheral nerve sheath tumors involving the eye and ocular adnexa

Peripheral nerve sheath tumors (PNSTs) are known to occur in the orbit and comprise 4% of all orbital tumors, but have not been well studied in contemporary literature. Ninety specimens involving the eye and ocular adnexa (1979-2015) from 67 patients were studied. The mean age was 32.5years. Locations included orbit (58.9%), eyelid (60.0%), and other ocular adnexa. Most specimens were neurofibromas (70.0%), followed by schwannomas (11.1%), neuromas (11.1%), granular cell tumors (n=4), nerve sheath myxomas (n=2), and malignant PNST (n=1). Fifty-six (88.9%) neurofibroma cases were neurofibromatosis 1 associated. Among neurofibromas, 31.7% were localized, 38.1% were plexiform, 25.4% were diffuse, and 4.8% were diffuse and plexiform. These tumors involved skin (31.7%), soft tissue (11.1%), skeletal muscle (22.2%), peripheral nerve (63.0%), lacrimal gland (20.6%), and choroid (n=1). Other histologic findings included pseudo-Meissner corpuscles (27%), Schwann cell nodules (4.8%), prominent myxoid component (7.9%), melanin-like pigment (3.2%), and inflammation (14.3%). Available immunostains included S100 (+ in 15/15 cases), EMA (+ in 2/4 cases), CD34 (+ in 4/4 cases), and Ki-67 (<1% in 4/4 cases). Among 10 schwannomas, 8 were conventional and 2 were plexiform. Observed features included capsule (n=5), hyalinized vessels (n=5), Verocay bodies (n=7), and Antoni B pattern (n=5). Immunostaining included S100+ in 4 of 4 cases, and collagen IV+ and Ki-67 <1% in 3 of 3 cases. Neurofibromas are the most common PNST involving the eye and ocular adnexa, and the majority are associated with neurofibromatosis 1. Plexiform and diffuse patterns and the presence of pseudo-Meissner corpuscles are relatively frequent in this area.

Stump Neuroma

A 24-year-old man presented for follow-up magnetic resonance imaging to rule out tumor recurrence 1 year after he underwent an above-knee amputation for synovial cell sarcoma.

Psychological Reactions and Persistent Facial Pain following Enucleation

Background. Enucleation is a psychologically and physically traumatic event associated with chronic pain. It would be desirable to better predict which patients will have pain after surgery. Methods. A cross-sectional postal questionnaire study of adults undergoing enucleation captured the demographic details, Pain Quality Assessment Scale (PQAS), Pain Catastrophizing Scale (PCS), and the Facial Pain Assessment questionnaire. Patients were classified as suffering from chronic pain if they reported a pain score of >1 out of 10 on the numerical pain score (NRS). Results. Seventeen of 60 adults participated in the study. 47% of patients reported chronic pain (mean pain score = 1.4 ± 0.7, n = 17); 25% experienced pain daily. No difference in age, surgical side, reason for surgery, or the duration of time since the surgery was noted. All patients had low PQAS scores and 50% of individuals with persistent pain were concerned about their facial appearance. There was no significant difference in the level of catastrophization noted in patients with or without pain or between the subgroups (rumination, magnification, or helplessness). Conclusions. Although persistent pain following enucleation affected a significant number of patients, the pain intensity was mild. Enucleation influenced the physical perception some individuals had of themselves.

Metastasis to optic nerve presenting as ill-fitting prosthesis

We report a rare case of metastatic adenocarcinoma of lung in anophthalmic socket, which presented as painful and difficult prosthetic wear long after an uneventful enucleation. Bulge in the socket indicated amputation neuroma, a rarity in itself; but further evaluation concealed a yet silent pulmonary mass. No case report so far describes metastatic mass in an anophthalmic socket and we describe first case of unknown lung malignancy presenting as ill-fitting prosthesis.

Sciatic neuroma presenting forty years after above-knee amputation

We report a case of a sciatic neuroma presenting forty years after above knee amputation. Patients developing neuroma following a limb amputation can present with stump pain which is commonly resistant to medical intervention. The length of interval from the initial injury to presentation is widely variable. Diagnosis relies on clinical suspicion and accurate assessment, radiological imaging and, if indicated, surgical exploration. MRI provides a better soft tissue definition than CT and is more accurate in identifying small lesions than ultrasound. The aim of treatment for symptomatic neuroma is pain relief and improvement of function. This is often achieved by surgical excision.

Posttraumatic headache: surgical management of supraorbital neuralgia

BACKGROUND

Supraorbital neuralgia is a distinct clinical entity that presents with episodic, often unilateral, long-lasting attacks of moderate to severe frontal pain. This may ensue following a traumatic or surgical insult to the supraorbital or supratrochlear nerve. Surgical management of these patients is only sporadically discussed in the available literature.

METHODS

The authors report a series of six consecutive patients undergoing surgical excision of the supraorbital and supratrochlear nerves on the affected side for refractory posttraumatic or postoperative supraorbital neuralgia. End-to-end nerve coaptation by means of a neural tube conduit was used to prevent future neuroma formation. Success was defined as a 50 percent or greater reduction of preoperative pain level.

RESULTS

Five of six patients demonstrated at least a 50 percent reduction in pain. Three patients experienced complete pain cessation postoperatively. There was one treatment failure. Pain was measured using a visual analogue pain scale. Preoperative average pain was 9.16 +/- 1.3 and postoperative average pain was 1.5 +/- 1.9, an improvement of 7.7 points or 84 percent (p = 0.03). Mean age of the patients was 42 years. Mean follow-up was 14 months. No surgical complications occurred.

CONCLUSION

Excision of the supraorbital and supratrochlear nerves with end-to-end coaptation of the proximal nerve stumps by means of a neural tube appears to be an effective treatment in selected patients with chronic, posttraumatic supraorbital neuralgia.

Rapid development of amputation neuroma following excision of an orbital cavernous hemangioma

A 48-year-old man with left proptosis and signs of optic nerve compression underwent medial transconjunctival orbitotomy for an excisional biopsy of a posteromedial orbital cavernous hemangioma. The left eye once again became proptotic and painful only 5 weeks later because of a more anteriorly growing orbital mass, which was homogeneously hyperintense relative to orbital fat on both T1- and T2-weighted MRI studies. The tumor proved to be an amputation neuroma after total excision. The latter tumor is presumed to originate most probably from the transected branch of the oculomotor nerve innervating the medial rectus muscle, which remained paralytic after the first operation.

Conjunctival cysts of the orbit

OBJECTIVE

This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts.

DESIGN

A case series review from four oculoplastic practices over 6 years.

PARTICIPANTS

Eleven patients with simple conjunctival cysts of the orbit were identified.

INTERVENTION

All cysts were excised and evaluated histopathologically.

MAIN OUTCOME MEASURES

Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling.

RESULTS

Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone.

CONCLUSIONS

Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.

Anophthalmic socket pain

We examined and treated four patients with anophthalmic socket pain. Conditions responsible for this problem in this series included scleritis after evisceration, amputation neuroma, pain from a skull-base meningioma, and chemical dependency with drug-seeking behavior. The pain associated with the scleritis after evisceration responded to removal of the scleral remnant. The pain associated with the amputation neuroma responded to removal of the orbital implant and its pseudocapsule in which the amputation neuroma was embedded. The pain associated with the meningioma was intractable. The pain associated with the chemical dependency remained a persistent problem. A careful history and physical examination are critical in the evaluation of anophthalmic socket pain. Computed tomography or magnetic resonance imaging may be helpful in some cases.