Aetiology of childhood proptosis

Neuroimaging in Children with Ophthalmological Complaints: A Review

Pediatric patients are commonly referred to imaging following abnormal ophthalmological examinations. Common indications include papilledema, altered vision, strabismus, nystagmus, anisocoria, proptosis, coloboma, and leukocoria. Magnetic resonance imaging (MRI) of the brain and orbits (with or without contrast material administration) is typically the imaging modality of choice. However, a cranial CT scan is sometimes initially performed, particularly when MRI is not readily available. Familiarity with the various ophthalmological conditions may assist the radiologist in formulating differential diagnoses and proper MRI protocols afterward. Although MRI of the brain and orbits usually suffices, further refinements are sometimes warranted to enable suitable assessment and accurate diagnosis. For example, the assessment of children with sudden onset anisocoria associated with Horner syndrome will require imaging of the entire oculosympathetic pathway, including the brain, orbits, neck, and chest. Dedicated orbital scans should cover the area between the hard palate and approximately 1 cm above the orbits in the axial plane and extend from the lens to the midpons in the coronal plane. Fat-suppressed T2-weighted fast spin echo sequences should enable proper assessment of the globes, optic nerves, and perioptic subarachnoid spaces. Contrast material should be given judiciously, ideally according to clinical circumstances and precontrast scans. In this review, we discuss the major indications for imaging following abnormal ophthalmological examinations.

Evaluation of Proptosis: A Primer

Collapse

Clinical Profile of Unilateral Proptosis in a Tertiary Care Centre

Proptosis, the forward protrusion of the eyeball, is a common manifestation of a wide variety of diseases inside the orbit and its spaces. Its diagnosis is usually a combined effort of the ophthalmologist, otolaryngologist, neurosurgeon, and radiologist. A clinical study of twenty-five cases with unilateral proptosis were studied in different age groups over a period of about 3 years under different headings like distribution, clinical features, radiological features, histopathological aspects, management, and outcomes of diseases. Proptosis measurement was done by simple/plastic ruler exophthalmometry, and diagnosis was made after a detailed clinical examination and ancillary tests. Treatment modality was decided based on radiological and histopathological examination reports, which included medical surgery, radiotherapy, and chemotherapy or a combination of all. In our study, most of the patients were in the age group of more than 60 years. The M : F ratio is 3 : 1. One case had a large proptosis of 18 mm above normal and 2 cases were as small as 3 mm. Diagnosis was mainly done by clinical features and confirmed by radiological and histopathological features. Most of them were treated medically (13 cases, i.e., 52%) and the rest by surgery with a combination of radiotherapy/chemotherapy (12 cases, i.e., 48%).

Isolated Neurofibroma of the Orbit: Case Report and Literature Review

PURPOSE

To summarize the clinical, radiographic, and intraoperative characteristics of isolated neurofibromas of the orbit (INFO) in the literature and report a case of INFO.

METHODS

Case report and a systematic review of the literature.

RESULTS

A total of 45 patients were identified from 18 previous studies. There was no sex predilection and mean ages were between 32.3 and 40.0 years with a standard deviation of 9.8 to 19.5 years, median age was 32 to 38 years with a range of 1.5 to 82 years. On CT imaging, INFO reveals homogeneous precontrast radiodensity similar to that of extraocular muscles. On MR imaging, INFO appears hypointense to orbital fat and isointense to brain on precontrast T1-weighted images. On T2-weighted images, they have been described as being predominantly hyperintense with possible hypointense intralesional islands. To the best of our knowledge, our case identifies the youngest patient with the myxoid histologic variant of INFO.

CONCLUSIONS

Patients with orbital neurofibromas should be evaluated for the presence of systemic neurofibromatosis, and the plexiform variant is a commonly associated subtype. The myxoid variant can be part of a lesser known condition called NAME syndrome (nevi, atrial myxoma, myxoid neurofibroma, and ephelides) which may warrant echocardiography in patients to evaluate for associated cardiac tumors.

[Pediatric case series in an ophthalmic camp in Turkana (Kenya)]

INTRODUCTION

Turkana is the largest district in Kenya, situated in the Northwest of the country. It features a semi-nomadic population of 850,000. Around 60% of population lives below the poverty threshold. The ratio of doctors is 1:75,000 inhabitants. Five ophthalmologists took part in the last deployment in November. Local staff had previously selected the patients from the rural areas, as well as in Lodwar, the capital of the district. Of the 371 patients who attended the clinic, 128 required surgery.

OBJETIVE

To describe the pediatric population attended to in the last «Turkana Eye Project» Camp.

METHODS

Description of the ophthalmic pathologies of the children seen in the clinic in this surgical camp, and the diagnostic and therapeutic options according to the limitations of the environment.

RESULTS

Of the 371 patients, 54 were younger than 15 years old (14.5%). Four children had surgery (3.25% of the 128 patients). In 2 more cases surgery was the indicated but not performed. Therefore, of the total of 54 cases, 6 could be considered as surgical (11.1%), and 17 suffered ophthalmic problems other than refraction defects, or mild ocular surface pathologies: traumatic cataracts, neuropathies, impetigo, exophthalmos, retinal dystrophies, dermoid cysts, or nyctalopia. The etiology was traumatic in four of the 17 children (23.5%).

CONCLUSION

Surgical camps are increasing in the developing countries. They are usually focused on particular pathologies, such as cataracts or trachoma. Our case series shows the importance of pediatric teams and the need to be prepared to face complex pediatric pathologies.

[Orbital tumours in children and adolescents. Differential diagnostics and clinical symptoms]

BACKGROUND

The aim of this retrospective study was to determine the incidence of and surgical strategies used for treating orbital tumours in children and adolescents.

PATIENTS AND METHODS

A retrospective chart review was carried out for 22 patients between the ages of 2 weeks and 18 years who were treated in the years 1997-2007 for suspected space-occupying orbital lesions. The specific investigation methods, therapy, and treatment results were described.

RESULTS

The most frequent orbital lesions in the children in this study were mesenchymal tumours; the second most common were dermoids. Nineteen patients were surgically treated. Three children with malignant tumours underwent radiochemotherapy after surgery, and two died in the first year after diagnosis. Two other children with benign tumours suffered recurrence of their disease.

CONCLUSION

The variety of orbital diseases in paediatric patients includes benign and malignant tumours as well as nonneoplastic lesions. The treatment of orbital disease is a diagnostic and therapeutic challenge for the attending physician.

Acute proptosis in a newborn infant: a presentation of infantile dural fistula

Rapidly increasing proptosis is rare in a newborn. The causes are diverse, and determining an exact etiology is difficult. We report a case of acute proptosis in a 26 day old infant due to dural fistula. To our knowledge, this is the youngest reported patient with a dural fistula. A multidisciplinary approach was essential to understanding the etiology of the proptosis in this child and providing adequate and successful treatment.

Malignant childhood proptosis: study of 104 cases

Children < or =18 years with malignant proptosis enrolled in ophthalmic tumor clinic at a tertiary cancer center from July 2003 to December 2006 were retrospectively analyzed. The incidence of proptosis among the pediatric cancer patients was 4.9%. Secondary tumors accounted for majority of cases (n=62, 59.6%) with retinoblastoma (51%) being the commonest cause of proptosis. Fourteen (13.5%) patients presented with bilateral proptosis; all but one had metastatic tumor as underlying cause. Metastatic malignancies had significantly lower hemoglobin and platelet count and higher white blood count. Therefore, careful analysis of symptomatology, hemogram, and those with bilateral proptosis warrant a hematologic work-up before imaging studies and invasive orbital biopsy.