Frequency of Lesions Involving Orbit at Tertiary Care Hospital

Purpose. To analyze frequency of lesions involving orbit at a tertiary care hospital.

Methods: A retrospective review of patients who were operated at ophthalmology department of Jinnah Postgraduate Medical Center Karachi between 2013 to 2018. Data included age, gender, type of lesion, site of lesion, histo-pathologic diagnosis, management and follow ups.

Result: A total number of 237 patients with orbital and ocular adnexal lesions managed in Jinnah Postgraduate Medical Centre Karachi over a 5 years period with 125 (52.7%) male and 112 (47.3%) female aged 2 to 85 years. Lesions which involved orbit had a total number of 74 (31.2%) with greater number of males 47 (63.5%) and less number of females 27(36.5%) and 52.7% of them were younger than 25 years and 32.4 % were older than 50years. Among orbital lesions 39 (52.7%) were benign and 35 (47.3%) were malignant. The most commonly diagnosed orbital lesion was dermoid cyst with number of 27 (36.5%)followed by squamous cell carcinoma 19 (25.7%). Among benign lesion 27 (69.2%) were diagnosed as dermoid cysts followed by pleomorphic adenoma 4 (10.2%) and 30 (76.9%) of all patients with benign lesion were children and young adults. Among malignant lesions 19 (54.29%) were diagnosed as squamous cell carcinoma followed by retinoblastoma 8 (22.8%) and 21 (60%) of all patients with malignant lesion had age more than 50 years. Among all cases of orbital lesions 40 (51.4%) orbital lesions underwent orbitotomy, in which 37 patients were diagnosed as benign lesion on biopsy while 33 (44.6%) underwent exentration in which 32 patients were diagnosed as malignant lesions.

Conclusion: The study was undertaken to determine types and number of orbital lesions according to age, gender, site and radiological findings which provide us important information regarding diagnosis before surgery and biopsy. Different approaches were preferred according to radiological and clinical findings to minimize complications and cosmetic purpose. Post-operative radiotherapy and chemotherapy preferred to minimize chances of recurrence in malignant lesions. Risk population should be provided education about orbital tumors and its preventions. Patient with diagnosed orbital lesions should be advised of the risk of recurrence and encouraged for regular follow up.

Orbit is a small space containing globe, fat, muscles, vessels, nerves, glandular and connective tissues.(1) Variety of tumors involve the orbit, most of which are primary in nature arising from structures inside the orbit while a few are secondary and rest of them are metastatic.(2–4)200 patients (21% Multiple departments related to orbit that is ophthalmology, radiology, pathology and ENT which reported different frequencies and types of tumors involving orbit from different geographic area, with example of uveal melanoma is more common in Europe and North America as compare to other regions.(5,6)

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Risk population should be provided education

about orbital tumors and its prevention. Patient

with diagnosed orbital lesions should be advised

of the risk of recurrence and encouraged for

regular follow up.

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A clinico-histo-pathological Study of Orbital and Ocular Lesions a Multicenter Study by Bastola P et al. reported non-Hodgkin’s lymphoma most common orbital lesion, conversely an analysis of Space-occupying lesions of the Orbit, by Giulio Bonavolontà et el. and Shields et al., reported cystic lesion as common orbital lesion, which denoting that frequency of orbital lesions differ in different geographical area.(7–11) ”container- title”:”Archives of Ophthalmology (Chicago, Ill.: 1960 Age is another important factor in depicting orbital lesions, that is with increase in age community becomes more prone to orbital tumors.(12) ”ISSN”:”0161-6420”,”note”:”PMID: 9442797”,”journalAbbreviation”:”Ophthalmology”,”language”:”eng”,”author”:[{“family”:”-Margo”,”given”:”C. E.”},{“family”:”Mulla”,”-given”:”Z. D.”}],”issued”:{“date-parts”:[[“1998”,1]]}}}],”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation. json”} Dermoid cyst is common in children while lymphoma and cavernous hemangioma in adult population.(4,13–15) 200 patients (21% As there is limited information on orbital lesion in our demographic area, this study may help ophthalmologist for early diagnosis and treatment plan.

 

MATERIAL AND METHOD:

 

A retrospective review of patients who were operated at ophthalmology department of Jinnah postgraduate medical center Karachi between 2013 to 2018, patients who underwent surgery for orbital (excisional or incisional) biopsy separated. Inclusion criteria was either primary orbital lesions or lesions primarily arising from lids and conjunctiva extending into orbit were included in study, patients who had orbital involvement secondary to other system like nose, throat, cranial cavity and patient who did not underwent surgery were excluded from record, all lesion were categorized into one of major groups of lesion (cystic, vascular, neurogenic, mesenchymal, lacrimal gland, lympho-proliferative) using a modified version of previously published classification.( 8,15), the frequencies and number of different lesion diagnosed on biopsy were categorized and tabulated.

 

RESULTS:

 

A total number of 237 patients with orbital and ocular adnexal lesions managed in Jinnah Post-grauduate Medical Centre Karachi over a 5 years period with 125 (52.7%) males and 112 (47.3%) females aged 2 to 85 years. Lesions which involved orbit had a total number of 74 (31.2%) with greater number of males 47 (63.5%) and less number of females 27(36.5%) and 52.7% of them were younger than 25 years and 32.4% were older than 50years.(Table 1),(Table 2).

Classifying orbital lesions, 35 (47.3%) patients were presented with secondary orbital lesions (arising from lids, conjunctiva), 30 (40.5%) with cystic lesions, followed by 5 (6.8%) patients with lacrimal gland lesions. (Table 3).

Among orbital lesions 39 (52.7%) were benign with percentage of 74.3% males and 25.7% females. Malignant lesions were 35 (47.3%) with percentage of 51.4% males and 49.6% females. (Table 4).

The most commonly diagnosed orbital lesion wasdermoid cyst with number of 27 (36.5%) with greater number (22) of male patients followed by squamous cell carcinoma 19 (25.7%) withmostly male, aged, farmer and laborer by occupation, with history of prolong sunlight exposure. Patients diagnosed with Retinoblastoma were 8 (10.8%) in number while pleomorphic adenoma and spindle cell carcinoma were diagnosed with same number of patients 5 (6.8%). (Table 5), (Figure 1).

Among benign lesion 27 (69.2%) were diagnosed as dermoid cysts followed by pleomorphic adenoma 4 (10.2%) and 30 (76.9%) of all patients with benign lesion were children and young adults. Among malignant lesion 19 (54.29%) were diagnosed as squamous cell carcinoma followed by retinoblastoma 8 (22.8%) and 21 (60%) of all patients with malignant lesion had age more than 50 years. (Table 6), (Table 7).

Among all cases of orbital lesions 40 (51.4%) orbital lesions underwent for orbitotomy, in which 37 patients were diagnosed as benign lesion on biopsy while 33 (44.6%) underwent Exentration in which 32 patients were diagnosed as malignant lesions. Among all 39 patients with benign lesions orbitotomy were done in 37(94.9%) patients, exentration and enucleation were done in 2 patients. Among all 35 patients with malignant lesions exentration were done in 32(91.4%) patients and 3(8.6%) underwent for Orbitotomy. (Table 8),(Table 9).

 

DISCUSSION:

 

According to American Cancer society incidence of orbital space occupying lesion is less than 1 for 1 lakh people. Diagnosis of orbital lesions delay due to surrounding tissues, slow growing nature and appearing of symptoms until size of tumour reaches 1cm.(16–19) Lin et al. also reported that it is difficult to detect proptosis of less than 4mm.(20) In our study over a 5 years of duration on orbital space occupying lesions the most of orbital lesions were benign (52.7%) where as malignant lesions were fewer in number (47.3%), which is supported by a study done by Shields et al. and another study done by Li et al. in which benign orbital tumours occurred in a greater number than to malignant.(19,21) In contrast Demirci et al. reported that the number of malignant lesions was greater in number in his study.(4) 200 patients (21% In our study age of patient ranged between 2 to 85 years and we found that increase of age had a strong relation with malignancy which is also supported by different studies done in Japan and India.(22,23) The incidence of orbital lesions were high in children and older patients in our study similar to a study done by Rootman J.(24) ”schema”:”https://github.com/ citation-style-language/schema/raw/master/csl-citation.json”} Dermoid cysts were most frequent orbital lesions that found in our study (36.5%)among all orbital lesions. Dermoid lesions were also most common lesions in children amongst all benign lesions (69.2%) which is supported by other studies.(11,21,22,25) Squamous cell carcinoma wasthe second most common orbital lesion among all and most common among malignant lesion in our study. Patients diagnosed with squamous cell carcinoma were mostly male, aged, farmer and laborer by occupation. History of prolong sun light exposure and delay in presentation for management were common features. Prolonged exposure to ultraviolet rays due to their occupations, lack of medical facilities, poor socioeconomic status were the main reasons for Squamous cell carcinoma presented frequently in our study. Demonstrating numbers of primary orbital lesions that originate from orbit itself, to secondary orbital lesions that extend to orbit from neighbouring tissue, secondary orbital lesions were found more to primary orbital lesions in our study.In contrast Shinder et al.(26) and Bonavolontà et al.(10) ”container-title”:”Ophthalmic Plastic and Reconstructive Surgery”,”page”:”79-86”,”volume”:”29”,”issue”:”2”,”source”:”PubMed”,”abstract”:” PURPOSE: To evaluate the frequencies of orbital space-occupying lesions seen at single orbital unit in a period of 35 years.\nMETHODS: In this retrospective case series, the authors reviewed the medical records of 2,480 consecutive patients referred to the authors’ Orbital Unit for evaluation of an orbital mass between 1976 and 2011. The final diagnosis in each case was established by a combination of history, ocular findings, diagnostic imaging, and histopathologic analysis, when available. The number and percentage of benign and malignant tumors were determinated, also according to the age of the patients and the tumor location within the orbit. This study adhered to the principles of the Declaration of Helsinki.\nRESULTS: Of the 2,480 lesions, 1,697 (68% and Teixeira F et al.(20) demonstrated that primary orbital lesions occurred more as compare to secondary orbital lesion. CT scan, MRI and incisional biopsy were the main stay to diagnose the cases in our study. MRI with contrast is gold standard for orbital lesions diagnosis in relation with anatomical structures and CT scan required for bony structures and calcifications.(27) surgical management of orbital space occupying lesions always depends upon the location, texture, and infiltration to other tissues.(28) For benign lesions orbitotomy were most frequent surgery (94.9%), while for malignant lesions in exentration (91.4%)followed by radiotherapy and chemotherapy were more frequently done. Exentration followed by radiotherapy and chemotherapy is management of choice for malignant tumours.(29,30)

 

CONCLUSION:

 

The study was undertaken to determine number of orbital lesions according to age, gender, site and radiological findings which provide us important information regarding diagnosis before surgery and biopsy. The leading two orbital lesions were dermoid cyst and squamous cell carcinoma with mostly effected age group of children and old people. Different approaches were preferred according to radiological and clinical findings to minimize complications and cosmetic purpose. The procedure commonly done was orbitotomy and exentration. Post-operative radiotherapy and chemotherapy preferred to minimize chances of recurrence in malignant lesions. Squamous cell carcinoma was the second most common orbital lesion in our study ending up exentration due to delay in presentation for management, lack of medical facilities, poor socioeconomic status. Preventive measures like hats, sunglasses should be used in those with prolong sun light exposure.Risk population should be provided education about orbital tumors and its preventions. Patient with diagnosed orbital lesions should be advised of the risk of recurrence and encouraged for regular follow up.

 

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