Cavernous Hemangioma

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

Symptoms of Cavernous Hemangioma

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

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

Diagnosis of Cavernous Hemangioma

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

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

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

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

Imaging of Cavernous Hemangioma

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

Treatment of Cavernous Hemangioma

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



Pathology of Cavernous Hemangioma

  • well encapsulated and tolerated
  • shows large cavernous spaces with red blood cells



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