Orbital Tumors

Introduction to Orbital Tumours

Gone are the days when every case of proptosis had to undergo a possibly futile biopsy procedure to the eyeball and face the consequences thereafter. The dawn of noninvasive radiodiagnostic techniques such as ultrasonography (USG), computerized tomography (CT) and magnetic resonance imaging (MRI) marked the end of this era of uncertainty. Biopsy is justified only in rare cases of malignancy or in lymphomatous lesions to confirm the histological variety.


About 20-25% of orbital disease are due to neoplasms and are commonly seen during and after the seventh decade of life. Malignant primary cancers of the orbit that call for a biopsy and radical surgery arise almost exclusively from the lacrimal gland.


Signs and Symptoms

Orbital tumors are suspected by the presence of following signs and symptoms:

  • Proptosis or exophthalmos due to anterior displacement of the globe
  • Superior orbital tumours displace the globe inferiorly while masses in the inferior orbit displace the globe vertically.
  • Globe motility is limited by simple mass effect, extraocular muscle involvement, involvement of nerves to extraocular muscles, and adhesions of tumour to the globe.
  • Orbital pain, particularly in rapidly growing tumours.
  • Increased retropulsion, which means increased resistance to digital pressure applied on the side of the tumour.
  • Mass effect flattens the globe with changes in refractive power of the eye termed as a foreshortened globe.
  • Pressure on sensory nerves resulting in periocular paraesthesia or anaesthesia.
  • Proptosis causing droopy eye lid or ptosis.
  • Palpable mass, when tumour is anteriorly placed.
  • Visual field defect limited to affected eye only.
  • Obstruction of venous outflow leading to lid edema.
  • Papilledema results from mass effect on the retrobulbar optic nerve

Benign and Malignant Diseases of the Orbit


Well-defined Orbital Masses: Well-circumscribed lesions of the orbit include cavernous hemangioma, neurofibromas, schwannoma, hemangiopericytoma, meningioma, and gliomas. Cavernous hemangioma is the most common benign orbital tumour in adults, similar to capillary hemangioma in children. Patients present with painless proptosis that is gradually progressive with features of mass indenting the globe, striae in the retina and flattened globe on imaging studies. Surgical treatment for en masse removal is advocated.
A mucocele or mucopyocele is the most common cause of proptosis in children, and presents as a cystic, encapsulated mass that usually originates from the nasal sinuses (usually frontal sinus), following repeated bouts of sinusitis. Surgical drainage is considered only after treatment failure with a course of antibiotics, or in the presence of optic nerve compression.

Diffuse Orbital Mass: These lesions usually require a biopsy to confirm the diagnosis. They include lymphoma, benign reactive lymphoid hyperplasia, orbital cellulitis, benign or malignant fibrous histiocytoma, neurofibromas, and sarcomas. Lymphomas are managed by radiation or chemotherapy, while pseudotumour is treated with steroids and ASA. Diffuse orbital masses requiring surgery include lymphangioma, fibrous histiocytoma, and neurofibroma.

Thyroid Ophthalmopathy: Many orbital tumours present with proptosis or bulging of the eyeball, the most common cause being thyroid-related immune orbitopathy. There may or may not be laboratory derangements in thyroid function tests. Thyroid ophthalmopathy is four to five times more common in women, particularly in their perimenopausal phase. History of cigarette smoking may precede a more fulminant course. Pathogenesis of the disease is unclear leading to ambiguity in treatment protocols. Anterior segment eye complaints are treated with lubricants and topical steroids. Resultant glaucoma is managed with topical anti-glaucoma medications. Diplopia may need steroids and surgery while proptosis might require steroids, radiation or corrective surgery.

Lacrimal Gland Tumours: They are easily diagnosed using ophthalmic B-scan at ultrasonography. More detailed analysis, particularly for bony involvement requires CT scans. Treatment comprises steroids, biopsy or excisional surgery.

       
  • Bilateral Masses are either inflammatory lesions such as sarcoid/pseudotumour, or lymphomas. Inflammatory lesions constitute an overwhelming majority and are usually tender.
  •    
  • Unilateral Masses are notorious and usually require a biopsy to rule out malignancy. Benign mixed tumours are painless, gradually progressive masses of the lacrimal gland causing inferior displacement of the globe among patients in their third and fourth decades of life. They are treated by surgical excision of the mass within its pseudocapsule.
  •    
  • Adenoid Cystic Carcinoma is the most common malignant epithelial tumour of the lacrimal gland and presents similar to a benign mixed tumour. However, there is pain, numbness, diplopia and visual disturbance and a circumscribed lacrimal gland mass with blurred margins infiltrating into bone on CT scan. Treatment is surgical. They may recur years later but with a mortality of 90%.
  •    
  • Pleomorphic Adenocarcinomas are highly aggressive, malignant mixed tumours seen in patients in their fifth and sixth decades of life. It is the second most common malignant tumour of the lacrimal gland and presents as a painless mass with or without new increase in size. They usually have a history of prior biopsy for a benign mixed tumour which has undergone malignant transformation. Treatment is surgical but more than 75% of the patients die of metastases within 5 years.
  •    
  • Lymphoid Masses: Lymphomas require careful pathologic analysis aided by fresh tissue with appropriate marker studies and systemic staging, which help to define the disease and guide treatment with chemotherapy alone, local radiation alone, or a combination of both. Bilateral orbital involvement indicates a poorer prognosis.

Bone Lesions of the Orbit: CT scan provides the best delineation of bony lesions causing proptosis.
       
  • Primary Bony Lesions: Osteomas, osteogenic sarcoma, and fibrous dysplasia.
  •    
  • Secondary Bony Lesions: Metastases from prostate, thyroid, lung, breast, kidney, and the non-metastatic eosinophilic granuloma, otherwise known as histiocytosis X spectrum



Cavernous Hemangioma

Orbital cavernous hemangioma is the among the most common benign neoplasm found within the adult orbit. It is a slow-growing, benign tumour involving vascular structures within the muscle cone of the orbit, which pushes the eyeball forward as it grows, resulting in proptosis. Bilateral cases are rare. It is most commonly reported in middle-age adults (20-40 years), with women more affected than men.


Symptoms of Cavernous Hemangioma

Cavernous hemangioma of the orbit presents with mass effect due to an increase in volume of the orbital contents. It causes the following symptoms and signs:

  • Painless, slowly progressive bulging of the globe
  • Decrease in visual acuity and visual field defects due to mass effect or involvement of the optic nerve, extraocular muscles or surrounding vasculature.
  • Double vision or diplopia due to extraocular muscle dysfunction or orbital axis mismatch between the two eyes.
  • Lagophthalmos due to extraocular muscle dysfunction or nerve involvement results in exposure keratopathy, keratitis, and corneal perforation.
  • Pupillary dysfunction due to involvement of neural structures within the orbit.

Diagnosis of Cavernous Hemangioma

A thorough ophthalmologic examination is key to formulating an exhaustive list of differential diagnoses.

  • A detailed history and review of symptoms is of paramount importance.
  • Examination should be thorough and should include observation and palpation of affected eye. Hertel exophthalmometry is done to document axial proptosis.
  • Assess near vision, distant vision, colour vision and visual fields followed by testing of pupillary and extraocular muscle function. Defect in any of these parameters signal compression of the optic nerve and imaging studies should be done. Extraocular muscle dysfunction is measured using prismatic evaluation.
  • Slit lamp or penlight evaluation may or may not detect any abnormalities.
  • Dilated fundoscopy may show choroidal folds due to mass effect while optic nerve compression shows up as visible edema, elevation, pallor, or even atrophic changes in the fundus.

Cavernous hemangioma is suspected clinically and usually confirmed with orbital imaging studies. Following investigations help to evaluate the presence and extent of the disease:

  • CT scan detects an oval or round, homogenous mass with sharp margins, but falls short of a definitive diagnosis.
  • A-Scan Ultrasonography shows a uniform high-echogenicity while Doppler flow study reveals decreased blood flow within the lesion.
  • MRI of the cavernous hemangioma exhibits a homogenous signal. Gadolinium shows an initial central patch enhancement followed by total homogenous enhancement.

Imaging of Cavernous Hemangioma

  • CT: smooth discrete lesion, fills with dye after 20 min; coronal cuts important to know tumor position relative to optic nerve. for sugical plan
  • MRI: hypointense to fat on T1, hyperintense to fat on T2
  • U/S: high reflectivity (A-scan high amplitude internal echoes)

Treatment of Cavernous Hemangioma

  • Most cavernous hemangiomas require no treatment. The surgical approach, when indicated, depends on location and size of the tumour.
  • Cavernous hemangioma involving the anterior two-thirds of the orbit is resected via an anterior eyelid, transconjunctival or transcaruncular approach. A lateral orbitotomy or its variant is more appropriate for tumours located more posteriorly. Lesions involving the orbital apex warrants a transcranial approach.
  • A cryoprobe aids removal of well-circumscribed tumours with minimal risk of capsular rupture or blood loss. Carbon dioxide laser, Nd:YAG laser and Gamma knife surgery are newer modalities of treatment that can be considered.
  • The visual prognosis with complete excision is excellent but incompletely excised lesions are notorious for recurrences. Occasionally, visual loss can occur as a complication of surgery.


Herniated Orbital Fat

General

  • Prolapse of subconjunctival intraconal orbital fat
  • First described in pathology literature in 2007 (Am J Surg Pathol 2007;31:193)

Clinical features

  • Rarely causes an intraorbital mass lesion
  • Mean age 66 years, 90% men
  • Prolapse is usually into superotemporal quadrant or lateral canthus
  • Usually due to orbital fat herniation through a dehiscence in Tenon's capsule
  • Manifests as unilateral or bilateral yellowish mass
  • Does not recur

Differential diagnosis

  • Pleomorphic lipoma: different clinical presentation; aggregates of bland spindle cells, floret cells and wiry collagen
  • Well differentiated liposarcoma: different clinical presentation; enlarged hyperchromatic cells within fibrous septae

Side effects

Possible side effects of this medication are:

  • May cause blurred vision.
  • May cause eyelid redness.
  • May permanently darken eyelashes.
  • May cause eye discomfort.
  • May eventually cause permanent darkening of the iris to brown.
  • May cause a temporary burning sensation during use.
  • May cause thickening of the eyelashes.
  • It may cause unexpected growth of hair if applied inappropriately, on the cheek, for example.
  • It may cause infection if the one-time applicators which come with the genuine product are reused.
  • Lashes may grow so long that they become ingrown and scratch the cornea.
  • May cause darkening of the eyelid or of the area beneath the eye.


Hemangiopericytoma

Description of Orbital Tumors - Hemangiopericytoma

Contractile cells that wrap around the endothelial cells of blood vessels are known as pericytes. Orbital hemangiopericytoma is a rare, solid, slow-growing tumour that arises from the proliferation of pericytes in the orbital blood vessels but can involve blood vessels in the conjunctiva, choroid, optic nerve or skin of medial canthus.

Hemangiopericytoma constitutes 1-3% of all biopsied lesions of the orbit and 1% of all lacrimal sac tumours. This tumour may be benign or malignant, and starts around 40 years of age with a predilection for men.



Pathophysiology of Orbital Tumors - Hemangiopericytoma

Orbital hemangiopericytoma is caused by inordinate layering of sheets of pericytes around improperly formed blood vessels within the orbital structures. The tumour cells contain few cytoplasmic organelles and are formed from pluripotent mesenchymal cells surrounding the blood vessels. “Staghorn” vessels are thin-walled, branching blood vessels seen specifically in hemangiopericytomas.

They have ovoid or spindle-shaped nuclei. 75% of the lesions are encapsulated and well-circumscribed while 30% of orbital hemangiopericytomas look very similar to a malignancy. They stain uniformly for CD34 and vimentin while 70% are positive for Leu-7.



Symptoms and Signs of Orbital Tumors - Hemangiopericytoma

Clinical presentation is variable. Patients may present with any of the following symptoms:

  • Painful or painless, slow-growing mass in the orbit
  • Proptosis and exophthalmos
  • Raised pressure within the orbit
  • A painless mass near the medial canthus may be a lacrimal sac hemangiopericytoma
  • Epiphora or watering of the eyes

Orbital hemangiopericytoma commonly involves the superior orbit and are commonly ballottable on palpation. There may be visual loss, proptosis during exophthalmometry and decreased extraocular muscle motility depending on location of the tumour.



Diagnosis of Orbital Tumors - Hemangiopericytoma

Even though proper clinical examination will aid in reaching a probable diagnosis, imaging studies like Computed Tomography or Magnetic Resonance Imaging help in planning for surgical excision. Definitive diagnosis is reached only through histopathologic evaluation of the tumour.

Hemangiopericytomas are easily confused with various orbital masses like fibrous histiocytoma, hemangioma, glomus tumour, sarcoma and vascular malformation.



Treatment of Orbital Tumors - Hemangiopericytoma

Definitive management of a case of hemangiopericytoma is complete local excision of the tumour along with the capsule. Maintaining proper haemostasis during surgery is of paramount importance as the tumour is highly vascular.

There has been some buzz about the role of chemotherapy and radiotherapy in preoperative management of the tumour, but with limited benefit.

There is an overall 89% 5-year-survival rate seen in hemangiopericytoma. There is also a possibility for local recurrence and local metastasis, but distant metastasis to lung, liver, bone and mediastinum is a rare occurrence.



Lacrimal Gland Tumors

General

  • look for fullness of upper lid, asymmetry of superior sulcus, abnormal lid contour
  • majority lacrimal gland masses are idiopathic inflammatory dacryoadenitis
  • especially S-shape, often palpable
  • check for mobility, smooth, rubbery or nodular
  • proptosis is evidence of posterior growth, otherwise globe is down and media

Imaging

CT very good for differentiating inflammation from tumor: inflammation and lymphoid with in gland cause diffuse enlargement, elongated shape, contour around globe; neoplasms are isolated, globular, displace & indent globe



Lacrimal Sac Tumors
  • rare
  • mass above medial canthal tendon
  • complaints of EpiphLacora (Epiphora, patients with epiphora complain of watery eyes; it is when there is an imabance between production and drainage of tears. Visit the Lacrimal page for more details) or chronic dacryocystitis
  • irrigation may pass to nose or blood may reflux from punctum
  • CT may show extent of mass
  • DCG may show filling defect
  • may have skin ulceration, telangiectasia, + lymph nodes
  • may originate from skin or nasal mucosal tumors
  • benign squamous papillomas most common 1o
  • squamous cell carcinoma more than adenocarcinoma most common malignant tumor


Lymphoma

General

  • almost exclusively in adults
  • continuum including benign reactive lymphoid hyperplasia (pseudolymphoma) to atypical lymphoid hyperplasia to low-grade then high grade malignant lymphoma;
  • also Orbital inflammatory syndrome pseudotumorplasmacytoma (including myeloma)
  • bimodal peak 30’s and 60’s
  • unilateral or bilateral
  • palpable rubbery mass fixed to orbital rim
  • maligant lymphoma & reactive lymphoid hyperplasia cause gradual (over a year or more) progressive, painless proptosis (vs. Obital inflammatory syndrome), lacrimal enlargement
  • usually on conjunctiva, anterior orbit so palpable or visible
  • eyelid or bilateral orbital involvement suggests systemic disease
  • putty-like molding to undisplaced tissues so little Visual Acuity (VA) or EOM loss; usually no bone erosion or infiltration unless
  • high-grade lymphoma
  • lymphoma in retrobubar fat is infiltrative

Imaging

all patients w/ orbital lymphoid lesions need exam for systemic lymphoma (by oncology) with orbital, abdominal, chest CT;

  • CBC
  • bone marrow biopsy
  • chest x-ray (CXR)
  • bone/liver/spleen scan

Pathology

all patients w/ orbital lymphoid lesions need exam for systemic lymphoma (by oncology) with orbital, abdominal, chest CT;

cytologic factors are more prognostic than mono/polyclonal; but

  • most benign lesions (reactive hyperplasia) are usually mostly T cells with polyclonal Bs;
  • malignant lymphoma usually more monoclonal B cells

both polyclonal and monoclonal varieties can develop systemic disease

open biopsy for path to give fresh tissue for touch preps; immunohistochemistry; flow cytometry; and gene rearrangement studies; in formalin for micro; gluteraldehyde for electron microscopy


Treatment & Course

X-Ray Therapy (XRT) for most orbital lymphoid lesions that are confined to orbit (50% of lymphomas)

Chemotherapy for systemic, therapy can be controversial

Course

  • up to 25% of patients have systemic lymphoma later on with benign reactive hyperplasia:
  • 40% of patients get systemic involvlement within 5 years with atypical lymphoid hyperplasia:


Neurofibroma

Description of Orbital Neurofibroma

Orbital neurofibroma is a peripheral nerve sheath neoplasm derived from Schwann cells, perineural cells and fibroblasts, and is probably the most common peripheral nerve tumour of the orbit. It constitutes about 0.8 to 3.0% of all histopathologically-proven lesions of the orbit. Orbital neurofibroma produce symptoms within the orbit, and may or may not be associated with systemic neurofibromatosis.


Orbital neurofibroma is classified into three subsets:

  • Plexiform neurofibroma is pathognomonic of neurofibromatosis
  • Diffuse nerofibroma has variable association with neurofibromatosis.
  • Localized neurofibroma is rarely associated with neurofibromatosis.

Symptoms and Signs of Orbital Neurofibroma

  • The presence of multiple painful, well-circumscribed orbital tumours in a patient should raise the suspicion of neurofibroma. Typically, it presents with progressive symptoms of an orbital mass, including proptosis, globe displacement, impaired extraocular motility, ptosis, numbness, and rarely with decreased visual acuity. There may also be associated features of neurofibromatosis. The clinical features of orbital neurofibroma is greatly dependent on its type and associated neurofibromatosis.
  • Plexiform orbital neurofibroma: The patient is usually a child in the first decade of life with undeniable signs of neurofibromatosis, with about 66% having eyelid involvement. It usually begins as an eyelid mass that is more localized to its lateral third, giving the eyelid an S-shaped appearance. It may extend further into the orbit, causing proptosis.
  • Diffuse orbital neurofibroma: The patient profile is similar to that of plexiform neurofibroma and usually presents with unilateral proptosis that may or may not involve the eyelids. It’s association with neurofibromatosis is not as strong as in plexiform neurofibroma.
  • Localized orbital neurofibroma: The typical patient is a young or middle-aged adult unlike the other forms which present in childhood. Clinical features include a solitary, well-circumscribed soft tissue tumour in the orbit causing proptosis and downward displacement of the globe. Less frequently, it can occur in the lacrimal gland and extraocular muscle, or even cause bony destruction to invade an adjacent sinus.

  • Diagnosis of Orbital Neurofibroma

    • Imaging studies are central to the evaluation of a suspected orbital neurofibroma. Both CT and MRI show smoothly marginated ovoid lesions, with or without lobulations.
    • Computerized Tomography: Shows lesions isodense or hypodense to extraocular muscles and shows variable contrast enhancement, with occasional ring-enhancement.
    • Magnetic Resonance Imaging: Demonstrates low-moderate T1 signal intensity and moderate-high T2 signal intensity. Heterogeneity of signal strength within the lesion is typical reflecting the mixed histopathology and vascularity of the tumours. Contrast enhancement is again variable.
    • Histopathology of a biopsy specimen or excised tumour confirms the diagnosis of orbital neurofibroma.

    Treatment of Orbital Neurofibroma

    • The management of localized orbital neurofibroma consists of total excision, which is possible in about 46% of cases of isolated orbital neurofibroma. It also has the distinction of low recurrence after surgical excision. However, 72% of postoperative patients reported a sensory skin deficit.
    • However, the management of plexiform and diffuse orbital neurofibroma is complex, with an unpredictable outcome. Eyelid sparing orbital exenteration and orbital reconstruction is possibly the best treatment approach in patients with total eyelid ptosis and severe visual loss. Surgery is difficult due to diffuse infiltration and intracranial involvement. Recurrence after incomplete surgical removal is a common phenomenon. Hence, close follow-up is must.


Neurofibroma

Description of Orbital Schwannomas

Schwannomas are slow-growing, benign tumours that develop within the outer covering of peripheral and sympathetic nerves formed by Schwann cells, called the nerve sheath. They are also known as neurilemmomas and frequently involve sensory and motor nerves supplying the orbital region. Schwannomas are rare tumours and constitute about 1% of all orbital tumours and 35% of peripheral nerve tumours within the orbit.
It has a primarily affects individuals between 20 and 60 years old, with 10-15% cases accompanied by neurofibromatosis.

Pathophysiology of Orbital Schwannomas

Orbital schwannomas are seen as encapsulated growths within a peripheral or sympathetic nerve, which distinguishes them from a neurofibroma that affect nerve fibres themselves. They are benign tumours and are rarely associated with malignant transformation. They usually occur in the superior temporal region or muscle cone of the orbit pushing the eyeball forward and downward.

The orbital schwannomas has the following histologic components that help in a pathologic diagnosis:

  • Antoni A type areas: Constitute solid areas of tumour cells forming the bulk of the tumour.
  • Antoni B type areas: Contains loose cystic spaces with no axons.
  • Verocay body: Represents palisading of the tumour nuclei in acellular zones of the tumour.

Verocay bodies, when present, are a useful marker for orbital schwannoma. Histochemical staining with S-100 may be positive.

Symptoms and Signs of Orbital Schwannomas

A patient with orbital schwannoma usually presents with a slowly progressive painless bulging of the eyeball, proptosis and takes years or even decades to produce symptoms.

Other symptoms and signs commonly seen are:

  • Oedema of the eyelids
  • Dystopia of the eyeball
  • Exophthalmos
  • Impaired ocular motility
  • Disturbances in vision including visual loss
  • Changes in the optic disc such as choroidal striae with hyperopia

Diagnosis of Orbital Schwannomas

Clinical history of a slow-growing tumour within the orbit producing symptoms hinting to a diagnosis of orbital schwannoma. This suspicion is further supported by the presence of an encapsulated mass.
Diagnosis is confirmed by Computed Tomography and Magnetic Resonance Imaging of the orbital region. Histologic diagnosis is obtained after surgical excision of the tumour and shows Antoni A or Antoni B areas, Verocay bodies and positive for S-100 immunohistological stain.


Treatment of Orbital Schwannomas

Complete surgical excision is the treatment of choice for orbital schwannoma. Being well-encapsulated, it is easily removed. There is however a small risk of recurrence. The risk of malignant transformation is minimal.


Meningioma

A meningioma is a benign brain tumor. It originates from the dura mater, the tissue enwrapping the brain and spinal cord. Meningiomas are much more common in females, and are more common after 50 years of age. Of all cranial meningiomas, about 20% of them are in the sphenoid wing. In some cases, deletions involving chromosome 22 are involved.


Diagnosis of Orbital Meningioma

Sphenoid wing meningiomas are diagnosed by the combination of suggestive symptoms from the history and physical and neuroimaging by magnetic resonance imaging (MRI) or computer averaged tomography (CT). Tumors growing in the inner wing (clinoidal) most often cause direct damage to the optic nerve leading especially to a decrease in visual acuity, progressive loss of color vision, defects in the field of vision (especially cecocentral), and an afferent pupillary defect.

If the tumor continues to grow and push on the optic nerve, all vision will be lost in that eye as the nerve atrophies. Proptosis, or anterior displacement of the eye, and palpebral swelling may also occur when the tumor impinges on the cavernous sinus by blocking venous return and leading to congestion. Damage to cranial nerves in the cavernous sinus leads to diplopia. Cranial nerve VI is often the first affected, leading to diplopia with lateral gaze. If cranial nerve V-1 is damaged, the patient will have pain and altered sensation over the front and top of the head. Horner’s syndrome may occur if nearby sympathetic fibers are involved.


Classification of Orbital Meningioma

Tumors found in the external third of the sphenoid are of two types: en-plaque and globoid meningiomas. En plaque meningiomas characteristically lead to slowly increasing proptosis with the eye angled downward. Much of this is due to reactive orbital hyperostosis.

With invasion of the tumor into the orbit, diplopia is common. Patients with globoid meningiomas often present only with signs of increased intracranial pressure. This leads to various other symptoms including headache and a swollen optic disc.

The differential diagnosis for sphenoid wing meningioma includes other types of tumors such as optic nerve sheathe meningioma, cranial osteosarcoma, metastases, and also sarcoidosis. Following the physical exam, the diagnosis is confirmed with neuro-imaging. Either a head CT or MRI with contrast such as gadolinium is useful, as meningiomas often show homogenous enhancement. Angiography looking for signs like stretched arteries may be used to supplement evaluation of vascular involvement and to determine whether embolization would be helpful if surgery is being considered.


Treatment of Orbital Meningioma

Meningiomas have been divided into three types based on their patterns of growth. Histological factors that increase the grade include a high number of mitotic figures, necrosis and local invasion.

Treatment of sphenoid wing meningiomas often depends on the location and size of the tumor. Gamma knife radiation and microscopic surgery are common options. Their encapsulated, slow growth makes meningomas good targets for radiosurgery. In one series, less than one-third of clinoidal meningiomas could be completely resected without unacceptable risk of damaging of blood vessels (especially the carotid artery) or cranial nerves, risks that are lower with radiosurgery.

If surgery is done and the entire tumor cannot be removed, then external beam radiation helps reduce recurrence of the growth. Fortunately, most all meningiomas grow very slowly and almost never metastasize to other parts of the body. In part because of its slow growth, if a tumor is asymptomatic and found only by imaging, the best course is often observation with serial clinical exams and imaging. Possible indications for intervention would be a rapid increase in growth or involvement of cranial nerves. Untreated, one small series showed survival rates ranging from 5 to over 20 years, though most suffered unilateral blindness as well as paresis of extraocular movements.

Procedures
Anophthalmos
- Anophthalmia is a medical term used to describe the absence of the globe and ocular tissue from the orbit. - This was first reported more than 400 years ago, yet it is only recently that significant reconstructive options became available. - There are many reasons why one might lose an eye. - Surgeries which result in anophthalmos
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Blepharoplasty
What is Blepharoplasty?
- Your eyes including your eyelids, are perhaps one of the first things people notice in you. This makes your eyes and eyelids one of the most important components for an appealing facial expression and aesthetic appearance. Any visible change in the shape or size of the orbital or periorbital region can spoil the look of your face.
- As you age and grow older, your eyelids may become ‘droopy’ or ‘baggy’ due to the stretching of your eyelid skin and gradually decreasing tone of your eyelid muscles. Your droopy eyelids and brow together cut a sorry figure for your face making you look tired, sleepy and haggard, further leading to eyelid or brow straining or both. In extreme cases, your saggy, baggy eyelids can even obstruct your vision, particularly peripheral vision causing difficulty in reading or driving.
- Blepharoplasty ensures cosmetic or functional corrections to the area around your eyes to enhance your look or to correct any abnormalities in function.
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Blepharospasm
- Blepharospasm is defined as an abnormal, involuntary, sustained and forceful closure or twitching of the eyelids. It is derived from the Greek word ‘blepharon’ which means eyelid, and ‘spasm’ which is an uncontrolled muscle contraction. Blepharospasm is usually associated with headache, eyebrow strain and occasionally loss of vision.
- Isolated blepharospasm is rare and represents a minority of patients presenting with blepharospasm. Blepharospasm is commonly associated with lower facial spasms as part of a syndrome or disease complex. Some examples are:
   - Meige Syndrome: Characterized by spasm of the eyelids and midface.
    - Brueghel’s Syndrome: Presents with blepharospasm and marked spasms in the lower face and neck.
    - Segmental Cranial Dystonia: In addition to the usual spasms of the eyelids and facial muscles it is associated with spasms along distribution of various cranial nerves, most frequently involving the Facial Nerve.
    - Generalized Dystonia: Presents with spasms across various body parts in addition to blepharospasm and facial spasms.
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Brow Lift
A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep worry lines that run across the forehead and may portray to others anger, sternness, hostility, fatigue or other unintended emotions
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Congenital
Congenital anomolies include :
- Eyelid Disorders
- Orbital Disorders
- Congenital Ptosis
- Congenital Nasolacrimal Duct Obstruction

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Dry Eye
What is Dry Eye?
- Dry eye is a reduction in your eye’s ability to produce sufficient natural tears.
- Insufficient tear production can lead to irritation and pain, and even scarring of the cornea (the transparent part of the eye that covers the pupil and iris).
- Many people will experience dry eye symptoms at some point in their lives.
- Often due to environmental factors such as indoor heating or air conditioning, it can also be caused by occupational factors such as prolonged computer use.
- Dry eye symptoms can affect anyone.
- Some of the symptoms of dry eye include a burning sensation or gritty feeling in the eyes. You may also experience decreased tolerance to contact lens wear or sensitivity to light.
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Eyelid Laxity
- Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.
Our eyelid is a complex structure consisting of three theoretical layers:
   - Anterior Layer contains the skin and orbicularis muscle
   - Middle Layer contains the orbital septum and eyelid retractors
   - Posterior Layer contains tarsus and conjunctiva.

- Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
- The most common forms of eyelid malposition are eyelid retraction, ptosis, entropion and ectropion.
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Face
The world of cosmetic surgery has advanced tremendously over the last two decades. New procedures have emerged that can make an individual look and feel younger in a matter of a few minutes. Amongst the vast number of cosmetic procedures currently available, the face lift is a commonly performed one that is sought after by both men and women. Here we shall take a look at this procedure in a little more detail.

- What is a face lift?    - A face lift is called a rhytidectomy in the world of medicine. It involves tightening the muscles of the face and smoothening of the skin so that the face appears younger.    - However, it must be remembered that a face-lift is not an anti ageing solution.
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Lacrimal System
- The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.    (1) excess tearing (tears may run down the face) and    (2) mucous discharge - This may lead to recurrent red eyes and infections. - The excessive tearing can also produce secondary skin changes on the lower eyelids.
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Lagophthalmos
Patients with lagophthalmos have an inability to close eyelids. This may occur, for instance, in patients with Thyroid eye disease.
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Latisse
LATISSE® makes lash growth possible because of its active ingredient: bimatoprost. Although the precise mechanism of action is not known, research suggests that the growth of eyelashes occurs by increasing the percent of hairs in, and the duration of, the anagen (or growth) phase. Lashes can grow longer, thicker and darker because bimatoprost can also prolong this growth phase.
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Orbital Tumors
- Orbital Tumor is any tumor that occurs within the orbit of the eye. The orbit is a bony housing in the skull about 2 inches deep that provides protection to the entire eyeball except the front surface. It is lined by the orbital bones and contains the eyeball, its muscles, blood supply, nerve supply, and fat.
- Tumors may develop in any of the tissues surrounding the eyeball and may also invade the orbit from the sinuses, brain, or nasal cavity, or it may metastasize (spread) from other areas of the body. Orbital tumors can affect adults and children. Fortunately, most are benign.
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Ptosis
- Ptosis is an abnormally low position (drooping) of the upper eyelid
- Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly.
- It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.
- Compare with dermatochalsis (extra skin and fat)
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Skin Rejuvination
A radiant, smooth, youthful skin is the essence of beauty and trendy looks. Skin care routine highly contributes in the slowing down of rate of aging of the skin. Choosing the right skin care products for your skin type enhances your beauty keeping the skin cleansed, moisturized and well toned. Use of superficial skin resurfacing treatments to counter fine lines and wrinkles, acne scars and blemishes before they deepen ensures skin rejuvenation.
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Skin Tumors
Cancer of the eyelid, like any other cancer, can be a worrying thing. Treatments are variable and depend on the type of cancer. In this article, we shall take a brief look at the different kinds of eyelid tumors.
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Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
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Thyroid
Graves' disease is an autoimmune disease.
It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos).
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Trauma
Eye injuries are extremely common with over 2 million cases reported every year that require medical treatment. Blindness in one eye is most commonly due to cataract and this is followed closely by eye injuries. In addition, in children, injury to the eye is a recognized as the most common cause of blindness in one eye that is not due to a birth defect.
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