Orbital masses, approaches and eye-removal procedures

Characterize a mass before choosing a surgical route

Orbital disease can arise from inflammation, vascular malformation, nerve, muscle, lacrimal tissue, bone or metastatic and primary tumours. Assess the speed of progression, pain, displacement of the globe, visual function and motility. Axial proptosis suggests a lesion behind the globe, whereas a superior-lateral lacrimal lesion may displace it inferomedially. These patterns help localization but are not a histological diagnosis.

Examine acuity, colour, pupils, fields, pressure and exposure. A relative afferent defect or worsening colour vision suggests optic-nerve compromise and increases urgency. Record globe displacement, resistance to retropulsion and sensory changes. Imaging should define the relationship to the optic nerve, orbital apex, sinuses and bone; CT and MRI provide different information.

Common mass patterns

A cavernous venous malformation, formerly called cavernous haemangioma, often presents as a slowly progressive intraconal mass in adults. A lymphatic or venolymphatic malformation may enlarge with haemorrhage or intercurrent illness and is often less neatly circumscribed. A dermoid commonly relates to a developmental suture and may have deeper extension. Sudden worsening in a longstanding lesion requires reassessment rather than reassurance from the old diagnosis.

Lymphoma can produce moulding soft tissue, including lacrimal or anterior orbital disease, and usually needs tissue classification and systemic staging. Rhabdomyosarcoma is an important rapidly progressive childhood orbital tumour. Neuroblastoma metastases may produce bruising and orbital signs. A presumed cellulitis that fails appropriate therapy or has an atypical course requires reconsideration of a mass and sampling strategy.

Approaches, fractures and foreign bodies

Anterior, lateral and selected endoscopic medial approaches are chosen by lesion position and access requirements. An orbitotomy is an approach, not a treatment diagnosis. Protect the optic nerve, muscles and vascular structures; a route that is suitable for a lateral mass may be inappropriate for an apical medial lesion. Discuss biopsy versus excision and the possibility of systemic therapy before operating.

Orbital fractures require assessment of globe injury, optic function, entrapment, diplopia, enophthalmos and associated facial trauma. A child with a trapdoor fracture, restricted movement and nausea or bradycardia may have an oculocardiac reflex and needs urgent assessment. Not every radiographic floor defect requires immediate surgery, and timing follows functional and anatomical findings.

Organic foreign bodies can cause infection and may be difficult to see. Metallic material requires MRI safety assessment. Deep inert foreign bodies are not always removed if extraction would create greater damage; location, composition, infection and symptoms determine the decision. Orbital compartment syndrome is an emergency in which threatened optic function may require immediate decompression without waiting for a perfect scan.

Craniofacial malformations can alter orbital volume and expose the cornea or affect optic function. Coordinate with craniofacial teams and assess vision and refraction throughout growth rather than treating proptosis solely as a cosmetic finding.

Enucleation, evisceration and exenteration

Enucleation removes the globe. Evisceration removes intraocular contents while retaining the scleral shell. Exenteration removes orbital contents to an extent defined by the indication. These procedures have different indications, pathology implications and reconstructive needs. Suspected intraocular malignancy generally precludes routine evisceration because it disrupts the tumour and compromises assessment.

A painful blind eye, irreparable injury or tumour may require discussion of eye removal, but confirm the indication, alternatives and visual potential. Do not confuse absence of current useful vision with an automatic requirement for removal. Consent includes appearance, implant complications, prosthesis care, phantom sensations and psychological impact. Tumour-related procedures require an agreed specimen plan and oncological follow-up.

An orbital implant restores volume and may transfer movement; an external ocular prosthesis provides the visible appearance. Fit, surface health and socket anatomy determine comfort. Exposure, infection, migration, contracted socket and discharge require review. An artificial eye still needs care and periodic prosthetic assessment. Rehabilitation should include monocular adaptation, protection of the remaining eye and emotional support.

Clinical application

A child with rapidly progressive proptosis needs urgent infection and malignancy assessment. An adult with a slowly growing intraconal lesion needs imaging and evaluation of compression before elective intervention. A suspected intraocular tumour requires a procedure and pathology plan that preserves diagnostic and staging information, together with a clear rehabilitation discussion.

Source: EBO orbital curriculum.