clinical study on orbital space occupying lesions

“CLINICAL STUDY ON ORBITAL SPACE OCCUPYING LESIONS”

DISSERTATION SUBMITTED TO

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY

CHENNAI

in partial fulfillment of

the requirements for the degree of

M.S (OPHTHALMOLOGY)

Registration No.: 221713253

(BRANCH-III)

TIRUNELVELI MEDICAL COLLEGE

TIRUNELVELI

MAY - 2020

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation titled “CLINICAL STUDY ON ORBITAL

SPACE OCCUPYING LESIONS” submitted by DR.V.THENDRAL to the

Tamilnadu Dr.M.G.R Medical university, Chennai, in partial fulfilment of the

requirement for the award of the MS degree (Branch III) in ophthalmology during the

academic period of 2017-2020 is an original bonafide research work carried out by her

under my direct supervision and guidance. I forward this to the Tamil Nadu

Dr.M.G.R. Medical University, Chennai, Tamil Nadu, India

Place: Tirunelveli

Date:

DR.M.RITA HEPSI RANI M.S., D.N.B., FAICO.,Assistant Professor

Department of Ophthalmology,Tirunelveli Medical College

Tirunelveli

CERTIFICATE BY THE HEAD OF THE DEPARTMENT

This is to certify that the dissertation entitled “CLINICAL STUDY ON ORBITAL

SPACE OCCUPYING LESIONS” is a bonafide and genuine research work carried

out by Dr.V.THENDRAL under the guidance and supervision of DR.M.RITA

HEPSI RANI M.S., D.N.B., FAICO., Assistant professor, Department of

Ophthalmology, Tirunelveli Medical College, Tirunelveli in the Department of

Ophthalmology, Tirunelveli Medical college, Tirunelveli, in partial fulfilment of the

requirements for the degree of M.S in Ophthalmology.

Date:

Place: Tirunelveli

DR.V.RAMALAKSHMI, M.S.,Professor & Head of the Department

Department of Ophthalmology,Tirunelveli Medical College

Tirunelveli

CERTIFICATE BY THE DEAN

I hereby certify that the dissertation entitled “A STUDY OF BEHAVIOURAL

PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION”

is a bonafide and genuine research work carried out by Dr.V.THENDRAL under the

guidance and supervision of DR.M.RITA HEPSI RANI M.S., D.N.B., FAICO.,

Assistant professor, Department of Ophthalmology, Tirunelveli Medical College,

Tirunelveli in the Department of Ophthalmology, Tirunelveli Medical college,

Tirunelveli, during his postgraduate degree course period from 2017-2020 in partial

fulfilment of the requirements for the degree of M.S in Ophthalmology. This work has

not formed the basis for previous award of any degree.

Date :

Place : TIRUNELVELI

Prof.Dr. S. M.KANNAN,M.S., MCh.,(Uro)The DEAN

Tirunelveli Medical College,Tirunelveli - 627011.

DECLARATION BY THE CANDIDATE

I solemnly declare that this dissertation titled “CLINICAL STUDY ON

ORBITAL SPACE OCCUPYING LESIONS” is a bonafide and genuine research

work carried out by me under the guidance and supervision of DR.M.RITA HEPSI

RANI M.S., D.N.B., FAICO., Assistant Professor, Department of ophthalmology,

Tirunelveli medical college, Tirunelveli.

Place : Tirunelveli

Date :

Dr. V.THENDRAL,Registration No.: 221713253

Post Graduate Student,Department of OphthalmologyTirunelveli Medical College,

Tirunelveli.

ACKNOWLEDGEMENT

I express my sincere gratitude and thanks to The Dean, Tirunelveli Medical

college, Tirunelveli, for providing all the facilities to conduct this study.

I sincerely thank Dr.V.Ramalakshmi, M.S., professor and HOD, For her

valuable advice, comments and constant encouragement for the completion of

this study.

I am highly thankful to Dr.M.Rita Hepsi Rani M.S., D.N.B., FAICO., Assistant

professor, Department of ophthalmology, TVMCH, for her valuable guidance

throughout the study.

I am thankful to Dr. Anandhi. D, M.S., D.O., F.I.C.O., Assistant professors,

Department of ophthalmology, TVMCH who helped me by offering their

valuable suggestions and for being with me throughout the study.

My special thanks to my Co-postgraduate colleagues Dr.M.Chandralekha,

Dr.V.C. Gitanjali, Dr. S. Tinustefi for their help and immense support.

I thank Dr.V.Arumugam M.D., DM., HOD of Oncology, Dr.R.Deivanaygam

MD., DM., HOD of Radiotherapy, Dr.K.Santharaman M.D., HOD of

Pathology, DR. S.Suresh Kumar MS., DLO., HOD of ENT., for their

immense support.

I thank all those patients who participated in the study, who made this study

possible.

I am also thankful to my beloved family and friends for giving me constant

support and encouragement.

CERTIFICATE – II

This is certify that this dissertation work title “CLINICAL STUDY ON

ORBITAL SPACE OCCUPYING LESIONS” of the candidate

Dr.V.THENDRAL with registration Number 221713253 is for the award of

M.S. Degree in the branch of OPHTHALMOLOGY (III). I personally verified

the urkund.com website for the purpose of plagiarism check. I found that the

uploaded thesis file contains from introduction to conclusion page and result

shows 16 percentage of plagiarism in the dissertation.

Guide & Supervisor sign with Seal.

CONTENTS

S.NO TITLE PAGE NO

1 INTRODUCTION 1

2 AIM OF THE STUDY 56

3 MATERIALS AND METHODS 57

4 REVIEW OF LITERATURE 58

5 RESULTS 62

6 DISCUSSION 74

7 CONCLUSION 78

BIBILIOGRAPHY

PROFORMA

MASTER CHART

List of Charts

Figure 1 Age wise sex distribution

Figure 2 Laterality

Figure 3 Involvement of Right eye and Left eye

Figure 4 Presenting complaints

Figure 5 visual acuity

Figure 6 Origin of IOSOL

Figure 7 Location of IOSOL

Figure 8 Age distribution in benign and malignant tumour

Figure 9 Type of proptosis

Figure 10 Nature of tumour

Figure 11 Type of IOSOL

Figure 12 Diagnosis of benign tumour

Figure 13 Diagnosis of malignant tumour

Figure 14 Treatment Modality

Figure 15 Kaplan – Meier Survival Analysis

ABBREVATIONS

RE-Right eye

LE- Left eye

IOSOL- Intra orbital space occupying lesions

SOF-Superior orbital fissure

DLCL – Diffuse large cell lymphoma

CLL- Chronic lymphoid leukemia

CT- Computed tomography

MRI-Magnetic resonance imaging

EBRT-External beam radiotherapy

R-CHOP- Rituximab , Cyclophosphamide , Oncovin , Prednisolone

VEC- Vincristine , Etoposide , Carboplatin

1

1.INTRODUCTION

Space-occupying lesions, both benign and malignant, cause significant functional

and anatomical problems. Intra orbital space occupying lesions can result in

double vision, exophthalmos, ptosis, loss of vision, limited action of extraocular

movements and even permanent visual loss. Orbital lesions can be diagnosed by

radiological examinations such as Magnetic Resonance Imaging (MRI) and

Computed Tomography (CT) but definite diagnosis is mostly obtained by

histopathological examination of the removed mass . CT provides useful

information about the relationship of the mass with the orbital bones, intralesional

calcifications and other orbital structures . MRI provides more detailed

information about the morphology of the soft tissue masses, their relationship to

the orbital tissues and their borders .

2.ANATOMY OF THE ORBIT AND PARANASAL SINUS

Dimension of the orbit

Orbital wall

Apertures

Soft Tissues

Periorbital Structures- paranasal sinuses

2

Orbit resembles a quadrilateral pyramid . The capacity of orbit is 30 ml of

which eye ball constitutes 6.5ml[1] .It has medial wall , lateral wall , roof and

floor .

DIMENSIONS[1]

Volume 30cm3

Entrance Width 40-45mm

Entrance height 35mm

Medial wall length 40-45mm

Distance between the posterior globe

to optic foramen

18mm

Length of optic nerve in orbital portion 25-30mm

3

Orbital walls[3]

4

Roof Lateral Wall Floor Medial Wall

Shape Triangular Triangular Triangular Oblong

Bones

Forming

Orbital plate of frontal

bone and lesser wing

of sphenoid bone

Zygomatic

bone and

greater wing

of sphenoid

bone

Maxillary

bone ,

palatine

bone and

orbital plate

of

zygomatic

bone.

Orbital plate of

ethmoid bone,

frontal process

of maxillary

bone , lesser

wing of

sphenoid bone

and lacrimal

bone .

Landmarks Lacrimal gland fossa

is formed by lacrimal

bone and frontal

process of maxilla. [3]

the fossa for the

superior oblique

tendon, supraorbital

notch or foramen ,

Superior orbital

fissure separates roof

Frontozygo

matic suture ,

Whitnall’s

tubercle ,

Infra orbital

fissure

separates

floor from

lateral wall[3]

.

Infraorbital

canal and

infraorbital

groove .

Frontoethmoid

al suture , The

nasolacrimal

canal is

formed by the

maxilla, the

lacrimal bone,

and

the lacrimal

process of the

5

from lateral wall. The

frontosphenoidal

suture

lies between orbital

plate of frontal bone

and lesser

wing of sphenoid [3].

The optic strut lies at

the superomedial

border of the fissure in

an angle position

between the upper and

medial SOF

edges[12]. The annulus

of

Zinn [11] is a circular

array of connective

tissue in the orbital

apex. Inferiorly, the

SOF terminates at a

transverse bony

inferior nasal

concha [16]

6

confluence above the

foramen rotundum,

which is referred to as

maxillary

strut. [13][14][15]

Relations Above-Frontal and

ethmoidal sinuses,

Frontal lobe of

cerebrum and

meninges

Anterolateral

ly -Temporal

Fossa and

Muscle

laterally -

Middle

cranial fossa

and temporal

fossa of

cerebrum[3]

Below-

Maxillary

Sinus

Anteromediall

y- Lateral

nasal wall,

Infundibulum,

Ethmoidal

Sinus

,Sphenoid air

sinus

Postero

medially -

Optic Foramen

Muscles

attached

Levator palpebrae

superioris and

Superior Rectus

Lateral

Rectus

Inferior

Rectus

adjoins near

the apex of

orbit

Superior

oblique

muscle -In the

angle between

7

Inferior

oblique

muscle gets

attached to

lateral to the

nasolacrima

l canal. [1]

medial wall

and roof[3]

Blood

Vessels

and Nerves

Frontal nerve is in

contact with the

periorbita of the roof

Supraorbital artery

accompanies it in

anterior half,

Trochlear nerve lies

medially

Lacrimal

nerve and

artery which

is above the

lateral rectus

muscle

Infraorbital

vessels and

nerve at

infraorbital

canal

Anterior and

Posterior

Ethmoidal

nerve ,Infra

trochlear nerve

and

termination of

ophthalmic

artery.

8

APERTURES[3]

Soft tissues

Periorbita

Intra orbital optic nerve

Extraocular muscles and orbital fat

Annulus of zinn

Vasculature of orbit

Nerves of orbit

Lacrimal gland

9

Extra ocular muscles[3]

Annulus of zinn

10

Vasculature of orbit[7]

Nerves of orbit

11

Lacrimal gland[8]

The lacrimal gland is a tear-shaped, bilobed gland with the main function being

secreting the aqueous tear film . It is located in the supero temporal quadrant

within the lacrimal fossa of the frontal bone. The levator palpebrae superioris

divides the gland into 2 lobes: a palpebral component which is smaller and a

larger orbital component. Histologically, it is comprised of mixed serous ,

myoepithelial cells, mucinous acini, and small interconnecting ductules.

12

Paranasal sinus

Spaces in orbit

There are five spaces in orbit

I. The subperiorbital (subperiosteal) surgical space- the potential space

between the bone and the periorbita .[1]

13

II. The extraconal surgical space (peripheral surgical space)- which lies

between the periorbita and the muscle cone with its fascia[1]

III. The episcleral (sub-Tenon) surgical space - lies between the Tenon

capsule and the globe[1]

IV. The intraconal surgical space (central surgical space) - lies within the

muscle cone[1]

V. The subarachnoid surgical space - lies between the optic nerve and the

nerve sheath[1]

3.CLASSIFICATION OF ORBITAL TUMOURS[4]

Origin Children Adult

Congenital congenital , teratoma

Vascular Capillary haemangioma,

lymphangioma.

Cavernous haemangioma,

hemangiopericytoma, Orbital

varices.

Neurogenic

tumour

Optic nerve glioma ,

Plexiform neurofibroma

Malignant optic nerve glioma ,

meningioma (optic canal

meningioma ,Optic nerve

meningioma ,Optic nerve

meningioma ,Schwannoma

,Neurofibroma

14

Mesenchymal Rhabdomyosarcoma Fibrous histiocytoma

Haemopoietic Acute myeloid leukemia

,Histiocytosis

Lymphomas

Metastatic Neuroblastoma ,Wilm

tumour ,Ewing sarcoma

Breast , lung , prostate carcinoma

Parasitic Cysticercosis Hydatid ,cysticercosis

Vascular Tumors, Malformations, and Fistulas[9]

Capillary Hemangiomas.

Cavernous Hemangioma,

Venous Malformation

Lymphatic Malformation .

Arteriovenous Fistula

Hemangiopericytoma

Arteriovenous Malformations.

Orbital Hemorrhage.

Neural Tumors [9]

Optic Nerve Glioma

Meningioma

Neurofibromatosis

Neurofibroma

Schwannoma

15

Mesenchymal Tumors[9]

Rhabdomyosarcoma

Miscellaneous Mesenchymal Tumors

Lymphoproliferative Disorders[9]

Lymphoid Hyperplasia and Lymphoma

Plasma Cell Tumors.

Histiocytic Disorders

Xanthogranuloma

Lacrimal Gland Tumors[9]

Nonepithelial Tumors of the Lacrimal Gland

Epithelial Tumors of the Lacrimal Gland .

Secondary Orbital Tumors [9]

Globe and Eyelid Origin

Sinus Origin

Metastatic Tumors[9]

Metastatic Tumors in Adults

Metastatic Tumors in Children .

16

Congenital tumour

Dermoid cyst

A dermoid cyst is a congenital choristoma of the orbit. A choristoma is a

benign tumour consisting histologically normal cells occurring in an abnormal

location. Dermoid cysts consist of keratinized epithelium and adnexal structures

like hair follicles, sebaceous glands and sweat glands. Dermoid cysts are the most

common orbital tumours in children, accounting for 46% of childhood orbital

neoplasms [5]. It constitute 3-9 % of all orbital tumours [6]. Dermoid cysts are

consists of keratinized stratified squamous epithelium with dermal appendages

and adnexal structures, including hair follicles, sebaceous glands, sweat glands,

smooth muscle, and fibro adipose tissue. The lumen contains keratin and hair.

CAPILLARY HEMANGIOMA (HEMANGIOENDOTHELIOMA)

Capillary hemangioma is also called hemangioendothelioma , a congenital

tumour which consists of tightly packed capillaries that usually presents during

the first 6 months of life .

It is mostly unilateral and visible on the surface, but it may lie deep in the orbit -

more common quadrant being the superonasal quadrant .

Superficial Lesions

Also called as the ‘strawberry nevus,’ capillary hemangioma is confined to

the dermis. It may be single or multiple and is generally elevated.

Symptoms include ptosis, sometimes associated with astigmatism and amblyopia.

17

Treatment

Observation is warranted in most cases, since involution usually occurs.

Recently, systemic propranolol for 8-12 months has been shown to achieve

dramatic resolution for lesions in the proliferative phase. Intralesional steroids,

radiotherapy, and, more recently, topical corticosteroids also have been tried.

Topical Timolol maleate oinment has also been tried .

Deep Lesions

Deep lesions occur most commonly in the lids or posterior to orbital

septum and the most common quadrant involved being supero nasal quadrant.

Symptoms are proptosis, increasing size with the Valsalva maneuver or crying

displacement of the globe, subtle pulsations due to high vascular flow . Secondary

amblyopia may result from distortion of the globe.

Orbital imaging

Orbital imaging shows a well-defined intraconal or extraconal lesion , with

moderate to intense enhancement. On MRI the signals can be homogeneous to

heterogeneous, being hypointense on T1 and hyperintense on T2 images .

Pathology

A proliferation of capillary endothelial cells and small capillaries

is seen, with few spaces . Mitoses are commonly observed .

Treatment

18

Treatment consists of mainly observation, since many lesion will involute

.If the lesion is large or amblyopia is present, local radiotherapy (500 cGy) or

corticosteroids (systemic or local) may be given. Recently, propranolol has been

shown to cause significant involution for tumors .

Orbital Lesions Frequency

Cavernous hemangioma 50 %

Capillary hemangioma 18 %

Hemangiopericytoma 13 %

Lymphangioma 10 %

Orbital varices 5 %

Other 5 %

Cavernous Hemangioma[9]

It is the commonly occuring benign neoplasm of the orbit in adult age

group.

Age-Adults (20-40 years)

Sex predilection -Women more than men.

Pattern of growth- Slowly progressive proptosis which accelerates during

pregnancy.

19

Histopathology-Encapsulated tumour wih larege cavernous spaces containing

red blood cells and the walls contain smooth muscles.

Echography- Shows well circumscribed round to oval lesions with high internal

reflectivity and regular acoustic structure.

CT Scan -Homogenous soft tissue density and may show small phleboliths [10]

.MRI- Isointense T1 signal and bright T2 signal, Dark internal septations ,daek

circumferential rims which represent pseudocapsule.

Lymphatic Malformations (Lymphangiomas) [9]

Age- 1st or 2nd decade of life.

Sex Predilection – No sex predilection

Histopathology -Large serum filled channels lined by flat endothelial cells .

Scattered follicles of lymphoid tissues are found in the interstitium . They are not

encapsulated.

Echography -Shows orbital lesion with poor outline and irregular shape and low

internal reflectivity and highly reflective internal septa.

CT- Shows phleboliths[23] in the venous component and it may also have bony

abnormalities. [22] Venous or solid components of the tumours are hyperdense

compared to brain tissue in non contrast CT .

MRI - Grape like cystic lesions with fluid filled layers of RBCs and serum.

20

Orbital Varices[9]

They are low flow vascular lesions resulting from vascular dysgenesis.

Age- can occur in any age group

Sex Predilection – no sex prediliction

Clinical Presentations – Patient may have enophthalmos at rest and proptosis

increases Valsalva Maneuver.

Echography- Poorly defined margins with Calcifications seen.

CT- Contrast enhanced CT during Valsalva Maneuver shows enlargement of the

engorged veins .Phleboliths may be seen

Arteriovenous Fistula [9]

Age-Traumatic Fistula (15-30 years ) ,Spontaneous Fistula (30-60 years )

Sex Predilection– Traumatic Fistula is more common in men , Sponatneous

Fistula is more common in women .

Echography-Shows a dilated superior ophtalmic vein amd mikd thickness of

extraocular muscles with medium to highinternal reflectivity.

CT-Shows diffuse enlagement of some or all of the extraocular muscles reulting

from venous engorgement and a characterstically enlarged superior ophthalmic

vein.

21

Neural Tumours [9]

Optic nerve glioma

Age-1st decade

Sex Predilection-No sex predilection

Clinical Presentations- Gradual painless unilateral axial proptosis associated with

vision loss and RAPD.It affect 28% in optic nerve alone 72% chiasma and 43%

involve chiasma and midbrain.

Histopathology-Smooth fusiform intradural lesion,cystic spaces that contain

mucoid material with pial septae which are separated by well differentiated

astrocytes,eosinopholic Rosnthal fibres will be present which represents

degenerated astrocytic process,Immunohistochemistry reveals positive for

neuron specifis enolase .

Echography-Fusiform enlargement of the optic nerve, low to medium regular

internal reflectivity will be present .

CT-Fusiform enlargement of the optic nerve with kinking of the nerve.

MRI- [33] The hallmark of optic nerve glioma is circumscribed tortuosity and

fusiform thickening of the optic nerve. Optic gliomas are T2 hyperintense .

[34] Diffuse thickening of the substance of the nerve , differentiates optic nerve

22

glioma from optic nerve sheath meningioma which shows tram track appearance

Optic nerve sheath meningioma[9]

It is a benign neoplasm of meningo endothelial cells. Age-Middle aged adults

Sex Predilection -Women (3:2) Clinical Presentation-Slowly progressive

proptosis with disc edema and optico ciliary shunt vessels.

Histopathology-1. Meningoepithelial type- Lobules of meningothelial cells

2.Psammous type - Psamoma bodies or Calcified concretions .

3.Angioblastic type-Vascular elements resembling hemangiopericytoma.

Echography-Medium to high internal reflectivity and calcification

Orbital Imaging.

CT -Tubular enlargement of the optic nerve with characteristic Tram -track

pattern enhancing nerve sheath with Radiolucent central portion of the nerve

MRI- T1 is hypointense and T2 is hyperintense .Optic nerve sheath meningioma

may produce a thin sheet around the optic nerve, termed “en plaque

meningioma”, producing the ‘tram track’ sign. [24]

Plexiform Neurofibroma

It is the most common benign peripheral nerve tumour in eyelid and orbit .

Age - 1st Decade

Sex Predilection -No sex predilection

23

Clinical Presentation - palpable “bag of worms” and an S shaped eye . 50% may

be associated with uveal neurofibromatosis and 77% associated with Lish nodule

25% associated with prominent corneal nerves 15%associted with optic nerve

glioma . The patient may have pulsatile proptosis due to the absence of greater

wing of sphenoid.

Histopathology - Bundles of axon , Schwann cells and endoneural fibroblast in

mucoid matrix. It has a characteristic cellular perineural sheath.

Immunohistochemistry is positive for S100 stain.

Echography- It has a irregular contour with high internal reflectivity and irregular

internal structure.

Orbital Imaging -A diffuse irregular mass with variable contrast enhancement

which may involve extraocular muscles ,orbital fat and Cavernous sinus .

MRI -T1 is hypointense and T2 is hyperintense to muscle .

Mesenchymal Tumours[9]

Fibrous Histiocytoma

It is a benign or malignant tumour which arises from fascia , muscle or other soft

tissues .

Age – Children and middle aged (40-60 years )

Sex Predilection- No sex predilection

24

Clinical Presentation-The most common orbital site is upper nasal quadrant .

Decreased vision, diplopia, exophthalmos , ptosis and epiphora are the presenting

symptoms .

Histopathology-A mixture of spindle shaped fibroblasts and histocytes arranged

in a storiform pattern around a central focus . Benign form – Well circumscribed

slowly growing lesion . Malignant – Rapidly growing , more infiltrative.

Echography – Well outlined lesion with low to medium internal reflectivity and

regular internal structure .

Orbital Imaging

MRI -Isointense with T1 and variable intense with T2 with respect to muscle .

Rhabdomyosarcoma

It is the most common soft tissue mesenchymal tumour in children .

Age-1st decade of life (7-8 years)

Sex Predilection -Males (Boys :Girls – 5:3)

Clinical Presentation- The onset will be Sudden and it progresses rapidly ,

discoloration of lids, edema , strabismus and ptosis .It can be divide into four

types :

1.Embryonal – Most common type . Represents more than 80% of cases. It mostly

affects the superior nasal quadrant.

25

2.Alveolar- – This is the most malignant form of rhabdomyosarcoma. It has a

predilection for inferior orbit which accounts for 9% of orbital

rhabdomyosarcoma.

3.Pleomorphic-It is the least common ad most differentiated form .

4.Botryoid- It is the rare variant of rhabdomyosarcoma which appears grape like.

It appears as a secondary invader from the paranasal sinus or conjunctiva

Histopathology-Myoglobulin is a specific immunohistochemical marker .

Embryonal – It consists of loose fascicles of undifferentiated spindle cells and

some may show cross striations on trichrome staining in immature

rhabdomyosarcoma

Alveolar –It has regular compartments which are composed of fibrovascular

strands in which rounded rhabdomyoblasts line up the connective tissues and float

in the alveolar spaces

Pleomorphic-It has strap like or round cells with cross striations which can be

visualised with trichrome stain.

Echography- They are usually well circumscribed, occasionally there may be

bony defects, low to medium reflectivity, moderate sound attenuation.

Orbital imaging

26

It represents a irregular well defined mass. Bony erosion is seenT1 is

isointense to hyperintense, T2 is hyperintense with respect to muscle. Globe

distortion [28] and extension to the paranasal sinuses [29] is seen. Calcification is

rare in untreated tumours. MRI shows bright T2 signal, which distinguishes

rhabdomyosarcoma from tumours such as chloroma or granulocytic sarcoma,

lymphoma and metastatic neuroblastoma . MR may delineate the true extent of

disease for surgical resection . [30] On occasion, a pyogenic abscess may mimic a

necrotic rhabdomyosarcoma clinically and by imaging. [31] In such cases, MRI

with DWI is important in distinguishing, through demonstration of restricted

diffusion of pus in an abscess cavity, [32] as opposed to elevated diffusion in the

necrotic portion of a tumour.

Staging -There are four stages :

I. Localised tumour, completely resected

II Regional spread ,with or without positive nodes, grossly resected

III Gross residual tumour remaining after incomplete resection

IV Distant metastases

Miscellaneous Mesenchymal Tumours

Solitary fibrous tumour – Composed of spindle shaped cells which are positive

for CD34 on immunohistochemical studies

27

Fibrous dysplasia -Benign developmental disorder. MRI shows the lack of dural

enhancement (which distinguishes it from meningioma) and CT shows

hyperostotic bone .

Osteoma- Benign tumours which involves any of the periorbital sinuses. CT scans

show dense hyperostosis with well defined margins. They are slow growing

lesions that can produce proptosis, compressive optic neuropathy.

Lymphoproliferative disorder [9]

Lymphoid hyperplasia and lymphoma

Lymphoid tumours mold around normal structures without deforming them, and

they are homogenous which does not erode the adjacent bone. They may be

well defined, or infiltrative.

Based on the REAL classification, types of orbital lymphomas are

I. Mucosa associated Lymphoid tissue (MALT) lymphoma-It accounts for

40-60% of orbital lymphomas. MALT lymphoma occurring in ocular

adnexa are not associated with mucosal tissues . Some conjunctival MALT

lymphomas are associated with chronic chlamydial infection .They have a

low grade malignancy. Long term follow up shows half of the patients

developed systemic disease in 10 years .

28

II. Chronic lymphocytic lymphoma (CLL) represents a low grade lesion with

small and mature -appearing lymphocytes.

III. Follicular Centre Lymphomas – Represents low grade lesion with

follicular centre.

IV. High grade lymphomas which includes lymphoblastic lymphoma, Large

cell lymphoma , Burkitt’s Lymphoma

It can also be classified as lymphocytic, plasmacytic and leukemic lesions .

Lymphocytic lesions are again classified into

Idiopathic inflammation (Pseudotumour)

Lymphoproliferative reactive and atypical disease

Lymphomas

Benign reactive lymphoid hyperplasia

It constitutes a benign proliferation of lymphoid follicles.

Clinical Presentation- Patient will present with painless and normal vision . A firm

rubbery mass is palpable and there may be subconjunctival “salmon patch”.

Histopathology-It has a polymorphic array of small lymphocytes and plasma cells.

It has mitotically active germinal centres.

Echography – A-scan shows low to medium internal reflectivity with regular

structure .

Orbital Imaging -It moulds to the globe and other adjacent structures. On MRI it

shows T1 hypointense and T2 hyperintense to muscle.

29

Atypical Lymphoid Hyperplasia

It represents an intermediate between Benign reactive lymphoid hyperplasia and

malignant lymphoma.

Clinical Presentations- Patient may present with painless exophthalmos and

normal vision .A firm rubbery mass is palpable and there may be subconjunctival

“salmon patch” . It may involve other systemic organs.

Histopathology – Monomorphous sheets of lymphocytes which have larger nuclei

than Benign reactive lymphoid hyperplasia

Echography – A-scan shows low to medium internal reflectivity

With regular acoustic structure .

Orbital Imaging -It moulds to the globe and other adjacent structures. MR imaging

shows T1 hypointense and T2 hyperintense .

Malignant orbital lymphoma (Lymphosarcoma )

It is characterised by proliferation of monoclonal B-cells (Non-Hodgkins) which

arises in lymph node or in extra nodal site (orbit)

Age-Older age group (50-70 years )

Sex Predilection- No sex predilection

Clinical presentation –Palpable mass in the anterior orbit. symptoms like lid

oedema, exophthalmos, ptosis and diplopia. Most lesions are located in the

anterior, superior and the lateral orbit and frequently involve the lacrimal gland.

75% of cases – Unilateral involvement

25% of cases – Bilateral involvement

30

40% of cases – Systemic Involvement.

Histopathology-It has an anaplastic , infiltrative lymphocytes with large cleaved

nucleus with no follicles .

Echography-It shows with low to medium internal reflectivity with regular

acoustic shadow.

Orbital Imaging – Well defined mass which moulds to the adjacent structures.

Lymphoma

CT density is similar to skeletal muscle. MRI demonstrates homogenous,

intermediate T1 and T2 signals, and homogeneous contrast enhancement. [25][26][27]

Lymphomas most commonly involve the superolateral aspect of the orbit, [26] and

bilateral disease is common.

Histiocytic tumours

They are rare proliferative disorders of histiocytes which range from a solitary

benign lesion to a malignant lesion.

Eosinophilic Granuloma ( Histiocytosis X)

Age-5-10 years of age

Sex Predilection-No sex predilection

Clinical Presentation –Rapid onset of eccentric displacement of globe with

painful superolateral swelling. Overlying skin shows erythema and inflammatory

signs .

31

Histopathology- It is a soft friable tan yellow tumour which has sheets of

binuclear histiocytes, giant cells and eosinophils. In the cytoplasm , characteristic

Langerhan cells are seen.

Echography – Shows a well circumscribed mass with low internal reflectivity.

Orbital imaging -It shows an osteolytic lesion near the supratemporal bony rim

with marginal hyperostosis .Occasionally the lesion may extend into the canial

fossa.

Xanthogranuloma

Adult Xanthogranuloma of the orbit and the adnexa is often associated with

systemic manifestations . They are classified into four syndromes in their order

of frequency of occurrence :

1.Necrobiotic-xanthogranuloma(NBX)

2.Adult onset asthma with periocular xanthogranuloma (AAPOX)

3.Erdhiemm -Chaster disease(ECD)

4.Adult onset xanthogranuloma (AOX)

1. Necrobiotic-xanthogranuloma(NBX)- It is characterised by presence of

subcutaneous lesion in the lids and the anterior orbit. It has the propensity

to ulcerate and fibrose. Systemically it is associated with paraproteinemia

and multiple myeloma .

32

2. Adult onset asthma with periocular xanthogranuloma (AAPOX)- It is a

syndrome which includes periocular xanthogranuloma, lymphadenopathy,

asthma and increase in IgG levels .

3. Erdhiemm -Chaster disease(ECD)-It is the most severe of the adult

xanthogranulma, is characterised by dense progressive , recalcitrant

fibrosclerosis of the orbit and internal organs, including the retroperitoneal

,pleural ,perinephric spaces, mediastinum and the pericardium .In ECD ,

the involvement of the orbit is diffuse , which is in contrast to the NBX and

the AAPOX and AOX where there is an anterior orbit invovlvement which

leads to severe visual loss.

4. Adult onset xanthogranuloma (AOX)- It is an isolated xamthogranuloma

without any systemic involvement.

Metastatic tumour [9]

Metastatic tumour in children -Neuroblastoma, Leukemia

Metastatic tumour in adults – From breast carcinoma, From bronchogenic

carcinoma, From prostate carcinoma

Metastatic tumour in children

Neuroblastoma

It is the second most common orbital tumour in children. It arises from primitive

neuroblast which may be metastatic to the orbit . Orbital neuroblastoma in

33

children commonly occurs due to metastasis with primary in the abdomen.

[17] 40% of orbital metastases are bilateral. Primary orbital neuroblastoma arises

from the ciliary ganglion, [20][21] derived from neural crest cells.

Differentiated neuroblastoma is made of mature ganglion cells, Schwann

cells, and nerve bundles [19].

Age-Mean age at presentation is 2 years . 75% of cases occur before 4 years .

Sex Predilection-No sex predilection

Clinical Presentation-Rapid progression of exophthalmos over several weeks ,lid

ecchymosis ,lid edema, Ptosis is and Horner’s Syndrome

Histopathology-soft friable bluish mass with small round cells, with calcium and

areas of necrosis. Orbital Imaging -Irregular and poorly defined mass associated

with bone destruction and separation of suture .

Leukemia

Acute lymphoblastic leukaemia (ALL) is the most common type of leukaemia

which metastases to the orbit. Granulocytic sarcoma or chloroma - It is a primary

leukemic orbital mass and a rare variant of mylogenic leukaemia .

Metastatic tumours in adult

The most common metastatic tumours to the orbit are the breast, lung , prostate,

gastrointestinal tract, kidney . Owing to its abundant blood supply , the

34

extraocular muscles are commonly involved. Because of the relatively high

volume of low blood flow ,the second most common site is the bone marrow of

the sphenoid bone.

Breast Carcinoma – It is the most common primary source of orbital metastasis

in women . After 3-5 years of primary diagnosis it metastasis to orbit . It may

elicit a fibrous response which causes enophthalmos and restriction of ocular

motility .

Bronchogenic Carcinoma – It is the most common primary source of orbital

metastasis in men . It occurs most commonly in smoking males aged 45-60 years.

Prostate Carcinoma – It occurs most commonly in elderly man which can produce

a clinical picture resembling that of acute non specific orbital inflammation .They

mostly present with pain due to bony involvement .Imaging shows a lytic bone

lesion.

Percentage of metastasis from various sites[9]

Origin Percent

Breast 53

Prostate 11

Gastrointestinal 11

Lung 4

Sarcomas and others 21

35

Other solid tumors that metastasize to orbit are Ewings sarcoma, Wilms'

tumor, and testicular sarcoma. [20] These tumors rarely metastasize to the eye

itself.

4.Diagnosis and investigations of orbital disorders

o History

o onset, course, and duration of symptoms (pain, changes in vision

altered sensation and diplopia,)

o signs (globe displacement , erythema, palpable mass,)

o prior disease (such as thyroid eye disease [TED] or sinus disease)

and therapy

o injury (especially head or facial trauma)

o systemic disease (especially cancer)

o family history

Progression[9]

Hours Days Weeks Months Years

Traumatic Inflammatory Inflammatory Neoplastic Neoplastic

Hemorrhagic Infectious Neoplastic Lymphoid Degenerative

Infectious Traumatic Traumatic Vascular Lymphoid

Hemorrhagic Lymphoid Inflammatory Vascular

36

Vascular Vascular Degenerative Inflammatory

CAUSES FOR ABAXIAL GLOBE DISPLACEMENT

DOWNWARD DISPALCEMENT

Fibrous dysplasia

Schwannoma

Frontal mucocele

Subperiosteal hamartoma

thyroid orbitopathy

Lymphoma

Neuroblastoma

UPWARD DISPLACEMENT

Maxillary sinus tumour

Lymphoma

Metastatic tumour

LATERAL DISPLACEMENT

Ethmoid mucocele

Lacrimal sac tumour

37

Nasopharyngeal tumours

Lethal midline granuloma

Metastatic tumours

Rhabdomyosarcoma

MEDIAL DISPLACEMENT

Lacrimal fossa tumours

Sphenoid wing meningioma

Periorbital changes[1]

Salmon patch in cul-de-sac Lymphoma

Corkscrew conjunctival vessels Arteriovenous fistula

S-shaped eyelid Plexiform neurofibroma

Lid lag and eye lid retraction Thyroid eye disease

Eczematous lesions over eyelids Mycosis fungoides (Tcell lymphoma)

Edematous swelling of lower id Meningioma , Inflammatory tumour ,

metastasis

Frozen globe Metastasis or Zygomycosis

38

Ecchymosis of eyelid Sign of metastatic neuroblastoma ,

Leukemia or amyloidosis

Opticociliary shunt (Retinociliary

venous collaterals )

Meningioma

Prominent temple Sphenoid wing meningioma and

metastatic neuroblastoma

Vascular anomaly of eyelid skin varix , Lymphatic malformation and

hemangioma .

Black crusted lesions in nasopharynx Phycomycosis

Facial asymmetry Fibrous dysplasia and

neurofibromatosis

Inspection

Enophthalmos, may occur as a result of volume expansion of the orbit (fracture),

in association with orbital varix, or secondary to sclerosing orbital tumors (eg,

metastatic breast carcinoma) . Proptosis often indicates the location of a mass

because the globe is usually displaced away from the site of the mass.

Exophthalmometry- is a measurement of the anterior-posterior position of the

globe. Commonly used are hertels and leuddes exophthalmometry .

It usually measures from the lateral orbital rim to the anterior corneal surface .

39

An asymmetry of greater than 2 mm between an individual patient's eyes suggests

proptosis or enophthalmos.

Proptosis can be tested clinically by asking the patient to sit and extend the neck

and the examiner has to stand behind the patient -Naffziger test .

Proptosis appreciated clinically when the examiner looks up from below with the

patient's head tilted back – WORMS EYE VIEW

Asymmetric orbital size- asymmetric palpebral fissures (usually caused by

ipsilateral eyelid retraction or facial nerve paralysis or contralateral ptosis)

Ocular movements- may be limited in a specific direction of gaze by neoplasm

or inflammation. In TED, the inferior rectus is the muscle most commonly

affected, followed by medial rectus, superior rectus and inferior rectus .

Palpation

Palpation around the globe may disclose the presence of a mass in the anterior

orbit.

Resistance to retrodisplacement - result either from a retrobulbar tumor

or from diffuse inflammation such as TED.

Pulsations of the eye -It may result from either abnormal vascular flow or

transmission of normal intracranial pulsations through a bony wall defect in the

orbit. Abnormal vascular flow may be caused by arteriovenous communications,

40

such as dural cavernous fistulas or carotid cavernous . Defects in the bony orbital

walls may result from sphenoid wing dysplasia in neurofibromatosis , trauma

sinus mucoceles, surgical removal of bone, or developmental abnormalities,

including encephalocele and meningocele .

Finger insinuation – If this is positive it indicates finger can be insinuated

between mass and bony orbital rim , hence there is no tumour infiltration .

Auscultation

Auscultation with a stethoscope over the globe may detect bruits in cases of

carotid cavernous fistula. The patient may also subjectively describe an audible

bruit.

Primary studies

CT

MRI

Ultrasonography

Secondary studies

Arteriography

Venography

CT and MR Angiography

41

5.Treatment modalities

A) Orbital surgery[2]

Anterior Routes

Anterior routes include the superior, inferior, medial, and transconjunctival

approaches. In this area are the orbital tumors that are palpated through the eyelids

or conjunctival fornices.

Tumors frequently managed by these approaches are the

carcinomas secondarily invading the orbit from a sinonasal source

the frontal mucocele extending into the superonasal orbit

some lymphangiomas, capillary hemangiomas, and rhabdomyosarcomas

and

the non-Hodgkin lymphomas clustered around the trochlea or protruding

into the conjunctival fornix

the inflammatory tumor extending along the back of the orbital septum

the orbitofrontal organizing hematoma without intracranial extension.

Excluded from this list are the palpable lacrimal gland tumor because these

lesions should be approached through a wider exposure through lateral or

superolateral orbitotomy because their size is often larger than expected. The

lacrimal gland tumours should be biopsied without rupturing its capsule . In all

the anterior approaches other the transconjunctival route, the location and length

42

of the incision is first outlined on the skin with a marking pen and then proceeded

.

Sites of surgical entry into orbit

A. Stallard – wright lateral orbitotomy

B. Eyelid crease lateral orbitotomy

C. Lateral canthotomy / cantholysis orbitotomy

D. Trans caruncular medial orbitotomy

E. Frontoethmoidal orbitotomy

F. Upper lid crease anterior orbitotomy

G. Vertical eyelid split superomedial orbitotomy

H. Medial bulbar conjunctival orbitotomy

I. Subciliary inferior orbitotomy

J. Trans conjunctival inferior orbitotomy

K. Lateral bulbar conjunctival orbitotomy

43

Inferior Approach

Since there is a less number of primary orbital tumours in inferior orbit,

inferior orbitotomy is less frequently done . For the management of secondary

tumors that invade from a source in either the nasal cavity or maxillary antrum,

the inferior orbitotomy is combined with some sino nasal procedure.

The objective of the inferior orbitotomy is to gain access to the junction of the

periosteum of the maxillary bone with the periorbita covering the floor of the

orbit and the fascia separating the tissues of the eyelid from the orbital space. The

skin overlying the inferior orbital rim also is very thin. This feature, combined

with the tendency of healing skin to adhere directly to the underlying periosteum,

creates a visible scar. So skin incision is placed somewhere in the lower eyelid

superior to the orbital rim. The incision is generally a millimeter or two below the

lashes in a subciliary position .

Once the inferior orbital space is entered, the orbital fat will prolapse into the

space and visibility is adequate and it may be retracted with cotton-tipped

applicators . The location of the inferior oblique muscle should be noted when

dealing with orbital fat during this approach to avoid postoperative diplopia.

There are no major sources of hemorrhage in the infero anterior orbital space.

Medial Approach

The curved contour of the supero nasal orbital rim is the landmark for the

medial approach . The incision is gull-wing shaped over the medial canthal

44

tendon. This is the standard external ethmoidectomy incision. Other options

include a trans marginal, lid-splitting procedure and medial lid crease.

The external ethmoidectomy incision is 25 to 30 mm in length and is roughly

equal to one-fourth the circumference of the orbital rim.

In the supero nasal quadrant the bleeding vessels are the terminal branches of the

frontal and dorsal nasal arteries in the area of the trochlea and the angular vein .

The foramen of the anterior ethmoidal artery is an important topographic

landmark. It is located at the level of the cribriform plate and the junction between

the ethmoid labyrinth and the frontal bone. The diplopia occurs as a complication

of surgery results from the postoperative malposition of the trochlea of superior

oblique and also because of the secondary malfunction of the superior oblique

muscle of the affected eye . The complication is secondary to disengagement of

the periosteal base of trochlea during the course of the elevation of the periosteum

from supero nasal orbital rim.

The most recent description of a medial orbitotomy is the trans caruncular

approach. Mainly used for biopsy of the medial rectus muscle belly or for lesions

within the medial extraconal or peripheral space. The incision should be just

immediately lateral to the caruncle itself and the dissection should continue down

to the posterior lacrimal crest.

45

Lateral Route

The incision is carried through the skin and subcutaneous tissue to the

periosteum, which covers the temporal orbital rim (anteriorly) and the temporalis

fascia (posteriorly). The subcutaneous tissue along these planes is undermined

with a sharp dissection augmented by mobilization of soft tissues by blunt

dissection, which is accomplished by a gauze that is wrap around the tip of the

index finger, which results in a nearly bloodless surgical field. Next an incision

is made in the periosteum directly over the lateral orbital rim starting above from

the zygomatic-frontal suture extending upto the level of the zygomatic arch, 2 to

3 mm posterior to the bony rim. The periosteum is removed away from the bony

rim along the length of the incision .Edges of the periosteal incision are sutured

with silk for the anatomic closure. This will prevent the malposition of the

lateral canthal tendon. When the periosteum is lifted from the anterior portion of

the zygomatic arch and the periorbita is reflected from the inner face of the lateral

orbital wall, terminal branches of the lacrimal artery are noted . These can then

be coagulated with a bipolar cautery. The temporalis muscle is released from its

attachment to the posterior lip of the orbital rim after which the muscle is pealed

posteriorly from the surface of the lateral orbital wall .

46

Tumour presenting anterior to the

equator of the globe

Anterior orbitotomy

Tumour presenting posterior to the

equator of the globe and lateral to

the optic nerve

Lateral orbitotomy

Tumour presenting posterior to the

equator of the globe and medial to

the optic nerve

Medial orbitotomy

Tumour presenting in posterior one

third of optic nerve , canal or optic

chiasm .

Transcranial orbitotomy

Exenteration

Exenteration of the orbit entails the total removal of the soft tissue of the

orbital cavity with or without conservation of portions of the skin of the eyelids.

In orbital tumors, the operation is usually interrelated with malignant neoplasms.

There are two types of exenteration .

Lid sparing exenteration and total exenteration .

The lid sparing exenteration may be done in posterior tumors within the orbit. If

there are macroscopic changes at operation suspicious of bone invasion, we have

47

to do a frozen section examination of the periorbita. If it is positive, bone should

be removed and sent for pathological analysis [35].

B) Chemotherapy

Lymphoma- High-grade tumors should be treated with standard

combination chemotherapy, cyclophosphamide, adriamycin, vincristine and

prednisone (CHOP). The current treatment of choice for elderly patients with

DLCL (Diffuse large cell lymphoma ) is that of CHOP chemotherapy with

rituximab (an anti CD-20 monoclonal antibody) , cyclophosphamide

,doxorubicin, (vincristine) oncovin prednisolone (R-CHOP) regimen. This is

based on a European study which studied CHOP vs R-CHOP in patients with

DLCL and showed prolongation of survival and overall survival in the group that

was treated with R-CHOP without additional toxicity.

Maxillary carcinoma- Induction chemotherapy (ICT) and concurrent

chemoradiation therapy (CCRT) are the common multimodality treatments for

stages III and IV locally advanced maxillary sinus carcinoma.

Cisplatin (100 mg/m2) was administered via a microcatheter into internal

maxillary artery over two hours on day 1, and 5-FU (1000 mg/m2/day) was

continuously infused from day 1 to day 5 over 120 hours through the IV line. A

standard hydration and mannitol diuresis regimen were applied. The entire

procedure was repeated 2–3 times for every 3–4 weeks.

48

C) Radiotherapy

Methods of Radiation Delivery

A. EXTERNAL BEAM RADIATION THERAPY

External beam radiation therapy (EBRT) is currently delivered utilizing photons

(gamma rays or X ray) or particles (protons or neutrons), with linear accelerators

(LINACs) doing the bulk of the work.

B. INTENSITY-MODULATED RADIATION THERAPY

Intensity-modulated radiation therapy (IMRT) utilizes controlled X-ray

accelerators to create a three-dimensional (3-D)--shaped conformal

treatment zone.

IMRT allows for a higher and more effective radiation dose to be delivered to the

tumor, with fewer normal-tissue side effects .

49

C.VOLUMETRIC MODULATED ARC RADIATION THERAPY

It is a volumetric arc therapy that delivers a precisely sculpted 3-D dose

distribution with a single 360degree rotation of the LINAC( linear particle

accelerator ).

D.STEREOTACTIC RADIOSURGERY

There are three basic types of SRS:

The gamma knife

The LINAC is preferred to deliver high-energy X rays, photons, or electrons

to larger tumors.

Charged-particle (e.g., proton) irradiation

E. PARTICLE RADIATION THERAPY

1. Proton

2.Neutron

F. BRACHYTHERAPY

Brachytherapy involves surgically placing a radio- active material (typically

seeds or wires) directly inside the body. It is commonly used to overlap with a

50

larger field of EBRT. Brachytherapy implants can be either temporary or

permanent.[36]For example, plaque radiation therapy for choroidal melanoma .

1. Brachytherapy Techniques

a.Finger’s Indications for the Brachytherapy Boost Technique

1 When the standard external beam radiotherapy dose would likely result in a

blind and painful eye due to radiation retinopathy, ulcerative keratopathy, and/or

neovascular glaucoma.

2 When exenteration of the orbit is the only option, but offers historically poor

local control rates (e.g., adenoid cystic carcinoma).

3 When a recurrent tumor has already received maximal external beam radiation

therapy.

4 When a patient refuses or is a poor medical candidate for exenteration surgery,

preferentially use brachytherapy to address residual microscopic orbital disease

in treatment of extra scleral extension of uveal melanoma.

51

Irradiation of Specific Orbital Tumors

A.OPTIC NERVE GLIOMA

Multiport beam arrangements are typically used to minimize the entry dose and

concentrate the radiation within the targeted zone. Orbital tumors are typically

treated with a wedged-pair external (photon beam) technique. Doses of 45 to 54

Gy (in 1.8 to 2.0 Gy daily fractions) are typically employed.

B.RHABDOMYOSARCOMA

The minimum tumor dose should be 45 to 50 Gy over 5 to 7 weeks.[37][38] Lens

blocks are typically placed to protect the anterior segment (when possible).

Although patient survival has been excellent, doses in this range are typically

associated with severe, late ocular, and orbital side effects.

Intraocular Tumors that Require Orbital Radiation Therapy

A.. METASTASIS

In most cases, prompt ocular and therefore orbital EBRT(External beam

radiotherapy) at 25 to 40 Gy (in 2-3 Gy daily fractions) makes the preservation

of vision likely.

52

Both breast and lung cancers are radiosensitive, and so most patients with uveal

metastasis can be treated with relatively low-dose EBRT(External beam

radiotherapy) .

B.RETINOBLASTOMA

In treatment of retinoblastoma and using schedules of 2 Gy daily fractions with

long-term follow-up, radiation retinopathy has been reported to occur in as many

as 10% of eyes dosed to 35 Gy (EBRT), in 66% of eyes treated to 45 Gy, and in

100% of eyes given 80 Gy or more. Radiation optic neuropathy has been reported

after high-dose EBRT and ophthalmic plaque radiation therapy[39][40][41][42].

Side Effects of Orbital Radiation Therapy

A.EYELIDS AND LASHES

Skin changes associated with radiation therapy

acute erythema,

atrophy,

hair loss,

ectropion or entropion of the eyelid .

depigmentation,

telangiectasias,

53

Most desquamation is more common after doses of 50-60 Gy (in 1.8 to 2.2 Gy

daily fractions) over 5-6 weeks.

Eyelash loss may occur depending on the dose and dose rate. It may occur with

as little as 10 Gy, and it is permanent with dose of 30 Gy. At more than 50 Gy,

radiation can produce permanent alopecia.

B. LACRIMAL APPARATUS AND DRY EYE

Doses in the range of 30--40 Gy can be safely delivered to the entire orbit without

long- term keratitis sicca and it can be treated with Puntal occlusion , tear

supplementation and lid tarsorrhaphy .

C.CORNEA

Temporary limbal stem cell dysfunction has been described.

Acute corneal toxicity results from a loss of the tear film with secondary

keratitis sicca .

D.LENS

As little as 2 Gy in a single fraction or 8 Gy in multiple fractions can induce

cataract.[43][44]

The most common cataract after EBRT is posterior subcapsular cataracts , donut

cataracts have also been reported .

54

E.SCLERA

Beta-emitting strontium-90 (90Sr) and ruthenium-106 (106Ru) episcleral

applicators are more likely to deliver much higher ‘‘sclera-thinning’’ doses as

compared with low-energy iodine-125 (125I) or palladium-103 (103Pd) . No

scleral radiation damage has been reported in external beam radiation doses of 60

Gy.

F.IRIS

Iritis can occur with a single dose of 10-20 Gy, but severe anterior uveitis has

been observed with doses of 30-40 Gy (in 10 Gy fractions) and after 70--80 Gy

(over 6--8 weeks).

Radiation therapy can also lead to iris neovascularization and neovascular

glaucoma.

G.RETINA, CHOROID, AND OPTIC NERVE

Radiation-related retinal and choroid vascular changes can occur to external beam

radiation doses in a range of 45-60 Gy .

Patients receiving 35- 50 Gy has a moderate risk of developing vasculopathy, and

those receiving ocular doses of more than 50 Gy will all finally develop radiation-

related ocular vasculopathy.

Also , radiation can occlude the blood vessels within the optic nerve (radiation

optic neuropathy) .

55

H.ORBIT

Orbital irradiation of children can decrease with bone development.[45]This leads

to hypoplasia and orbital asymmetry. secondary sarcoma can develop [46][47]

I.HYPOTHALAMUS AND PITUITARY DYSFUNCTION

pituitary and hypothalamic dysfunction is most commonly seen in children

irradiated for optic nerve glioma.

56

AIM

To study the clinical & histopathological Etiology of orbital space

occupying lesions.

Objective:

1.To study the Etiology

2. To study the Radiological features (CT/MRI/B scan)

3. To study the Treatment modalities & Prognosis over one year follow up period.

Study Design:

Observational prospective cohort study.

Inclusion Criteria:

All age group including both males and females presenting with unilateral

and bilateral orbital swelling.

Exclusion Criteria:

Patient with History of trauma

Patient with Orbital infections / Inflammation

Patient who are not willing to participate in the study.

Eyelid swellings/tumours not extending into orbit .

57

MATERIALS AND METHODS

Sample size 35

The study will include patients of all age groups who are presenting in the

Department of Ophthalmology, Tirunelveli Medical College , and they will be

subjected to ,

I. Informed written consent

II. Detailed history regarding age, sex , duration of complaints , including

history of trauma ,infection ,ocular co morbidities .

III. Previous treatment history and systemic illness .

IV. Visual acuity assessment , slit lamp examination, fundus examination ,

extra ocular movement assessment, Intraocular pressure measurement

using Goldman applanation tonometry and differential tonometry .

V. CT, MRI, & B scan will be taken if necessary.

VI. Histopathological examination and immunohistochemistry will be

checked if needed .

VII. Treatment options like surgery , chemotherapy , Radiotherapy , surgery

with chemotherapy , surgery with radiotherapy will be done depending

upon the diagnosis .

VIII. Patients will be followed up on 3months, 6months, 1year and their

visual acuity , colour vision , extraocular movements , anterior segment

and fundus examination prognosis will be assessed.

58

REVIEW OF LITERATURE

Neto et al[48] described that in 11 year study period our of 181 tumours studied

70% were primary , 23% secondary , 6% metastatic and lymphomas, and 1%

was not classified .

Bajaj et al[49] described the profile of orbital lesions histopathologically and

found 63 malignancies among 119 cases, with malignancy rate of 53%. Among

children , Orbital rhabdomyosarcoma and retinoblastoma with orbital spread

were the most common causes of proptosis .

Bonavolonta et al[50] analysed that the most common benign tumour is dermoid

cyst (14%) and cavernous hemangioma (9%) . Non-Hodgkin lymphoma was the

most common malignant neoplasm (12%). And among lacrimal tumours , 64 %

were benign and among malignant tumours adenoid cystic carcinoma .

Mathew et al [51] described that 68% were benign and 32 % were malignant .

Benign tumors were more common in patients less than 60 years and malignant

tumors were more common in patients older than 60 years. Benign tumors were

most common in the superior temporal quadrant .

Tailor et al[52] cavernous hemangiomas appear as a well-circumscribed, ovoid

intraconal mass on cross-sectional images. Breast cancer is the most common

malignancy to metastasize to the orbit, followed by prostate cancer, melanoma,

and lung cancer. At imaging, gliomas often cause fusiform expansion of the optic

59

nerve, in which the nerve itself cannot be delineated from the lesion. In contrast,

meningiomas classically have a "tram-track" configuration .

Sarah et al [53] described the radiological features of Orbital space occupying

lesions classic finding of optic nerve glioma , which are T2 hyperintense and

involves substance of optic nerve . MRI of rhabdomyosarcoma shows bright T2

signals , which distinguish it from chloroma ,metastatic neuroblastoma and

lymphoma .

Sim et al [54] described that due to the lack of lymphatics in the orbit,

haematogenous spread is the mode of development of metastasis . Orbital breast

metastases tend to preferentially localize within orbital fat or extraocular muscles.

Mohammed Jaber Al-Mamoori [55] described presenting clinical

manifestations of patients proptosis (94.7%), visual acuity impairment (49.5%),

diplopia (18.9%), strabismus (10.5%), ptosis (4.2%), ocular/orbital pain (26.3%),

conjunctival edema (12.6%), subconjunctival hemorrhage (5.3%),

lacrimation (21.1%), tinnitus (2.1%), epistaxis (2.1%), vertigo (2.1%) .

McNab et al[56] studied the anatomical location and laterality of Orbital

cavernous hemangioma and found that it occurs in the intraconal space (87%) and

lateral to the optic nerve (47%), a distribution which is similar to the distribution

of small arteries and arterioles in the orbit.

60

Gensheimer et al[57] studied the survival index of patients using Kaplan-Meier

analysis which showed 5-year local tumor control was 80%, disease-free survival

was 61%, and total overall survival was 90%.

Isaacson PG et al[58] described that the majority of non-Hodgkin’s lymphomas

of the orbit and orbital adnexa are extra nodal marginal-zone B-cell lymphomas

of mucosa-associated lymphoid tissue (MALT)-type lymphomas .

Gill et al[59] studied the response and complications of 150 mg oral vismodegib

in 7 patients with locally advanced BCC. The mean treatment duration is 11

weeks (range, 4 to 16 weeks), 58% had 80-100% regression, 29% had less than

35% partial regression, and there was progression in 1 patient (14%). The most

common side effects of oral vismodegib are muscle spasm (100%) and weight

loss (83%) .

Tuncer et al[60] evaluated the therapeutic efficacy of rituximab in 10 patients with

Orbital adnexal lymphoma .Complete response was achieved in 36% and the

remainder required adjuvant radiotherapy for recurrence.

Raksha rao and Santosh honaver [61] described the use of intra-arterial

chemotherapy (IAC), periocular chemotherapy (POC), and intravitreal

chemotherapy (IVitC) has enabled to focus direct drug delivery to the tumor.

Unlike intravenous chemotherapy (IVC) which can be used in the primary

management of all retinoblastomas, IAC, POC and IVitC have specific

61

indications. The prognosis for life salvage is now around 98%, with 90% eye

salvage and 80% vision salvage.

62

RESULTS

Figure 1: Age wise sex distribution

Figure 1 represents age wise sex distribution of study population. In less than one

year 1 male and no female . In the 1-10 years age group 5 were male and 1 female.

In the 11-20 years age group 1 was male and no female. In the 21-40 years age

group 3 were male and 5 female. In the 40-60 years age group 6 were male and 6

female . In the more than 60 years age group 7 were male and 2 female .

0

1

2

3

4

5

6

7

LESS THAN 1 1 TO 10 11 TO 20 21 TO 40 40 TO 60 60 PLUS

Sex and age Distribution

Female

Male

63

Figure 2: Laterality

Figure 2 represents laterality of the involved eye . In 36 patients there was

unilateral involvement and 1 bilateral involvement .

Figure 3 : Involvement of Right eye and Left eye

Figure 3 represents percentage of involvement of right eye and left eye. 51 %of

the patients had Right eye involvement and 49% of patients had Left eye

involvement .

35

1

LATERALITYUnilateral Bilateral

51%49%Right Eye

Left Eye

64

Figure 4 : Presenting complaints

Figure 4 represents the presenting complaints which shows that 46% of the

patient presented with proptosis , 35% presenting with swelling , 5% presented

with watering , 3% presented with pain ,3% presented with ptosis , 3% presented

with epistasis , 3% presented with white reflex and 3% presented with growth in

eyelid .

02468

1012141618

Complaints

65

Figure 5: visual acuity

Figure 5 represents visual acuity of study population . The visual acuity was

calculated in logmar . 24% patients had visual acuity of logmar 0.00 – 0.50 (

>6/18 ) , 27% patients had logmar 0.52-1 ( <6/18 – 6/60 ) , 11% patients had

logmar 1.02-1.30 (<6/60 – 3/60) 35% patients had visual acuity of logmar 1.32 -

1.80 (<3/60-1/60) and 3% patient had vision of logmar 4 (no light perception) .

1

9

10

4

13

0

4

0.00 - 0.50

0.52 - 1

1.02 - 1.30

1.32 - 1.80

1.82 - 3.0

Visual Acuity

66

Figure 6 : Origin of IOSOL

Figure 6 represents the origin of tumour , which shows 19 were arising from

surrounding tissues , 17 were primary and 3 were metastasis .

Figure 7: Location of IOSOL

Figure 7 represents location of IOSOL , 72 % were Extraconal mass , 13 % were

intraconal and 15% were both intra and extraconal .

3

17

19

Orgin of IOSOL

Metastasis

primary

From surrounding sinusesand other tissues

15%

72%

13%

Location of IOSOL

Both intraconal andextraconal mass

Extraconal mass

Intraconal mass

67

Figure 8 : Age distribution in benign and malignant tumour

Figure 8 represents age distribution of beningn and malignant tumours which

shows benign tumour were more common under 60 years of age and malignant

tumour were more common above 60 years of age .

Figure 9: Type of proptosis

Figure 9 demonstrates type of proptosis in the study population . Of which

eccentric proptosis was 85% , Axial proptosis was 15% .

1513

2

7

0

2

4

6

8

10

12

14

16

Benign malignant Benign malignant

<60 >60By Age

Axialproptosis

15%

eccentricproptosis

85%

68

Axial

proptosis

eccentric

proptosis

Column

totalP value

Both

intraconal and

extraconal

mass

3 3 6

P<0.05Extraconal

mass0 27 27

Intraconal

mass4 0 4

Row total 7 30 37

Figure 10 :Nature of tumour

Figure 10 represents the nature of the tumour in study population which shows

51% were malignant and 49 % were benign .

49%51%

Nature of Tumor

Benign

malignant

69

Figure 11: Type of IOSOL

Figure 11 represents the type of IOSOL which shows 22% were congenital

tumour , 13% were lympho proliferative disorders , 13 % were Neurogenic

tumours , 13 % were local extension , 13% were secondary tumour of sinus origin

, 8% were metastatic tumour, 6% were lacrimal gland tumour , 6% were vascular

tumour , 6% were granulocytic sarcoma .

0123456789

Type of IOSOL

70

Figure 12 : Diagnosis of benign tumour

Figure 12 represents Diagnosis of benign tumour in our study population which

shows dermoid being the most common benign tumour of 42% , optic nerve

meningioma (11%) , Frontal mucocele (11%) , Orbital hemangioma (11%) ,

Optic nerve glioma (10%) , Sphenoid wing meningioma extending int orbit (5%)

.

Optic Nerve Glioma,10%

Dermoid, 42%

Lacrimal GlandTumour, 10%

Optic NerveMeningioma,11%

OrbitalHemanigioma, 11%

Frontal mucocele11%

spenoid wingmeningioma

extending into orbit5%

DIAGNOSIS OF BENIGN TUMOUR

71

Figure 13 : Diagnosis of malignant tumour

Figure 13 represents diagnosis of malignant tumour which shows the most

common malignant tumour being lymphoma 25% , carcinoma of maxilla

extending into orbit 25% , Secondaries 15%, Carcinoma nasopharynx 10%,

Chloroma or granulocytic sarcoma 10% ,malignant melanoma 5% , Basal cell

carcinoma of lid extending into orbit 5% , Retinoblastoma 5% .

Basal Cell Carcinoma Of Lid Extending Into Orbit5%

Ca Nasopharynx10%

Retinoblastoma5%

Secondaries15%

Lymphoma25%

Other Ca MaxillaInvolving orbit

25%

Malignant melanomaof eyelid extending

into orbit5%

Chloroma10%

DIAGNOSIS OF MALIGNANT

72

Figure :14 Treatment modality

Figure 14 represents the treatment modality which shows 46% of patients were

treated by surgery alone , 24% were treated by Chemotherapy , 8% were treated

by surgery with radiotherapy , 5% were treated with radiotherapy alone , 5% were

treated with chemotherapy and radiotherapy , 5% were treated with surgery and

chemotherapy and 5% of the patient was observed with regular follow up .

02468

1012141618

Treatment Modality

73

Figure 15 : Kaplan – Meier Survival Analysis

Figure 15 represents the survival analysis of malignant tumour in one year follow

up in the study population which shows 90% survival in the first month and the

survival at the end of one year is 75 % and average survival rate is 81 %

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1 3 6 12

Prop

otio

n su

rviv

ing

Months

KM Survival Analysis

74

DISCUSSION

In my study the most common age group involved was 40-60 years. Females were

40% and males were 59% which is similar with study of Ralene et al[54] in which

53% were male .

In my study benign tumours were more common in patients less than 60 years of

age and malignant tumours were more common in patients above 60,

Out of the total IOSOL (Intraorbital space occupying lesions) 97.3% were

unilateral and only 2.7% were bilateral. In bilateral tumour, the neurofibromatosis

patient presented with bilateral optic nerve glioma.

In my study Right eye involvement was 51% and left eye involvement was 49%.

In my study , the most common clinical presentation was proptosis 46% followed

by orbital swelling 36% and the other presentation included watering (5%) , pain

(5%) , ptosis (5%) ,epistaxis (5%) , white reflex (5%) and growth in eyelid (5%)

which is similar to Mohammed Jaber Al-Mamoori et al[55] study in which the

most common clinical features at presentation was proptosis .

In my study most common (27%) presenting visual acuity is logmar 0.52-1 (<6/18

– 6/60) and the least common presenting visual acuity is no light perception.

Orbital retinoblastoma presented with visual acuity of no light perception.

The origin of tumour showed 49 % of tumours were arising from surrounding

tissues , 43% of tumours were primary and 8% were metastasis , from invasive

75

ductal carcinoma breast , Papillary carcinoma thyroid and small round cell

tumour of lung . Old age with history of lump in breast , visible thyroid swelling

, history of chronic cough with haemoptysis was present in patients with orbital

metastasis in my study .

Out of IOSOL (Intra orbital space occupying lesions) 72 % of tumours were

Extraconal mass , 13 % of tumours were intraconal and 15% of the tumours were

both intra and extraconal .Of which eccentric proptosis was 85% , axial proptosis

was 15% . Most of the extraconal lesions caused eccentric proptosis and

intraconal lesions caused axial proptosis with statistically significant p value of

<0.05.

Histopathology showed that 51% of the tumours were malignant and 49 % of

tumours were benign which is in accordance with the study by Geeta et al

[63]which showed 48% to be malignant and 52 % benign .

Of the benign tumour the most common tumour is dermoid (42%). Most of the

Dermoids are located in supero temporal quadrant which is same as the study

described by Mathew et al in which the most common occurrence of benign

tumour is supero temporal . In my study 50% of the patients with dermoid tumour

presented to us in the age group of 1- 10 years.

Of the malignant tumours the most common tumour is non-Hodgkins lymphoma

(25%) , which is similar to the Bonavolonta et al[50] study which showed the most

common malignant tumour being to be non-Hodgkin lymphoma of diffuse large

76

B cell type . PET scan was done to rule out systemic lymphoma. By

immunohistochemical marker study all the 4 non-Hodgkins lymphomas were

CD20 positive. patients treated with chemotherapy R-CHOP (Rituximab,

Cyclophosphamide, Hydroxydaunorubicin, Oncovin ,Prednisolone)regimen .

One patient recovered completely, two of them recovered with additional

radiotherapy and one patient died of systemic disease.

The only patient with orbital Retinoblastoma was presented with history of

swelling for 2 years duration and took native treatment and presented to us with

visual acuity of no light perception, we have treated the patient with 4 cycles of

chemotherapy of VEC (Vincristine, Etoposide and Carboplatin) regimen in the

interval of 21 days. The complications of chemotherapy like Hair loss, decreased

appetite has been observed. As per the suggested protocol in managing orbital

lymphoma by Santosh honavar et al[64] , the patient has been treated with 4 cycles

of neo adjuvant chemotherapy , followed by enucleation and there was no residual

tumour present .

The complications of Radiotherapy like Keratitis, Skin discolouration was

observed in 50% of the patients.

Survival analysis of malignant tumour in one year follow up was calculated using

Kaplan – meier survival index which showed 90% survival at the end of one

month and 75 % at the end of one yea . which differs from the study of devron et

al[65] which shows mean survival of patients was 1.3 years; the 2 year survival

77

rate was 27% . The good survival index in my study is possibly because of short

follow up period of one year and also the survival index was calculated for all the

malignant tumour in my study whereas in devron et al study only patients with

orbital metastasis was included.

78

CONCLUSION

In my study the most common age group involved is 40-60 years .

In my study males were more than females.

Most of the benign tumours presented under 60 years of age and most of the

malignant tumours above 60 years of age .

Most of the IOSOL (Intraorbital space occupying lesions ) are unilateral in

presentation .

There was no statistical significance in involvement of right eye or left eye .

In my study , the most common presenting complaint is proptosis . Rarely they

may also presented with epistaxis , Ptosis and white reflex as the only

presenting complaint .

Most of the patients presented with visual acuity of logmar 0.52-1 ( <6/18 –

6/60 ) and the least common is no light perception . The most common cause

for poor visual acuity of <6/60 is Optic nerve involvement and exposure

keratopathy .

Of the location of IOSOL , majority of the tumour are located in extraconal

space compared with intraconal space.

Both benign and malignant tumour were almost equal in number .

Most common benign tumour is Dermoid followed by optic nerve

meningioma .

Most common malignant tumour is lymphoma and maxillary carcinoma

extending into orbit .

79

Though Retinoblastoma is a rare tumour , timely diagnosis and management

is important to prevent distant metastasis.

Most of the patients were treated by surgery alone followed by chemotherapy

. The other treatment modalities were Radiotherapy , Chemotherapy with

radiotherapy , surgery with radiotherapy , surgery with chemotherapy , surgery

with chemotherapy and radiotherapy .

A multimodal workup protocol for IOSOL would ensure early definitive

diagnosis . The choice of appropriate treatment is the key to a good survival

rate as in our study .

ORBITAL LYMPHOMA

After 6 cycles of R-CHOP Regimen

ORBITAL LYMPHOMA Before treatment

ORBITAL LYMPHOMA after treatment with 6 cycles of

R-CHOP regimen

Orbital metastasis from thyroid carcinoma

Post Op – Total thyroidectomy

Secondaries from Lung carcinoma

Orbital retinoblastoma

After 4 cycles of chemotherapy -VEC regimen

Maxillary and frontal mucocele

Post surgery

Neurofibromatosis type 2

Proptosis

Cerebellopontine angle tumour

Optic nerve glioma

Complications of Radiotherapy

Keratitis

Skin discolouration

Lid sparing exenteration with maxillectomy

Extended exenteration for malignant melanoma

Supero temporal location of Dermoid tumour

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Millerb, Stewart Krolla .

PATIENT ID DATE

AGE

1. <1

2. 1-10 years

3. 11-20 years

4. 21-40 years

5. 40-60 years

6. > 60 years

SEX

1. Male

2 . Female

PRESENTING COMPLAINTS

Pain

proptosis

Loss of vision

Dilopia

Proptosis

Duration (DAYS/WEEKS/MONTHS/YEARS)

Unilateral or Bilateral

onset: Insidious or sudden

Progression/stationary/regression

Constant/Intermittent

Variation of proptosis :postural variation or cough or strain

Aggravating or Relieving factors

Assosiated "swishing sound "

Pain

Duration and relation to onset of proptosis(DAYS/WEEKS/MONTHS/YEARS)

site

RAdiation

Character

Aggravating and releiving factors

Relation to eye movement

Vision loss

Duration and relation to proptosis (DAYS/WEEKS/MONTHS/YEARS)

ONset:Insidious or sudden

Progression :Raid or slow

Gaze evoked amarousis

Diplopia

Duration and relation to proptosis (DAYS/WEEKS/MONTHS/YEARS)

Monocular or binocular

Horizontal or vertical

Variablity

Maximum fied of diplopia

Ptosis

lid retraction

Edema

Redness

Watering

Phoophobia

Infraorbital tingling numbness

Swelling elsewhere on body

Trauma

CNS:Headache,nausea,vomiting,convulsion,ataxia

Focal sepsis :

Boil on eyelid

Dacrocystitis :swelling near medial canthus ,discharge,matting of lashes

Sinusitis :Headache,nasal stuffiness or discharge , fever

Tooth pain

EAR: discharge,tinnitus,hearing loss

PAST HISTORY

DIabetes / HT

medical h/o

ocular h/o

previous surgeries

Personal history

Weight loss

Family history

EXAMINATION:

General apperance

vitals:pulse BP Respiratory rate

Pallor,Icterus,Cyanosis,Edema

Lymph nodes

Thyroid

Skin:Naevi,cafe-au-lait,port wine stain

Systemic examination:

ENT

CNS

Breast

Thyroid

CVS

RS

ABDOMEN

MUSCULOSKELETAL

OCULAR EXAMINATION

1.General ocular examination

Head posture

Ocular posture

Fascial assymetry

2.Examination of proptosis

INSPECTION

Unilateral or Bilateral

Axial or Eccentric

Visible pulsatility

change with valsalva ,cough or posture

Lid position: Retraction or Ptosis

Lid fullness

Skin over the Lid :INflammation/Pigmentation/Ecchymosis/venousdilatation

PALPATION

Rise in tmperature

Tenderness

Pulsatility

Thrill

Mass palpated :

size and shape

Discrete/Ill defined

Margins

Consistency

Compressibility

Insunuation

Resistance to retropulsion of globe

Auscultation over orbit

Exophthalmometry

Mild proptosis

Moderate proptosis

Severe proptosis

DETAILED OCULAR EXAINATION

Visual acuity

Colour vision

Field

eyelid : PFH

Lagophthalmos(lid closture /Blink rate )

Eyelid sensation

Bells phenomnon

lid signs of thyroid

Conjunctiva (chemosis ,congestion ,hemorrhage ,conjunctival extension oftumours )

cornea (size ,clarity ,kp ,staining ,sensation)

AC (depth , cells/flare )

Iris (colour,pattern,atrophy,neovascularisation)

Pupil :Rapd ,light near dissosisation

lens

Fundus :

Direct ,IDO

Disc edema , Optic atrophy

Posterior pole indentation

Choroidal folds

Optociliary shunts

Torturous vessels

Refraction

Ocular motility : DUCTIONS AND VERSIONS

IOP :straight ahead gaze

: In upgaze for thyroid ophthamopathy

Diplopia charting

Investigations

1. Complete blood count

2.ESR

3. Random blood sugar

4. Thyroid function test

5. Chest X ray

6. Bscan

7. CT orbit

7. MRI orbit

8.PET scan

9.Histopathology

Treatment

1.Observation

2.Medical

3.Surgery

4.Radiotherapy

5.Chemotherapy

Follow up

1. 1month

Visual acuity

colour vision

Eom Fundus

2. 3 month

3. 6month

4. 1 year

MASTER CHART EXPLANATION

1.SEX

FEMALE 1

MALE 2

AGE

<1 1

1 to 10 2

11 to 20 3

21 to 40 4

40 to 60 5

>60 6

2.COMPLAINTS

Proptosis 1

Loss of vision 2

Diplopia 3

Pain 4

PTOSIS 5

swelling 6

Watering 7

Epistaxis 8

White reflex 9

Growth in eyelid 10

3.DURATION

Days 1

Weeks 2

Months 3

Years 4

4.laterality

Unilateral 1

Bilateral 2

5.ONSET

Insidious 1

Sudden 2

6.COURSE

Progression 1

Stationary 2

Regression 3

7 Types of Tumor

Constant 1

Intermittent 2

PAST HISTORY

Systemic illness no 1

DIABETIC 2

HT 3

CAD 4

TB 5

THYROID 6

CVA 7

BREAST carcinoma 8

Blood malignancy 9

Lung carcinoma 10

Brain tumour 11

PERSONAL HISTORY

Weight loss yes 2

Weight loss no 1

Family history

YES 2

NO 1

GENERAL EXAMINATION

Vitals

Normal 1

Abnormal 2

LYMPHNODES

NO 1

YES 2

Submental and submandibular 3

Upper deep cervical 4

Middle deep cervical 5

Lower deep cervical 6

Posterior triangle lymphnodes 7

Pretracheal prelaryngeal 8

Superior mediastenial nodes 9

Distant lymphnode involvement 10

PALLOR

NO 1

YES 2

CYANOSIS

NO 1

YES 2

CLUBBING ,ICTERUS, EDEMA

NO 1

YES 2

THYROID

NORMAL 1

ABNORMAL 2

BREAST

NORMAL 1

ABNORMAL 2

SKIN

NORMAL 1

ABNORMAL 2

CAFÉ LU SPOTS 1

NEUROFIBROMA 2

Edema 3

OCULAR EXAMINATION

1.GENERAL

Head posture normal 1

Head posture abnormal 2

Ocular posture normal 1

Ocular posture abnormal 2

Facial asymmetry normal 1

Facial asymmetry abnormal 2

INSPECTION

proptosis

Unilateral 1

Bilateral 2

No proptosis 3

Axial 1

Eccentric 2

No proptosis 3

Visible pulsation NO 1

Visible pulsation YES 2

CHANGE WITH VALSALVA NO 1

CHANGE WITH VALSALVA YES 2

SKIN OVER THE LID NORMAL 1

SKIN OVER THE LID ABNORMAL 2

INFLAMMATION 1

PIGMENTATION 2

ECCHYMOSIS 3

VENOUS DILATATION 4

ULCER 5

PALPATION

RISE IN TEMPERATURE 1

TENDERNESS 2

PULSALITITY 3

THRILL 4

Compressibility

yes 1

no 2

Insinuation

yes 1

no 2

Resistance to retropulsion

NO 1

Yes 2

EXOPHTHALMOMETRY

No proptosis 1

Mild proptosis 2

Moderate proptosis 3

Severe proptosis 4

DETAILED OCULAR EXAMINATION

VISUAL ACUITY in log mar

0.00 - 0.50 00.52 – 1 11.02 - 1.30 21.32 - 1.80 31.82 - 3.0 44 5

COLOUR VISION

NORMAL 1

DEFECTIVE 2

COULD NOT BE CHECKED 3

FIELD

NORMAL 1

DEFECTIVE 2

COULD NOT BE CHECKED 3

EYELID

LAGOPHTHALMOS YES 1

LAGOPHTHALMOS NO 2

BELLS INTACT 1

BELLS DEFECTIVE 2

Conjunctiva

Normal 1

chemosis 2

hemorrhage 2

Congestion 3

sch 4

CORNEA NORMAL 1

CORNEA ABNORMAL 2

AC NORMAL 1

AC ABNORMAL 2

PUPIL NORMAL 1

PUPIL ABNORMAL 2

LENS NORMAL 1

LENS ABNORMAL 2

FUNDUS NORMAL 1

FUNDUS ABNORMAL 2

COULD NOT BE CHECKED 3

IOP NORMAL 1

IOP ABNORMAL 2

EOM FULL 1

EOM DEFECT 2

DIAGNOSIS

Normal 0

OPTIC NERVE GLIOMA 1

SECONDARIES 2

LYMPHOMA 3

DERMOID 4

OTHER CA MAXILLA INVOLVING 0RBIT 5

Orbital hemanigioma 6

Lacrimal gland tumour 7

Ca nasopharynx extendinginto orbit 8

Retinoblastoma 9

Optic nerve meningioma 10

Basal cell carcinoma of lid extending into orbit 11

Frontal mucocele 12

Malignant melanoma of eyelid extending into orbit 13

Spenoid wing meningioma 14

Chloroma 15

TREATMENT

CHEMOTHERAPY 1

RADIOTHERAPY 2

CHEMO AND RADIO 3

SURGERY 4

SURGERY WITH CHEMO 5

SURGERY WITH RADIO 6

SURGERY CHEMO AND RADIO 7

Observation 8

FOLLOW UP

1 MONTH

3 MONTHS

6 MONTHS

1 YEAR

1 Subramani 6 60 plus MALE 2 1 3 1 1 2 1 1 1 1 2 1 1 1 1 1 2 2 1 1 1 1 1 2 1

2 Karpagavalli 3 11 to 20 FEMALE 1 1 3 2 1 1 1 1 1 1 1 1 1 2 1 1 2 1 1 1 1 2 1 2 2

3 Chitradevi 4 21 to 40 FEMALE 1 5 4 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 2 2

4 Perumal 5 40 to 60 MALE 2 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 25 Sayedelli 6 60 plus MALE 2 1 3 1 1 2 10 2 1 1 3 2 1 1 1 1 1 1 1 2 1 1 1 2 26 Mariyadoss. 4 21 to 40 MALE 2 1 4 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 27 Subiah 4 21 to 40 MALE 2 6 4 1 1 1 1 1 1 1 6 1 1 1 1 1 1 1 1 1 1 1 1 2 28 Nesamani 5 40 to 60 MALE 2 1 3 1 1 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 2 1 2 2

9 Mangalaselvi 5 40 to 60 FEMALE 1 1 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2

10 Paulraj 6 60 plus MALE 2 1 4 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 111 Chellappa 6 60 plus MALE 2 6 4 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1

12 Chellathangam 5 40 to 60 FEMALE 1 4 4 1 1 2 1 2 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 2

13 Rakesh 1 Less than 1 MALE 2 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

14 Ibrahim 6 60 plus MALE 2 8 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 215 duraipandian 6 60 plus MALE 2 7 3 1 1 1 1 1 1 1 4 1 1 1 1 1 1 2 1 1 1 1 1 2 216 Sadhasivam 5 40 to 60 MALE 2 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 2

17 Latha 4 21 to 40 FEMALE 1 1 2 1 1 1 8 2 1 1 4 2 1 1 1 2 1 1 1 1 2 2 1 2 2

18 Saravanan 5 40 to 60 MALE 2 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 2 2

CO

MP

LAIN

TS

DU

RA

TIO

N

LATE

RA

LITY

ON

SET

CO

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SYST

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S.N

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TIEN

T ID

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Age

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FAM

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HIS

TOR

Y

GENERAL EXAMINATION OCULAR EXAMINATION

VIT

ALS

LYM

PH

NO

DES

PA

LLO

R

CYA

NO

SIS

EDEM

A

THYR

OID

BR

EAST

SKIN

CN

S

GENERAL

CO

MP

LAIN

TS

DU

RA

TIO

N

LATE

RA

LITY

ON

SET

CO

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SE

SYST

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S.N

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PA

TIEN

T ID

AG

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RO

UP

Age

gro

up

Gen

der

SEX

ENT

CV

S

RS

PA

HEA

D P

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OC

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FAC

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YMET

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WEI

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T LO

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FAM

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HIS

TOR

Y

GENERAL EXAMINATION OCULAR EXAMINATION

VIT

ALS

LYM

PH

NO

DES

PA

LLO

R

CYA

NO

SIS

EDEM

A

THYR

OID

BR

EAST

SKIN

CN

S

GENERAL

19 Sulochana 6 60 plus FEMALE 1 6 3 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2

20 Valli 5 40 to 60 FEMALE 1 6 4 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2

21 Sornam ponnammal 6 60 plus FEMALE 1 7 3 1 1 1 3 2 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 2

22 Jeya anandharaj 5 40 to 60 MALE 2 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 223 Vinoth 4 21 to 40 MALE 2 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

24 Poornima 4 21 to 40 FEMALE 1 1 2 1 1 1 9 2 1 1 4 2 1 1 1 1 2 1 1 1 1 1 1 2 2

25 Syed ambiya 6 60 plus MALE 2 10 4 1 1 2 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 2 226 Thangavel 5 40 to 60 MALE 2 1 3 1 1 1 9 2 1 2 2 2 1 1 1 1 2 1 1 1 1 1 1 2 227 Mukesh kumar 2 1 to 10 MALE 2 9 4 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 228 rajan 2 1 to 10 MALE 2 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

29 pitchammal 5 40 to 60 FEMALE 1 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 2

30 petchiammal 4 21 to 40 FEMALE 1 1 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2

31 Thavasi 2 1 to 10 MALE 2 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 232 Antony 2 1 to 10 MALE 2 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

33 muthuselvi 5 40 to 60 FEMALE 1 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2

34 Mytheeleshwar 2 1 to 10 MALE 2 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

35 Surushi 2 1 to 10 FEMALE 1 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

CO

MP

LAIN

TS

DU

RA

TIO

N

LATE

RA

LITY

ON

SET

CO

UR

SE

SYST

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ILLN

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S.N

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PA

TIEN

T ID

AG

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Age

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Gen

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FAC

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FAM

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HIS

TOR

Y

GENERAL EXAMINATION OCULAR EXAMINATION

VIT

ALS

LYM

PH

NO

DES

PA

LLO

R

CYA

NO

SIS

EDEM

A

THYR

OID

BR

EAST

SKIN

CN

S

GENERAL

36 Rani 5 40 to 60 FEMALE 1 6 4 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

37 kalpana 4 21 to 40 FEMALE 1 6 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2

1

2

3

45678

9

1011

12

13

141516

17

18

S.N

o

AU

SCU

LTA

TIO

N

RIG

HT

EYE

LEFT

EYE

1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 1 2 1 12 0 4

1 1 1 1 1 1 1 1 1 2 2 2 3 1 1 1 3 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 2 2 1 1 1 1 2 1 1 1 4

1 2 1 1 2 1 1 1 1 2 2 2 2 1 1 1 3 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 2 2 3 3 3

1 1 1 1 1 1 1 1 1 2 2 2 3 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 1 5 0 61 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 3 3 2 1 3 1 1 1 2 1 1 1 1 1 1 1 2 2 1 1 1 1 2 1 2 0 11 1 1 1 1 1 1 1 1 2 1 2 3 1 1 1 1 1 1 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 10 81 2 1 1 5 1 1 1 1 2 2 2 3 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 0 13 11 1 1 1 1 1 1 1 1 2 2 2 4 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 0 2 4

1 2 1 1 1 1 1 1 1 2 1 2 2 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 12 4

1 1 1 1 1 1 1 1 1 2 2 2 3 1 1 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 0 3 11 1 1 1 1 1 1 1 1 2 2 2 3 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 0 3 1

1 1 1 1 1 1 1 1 1 2 2 2 3 1 1 1 3 3 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 5 0 5

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 0 4

1 2 1 1 1 1 1 1 1 2 2 2 3 1 1 1 0 0 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 3 0 11 2 1 1 1 1 1 1 1 2 2 2 3 1 1 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 2 0 8 21 2 1 1 1 1 1 1 1 2 2 2 3 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 0 6

1 1 1 1 2 2 2 1 1 2 2 2 4 1 1 1 1 3 1 2 1 2 1 2 1 2 1 2 1 1 1 1 1 1 1 1 1 1 1 2 0 2 1

1 1 1 1 2 1 2 1 1 2 2 2 4 1 1 1 3 1 2 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 8 0 3

DIAGNOSIS

INSPECTION PALPATION

RE LE RE

LENS FUND IOP EOM

PU

LSA

LITI

TY

THR

ILL

LE

LATE

RA

LITY

CO

MP

RES

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AN

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ILIT

Y

INSI

NU

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ON

RES

ISTA

NC

E TO

RET

RO

PU

SIO

N

EXO

PH

THA

LMO

MET

RY

TYP

E

OCULAR EXAMINATION DETAILED OCULAR EXAMINATION

RE LERE

EXAMINATION OF PROPTOSIS VISUAL COLOUR FIELD

LE RE

PU

LSA

TIO

N

CH

AN

GE

WIT

H V

ALS

ALV

A /

CO

UG

H /

PO

STU

RE

SKIN

OV

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HE

LID

RIS

E IN

TEM

PER

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RE

TEN

DER

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AP

PLA

NA

TIO

N

TON

OM

ETR

Y

BR

UIT

LAG

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BEL

LS P

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ENO

N

Conjun CORNE AC PUPIL

RE LE LE RE LERE LE RE LE RE LE

TREA

TMEN

T

LE RE LE RE

1

S.N

o

19

20

21

2223

24

25262728

29

30

3132

33

34

35

AU

SCU

LTA

TIO

N

RIG

HT

EYE

LEFT

EYE

DIAGNOSIS

INSPECTION PALPATION

RE LE RE

LENS FUND IOP EOM

PU

LSA

LITI

TY

THR

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LE

LATE

RA

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MP

RES

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AN

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NU

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RES

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NC

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RO

PU

SIO

N

EXO

PH

THA

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MET

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TYP

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OCULAR EXAMINATION DETAILED OCULAR EXAMINATION

RE LERE

EXAMINATION OF PROPTOSIS VISUAL COLOUR FIELD

LE RE

PU

LSA

TIO

N

CH

AN

GE

WIT

H V

ALS

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A /

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UG

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NA

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TON

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BR

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Conjun CORNE AC PUPIL

RE LE LE RE LERE LE RE LE RE LE

TREA

TMEN

T

LE RE LE RE

3 2 1 1 1 1 2 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 7 4

3 2 1 1 1 1 2 1 1 1 1 1 3 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 6 4

1 1 1 1 2 1 1 1 1 2 2 2 3 1 1 1 3 1 2 1 1 1 1 1 2 1 2 2 1 1 2 1 1 1 1 1 1 1 2 1 5 0 6

1 1 1 1 1 1 1 1 1 2 2 2 4 1 1 1 2 1 2 1 2 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 5 0 23 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 0 4

1 1 1 1 1 1 2 1 1 2 2 2 4 1 1 1 3 1 2 1 3 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 15 0 1

1 1 1 1 5 1 2 1 1 1 2 1 3 1 1 1 1 2 1 1 1 3 1 1 1 2 1 1 1 1 1 1 2 2 1 1 1 1 1 2 0 11 51 1 1 1 2 2 2 1 1 2 2 2 4 1 1 1 0 1 3 1 3 1 2 2 2 1 2 1 1 1 2 1 1 1 1 1 1 1 2 1 15 0 11 1 1 1 1 2 2 1 1 2 2 2 4 1 1 1 5 0 3 1 3 1 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1 1 2 1 9 0 13 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 0 4

1 1 1 1 1 1 1 1 1 2 1 2 3 1 1 1 1 3 1 3 1 3 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 2 0 14 4

1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 0 3 1 2 1 2 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 0 10 8

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 0 43 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 0 4

1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 0 6 4

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 0 4

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 7 4

1

S.N

o

36

37

AU

SCU

LTA

TIO

N

RIG

HT

EYE

LEFT

EYE

DIAGNOSIS

INSPECTION PALPATION

RE LE RE

LENS FUND IOP EOM

PU

LSA

LITI

TY

THR

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LE

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CO

MP

RES

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AN

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NU

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NC

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SIO

N

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PH

THA

LMO

MET

RY

TYP

E

OCULAR EXAMINATION DETAILED OCULAR EXAMINATION

RE LERE

EXAMINATION OF PROPTOSIS VISUAL COLOUR FIELD

LE RE

PU

LSA

TIO

N

CH

AN

GE

WIT

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TON

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Conjun CORNE AC PUPIL

RE LE LE RE LERE LE RE LE RE LE

TREA

TMEN

T

LE RE LE RE

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 4 4

3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 4 4

1

2

3

45678

9

1011

12

13

141516

17

18

S.N

o

3 3 1 1 1 1 2 2 3 3 1 1 1 1 2 2 3 3 1 1 1 1 2 2 3 3 1 1 1 1 2 2

3 1 1 1 2 1 1 1 3 1 1 1 2 1 1 1 3 1 1 1 2 1 1 1 3 1 1 1 2 1 1 1

3 1 1 1 2 2 1 1 3 1 1 1 2 2 1 1 3 1 1 1 2 2 1 1

5 2 3 1 2 1 3 1 5 2 3 1 2 1 3 1 5 2 3 1 2 1 3 1 5 2 3 1 2 1 3 13 3 2 1 2 1 1 1 3 3 2 1 2 1 1 1 3 3 2 1 2 1 1 1 3 3 2 1 2 1 1 11 1 1 2 1 1 1 2 1 1 1 2 1 1 1 2 1 1 1 2 1 1 1 2 1 1 1 2 1 1 1 22 5 1 3 1 2 1 3 2 5 1 3 1 2 1 3 2 5 1 3 1 2 1 3 2 5 1 3 1 2 1 3

0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1

3 3 1 1 1 2 1 1 3 3 1 1 1 2 1 1 3 3 1 1 1 2 1 1 3 3 1 1 1 2 1 11 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1

5 3 2 1 2 1 1 1 5 3 2 1 2 1 1 1 5 3 2 1 2 1 1 1 5 3 2 1 2 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

0 0 1 1 2 1 1 1 0 0 1 1 2 1 1 1 0 0 1 1 2 1 1 1 0 0 1 1 2 1 1 13 3 1 1 1 2 1 2 3 3 1 1 1 2 1 2 3 3 1 1 1 2 1 2 3 3 1 1 1 2 1 20 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1

1 3 1 2 1 2 1 3

3 1 2 1 1 1 1 1 3 1 2 1 1 1 1 1 3 1 2 1 1 1 1 1 3 1 2 1 1 1 1 1

LE RE LE RE LE

EOM

FUN

DU

S

VIS

UA

L A

CU

ITY

CO

LOU

R V

ISIO

N

EOM

FUN

DU

S

VIS

UA

L A

CU

ITY

CO

LOU

R V

ISIO

N

1 MONTH 3MONTHR

E LE RE LE

VIS

UA

L A

CU

ITY

CO

LOU

R V

ISIO

N

FOLLOW UP6MONTH 1YEAR

EOM

FUN

DU

S

RE LE RE LE

EOM

FUN

DU

S

VIS

UA

L A

CU

ITY

CO

LOU

R V

ISIO

N

Passed away

passed away

passed away

RE LE RE LE RE LERE LE RE LE RE LERE LE RE LE RE LERE

1

S.N

o

19

20

21

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