Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
In an article by Gil et al.,22 various approaches for anterior skull base reconstruction after oncological resection are discussed, including the use of a temporalis muscle flap to cover the orbital socket in cases of exenteration, as was performed in our patient. They report a 5% incidence of CSF leak, intracranial infection, and tension pneumocephalus in their series, concluding that double-layer fascial graft alone for repair of skull base defects was adequate in prevention of these complications in the majority of cases. Although rare, tension pneumocephalus should be considered in any patient experiencing headache or altered mental status following orbital exenteration.
REFERENCES 1. Sweni S, Senthilkumaran S, Balamurugan N, et al. Tension pneumocephalus: a case report with review of literature. Emerg Radiol 2013;20:573–8. 2. Finch MD, Morgan GA. Traumatic pneumocephalus following head injury. A complication of general anaesthesia. Anaesthesia 1991;46:385–7. 3. Reasoner DK, Todd MM, Scamman FL, et al. The incidence of pneumocephalus after supratentorial craniotomy. Observations on the disappearance of intracranial air. Anesthesiology 1994;80:1008–12. 4. Pitts LH, Wilson CB, Dedo HH, et al. Pneumocephalus following ventriculoperitoneal shunt. Case report. J Neurosurg 1975;43:631–3. 5. DelGaudio JM, Ingley AP. Treatment of pneumocephalus after endoscopic sinus and microscopic skull base surgery. Am J Otolaryngol 2010;31:226–30. 6. Michel SJ. The Mount Fuji sign. Radiology 2004;232:449–50. 7. Campanelli J, Odland R. Management of tension pneumocephalus caused by endoscopic sinus surgery. Otolaryngol Head Neck Surg 1997;116:247–50. 8. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care 2010;13:152–8. 9. Pepper JP, Lin EM, Sullivan SE, et al. Perioperative lumbar drain placement: an independent predictor of tension pneumocephalus and intracranial complications following anterior skull base surgery. Laryngoscope 2011;121:468–73. 10. Ishiwata Y, Fujitsu K, Sekino T, et al. Subdural tension pneumocephalus following surgery for chronic subdural hematoma. J Neurosurg 1988;68:58–61. 11. Markham J. Pneumocephalus. In: Vinken PJ, Bruyn GW, ed. Handbook of Clinical Neurosurgery. Amsterdam: North Holland Publishing Co; 1976:201–13. 12. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: a retrospective analysis of 488 cases. Neurosurgery 1984;14:649–58. 13. Eljamel MS, Foy PM. Acute traumatic CSF fistulae: the risk of intracranial infection. Br J Neurosurg 1990;4:381–5. 14. Bernal-Sprekelsen M, Bleda-Vázquez C, Carrau RL. Ascending meningitis secondary to traumatic cerebrospinal fluid leaks. Am J Rhinol 2000;14:257–9. 15. Kang BS. Disseminated head and neck emphysema with pneumocephalus due to air compressor injury into orbit. Am J Emerg Med 2007;25:223–5. 16. Yuksel M, Yuksel KZ, Ozdemir G, et al. Bilateral orbital emphysema and pneumocephalus as a result of accidental compressed air exposure. Emerg Radiol 2007;13:195–8. 17. Williams TR, Frankel N. Intracerebral air caused by conjunctival laceration with air hose. Arch Ophthalmol 1999;117:1090–1. 18. Walrath JD, Kazim M. Compressed helium injury to the or bit resulting in pneumocephalus. Ophthal Plast Reconstr Surg 2006;22:234–5. 19. Koenig RP. Traumatic eye and intracranial air-movement from a subconjunctival to an intracranial position. Am J Ophthalmol 1977;83:915–7. 20. Detorakis ET, Drositis I, Drakonaki EE, et al. Pneumocephalus and presumed meningitis following inconspicuous penetrating periocular trauma. Acta Ophthalmol Scand 2004;82:603–5.
Case Reports
21. Esson MD, Blanco-Guzman M, Douglas PS. Delayed tension pneumocephalus complicating orbital exenteration. Br J Oral Maxillofac Surg 2005;43:123–5. 22. Gil Z, Abergel A, Leider-Trejo L, et al. A comprehensive algorithm for anterior skull base reconstruction after oncological resections. Skull Base 2007;17:25–37.
Forget Me Not: A Case of Gossypiboma (Textiloma) Mimicking an Orbital Tumor Kaustubh Mulay*, Vishal Sharma†, and Santosh G. Honavar† Abstract: Retained foreign bodies are not infrequent following surgical procedures and are associated with medico-legal issues. Gossypiboma following ocular surgeries is rare but should be included in the differential diagnosis of a postoperative patient presenting with pain or mass. We report on one such case of gossypiboma following surgical excision of lacrimal gland.
A
surgical sponge is the most frequently encountered retained foreign-body (RFB). Gossypiboma (textiloma) is a rare surgical complication resulting in the formation of a mass around a surgical swab retained inside the body following a surgery. The term “gossypiboma” is derived from 2 words, “gossypium” (Latin) meaning “cotton” and “boma” (Swahili) meaning “place of concealment.” “Textiloma” is derived from the words “textilis” (Latin = weave) and “oma” (Greek = disease, tumor).The earliest report on “gossypiboma” was by Wilson in 1884.1 The actual incidence of gossypiboma is difficult to estimate because of the low reporting rates due to medico-legal complexities associated. Gossypiboma occurs most commonly following intraabdominal surgery, the reported rate of occurrence being 1 in 1000 to 1500 interventions.1 Gossypiboma in the eye or orbit is rare. We report a case of orbital gossypiboma in a 63-year-old female following excision of lacrimal gland.
CASE REPORT Eleven months after surgical excision of left lacrimal gland for a suspected adenoid cystic carcinoma, a 63-year-old female presented to our clinic with a burning sensation and stickiness in the left eye since the surgery. On examination, proptosis (2 mm) of the left eye (Fig. 1A) was observed with restriction of left eye movements in the lateral gaze. Schirmer test showed wetting of 35 mm and 1 mm of paper strip in the right and left eyes, respectively. A soft mass was palpable in the temporal orbit. CT scan showed a homogenously enhancing, diffuse mass involving the lateral, superior and inferolateral orbit (Fig. 1B,C). Per-operatively, a surgical gauze (Fig. 1D) was found at the center of a firm mass in the inferotemporal orbit. Microscopy showed granulation tissue composed of proliferating vascular channels, fibrocollagenous stroma, and dense
Accepted for publication December 8, 2014. *National Reporting Centre for Ophthalmic Pathology; and †Oculoplastic, Facial Aesthetic and Ocular Oncology, Centre For Sight, Hyderabad, India The authors have no financial or conflict of interest to disclose. Address correspondence and reprint requests to Kaustubh Mulay, Centre For Sight, Ashoka Capitol Building, Banjara Hills, Road No. 2, Hyderabad 500034. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000406
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e5
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
Case Reports
FIG. 1. A, 63-year-old female without any inflammatory signs. B, CT scan (coronal section) showing a diffuse mass in the superotemporal and inferotemporal orbit. C, CT scan (axial view) showing a homogenous and well-defined mass in the orbit with central enhancement. D, Surgical gauze found in the orbital mass. E, Microscopy of the mass showing lymphoplasmacytic infiltrate and fibrosis (hematoxylin-eosin; ×40). F, Cotton fibers (arrows) engulfed and surrounded by multinucleate, foreign-body type giant cells ( hematoxylin-eosin; ×400).
lymphoplasmacytic infiltrate (Fig. 1E). Numerous foreign-body giant cells were seen, some with engulfed cotton fibers (Fig. 1F).
DISCUSSION Gossypiboma has been reported after phacoemulsification cataract surgeries and external dacryorhinostomy.2,3 Emergency surgeries, unplanned change in operation, body mass index, surgical counts, involvement of more than 1 surgical team, change in nursing staff during procedure, volume of blood loss, and female gender are risk factors for RFB.4 Cotton fibers are inert and do not incite biochemical reactions without granuloma formation. Hence, gossypiboma may remain undetected for several years and may be an incidental finding during radiologic evaluations. Gossypiboma may evoke an aseptic, fibrotic reaction resulting in formation of a mass or may trigger an inflammatory and exudative reaction with formation of an abscess in which case it may be detected early. Retained foreign-body should be a differential diagnosis in any patient who postoperatively presents with infection, pain, or mass. Radiology is the cornerstone in the diagnosis of a gossypiboma. Surgical gauzes impregnated with radio-opaque threads may be easily detected in a plain x-ray. However, they may be distorted due to twisting, folding,
e6
or deterioration with time thus making detection by a plain x-ray difficult.5 No such markers were seen in our case. CT scan shows a rounded mass with a dense central part and an enhancing wall. MRI is not helpful as the radio-opaque marker is not magnetic or paramagnetic and thus not visible in MRI. Surgical removal of the RFB is the treatment of choice in gossypiboma. To conclude, an RFB is an uncommon complication following ocular surgeries. Gossypiboma should be included in the differential diagnoses of an explained mass in a postoperative patient. CT scan is the investigation of choice in suspected cases. A careful approach in high risk cases will help avoid this embarrassing complication.
REFERENCES 1. Manzella A, Filho PB, Albuquerque E, et al. Imaging of gossypibomas: pictorial review. AJR Am J Roentgenol 2009;193(6 Suppl):S94–101. 2. McPherson ZE, Jung-Yeon Ku J, Chong E, et al. Fibres found in the eye during and after phacoemulsification cataract surgery. Eye (Lond) 2014;28:958–61. 3. Shoaib KK. An enlarging mass due to a retained gauze piece-an unusual complication of dacryocystorhinostomy. Can J Ophthalmol 2011;46:372–3.
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
4. Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229–35. 5. Kohli S, Singhal A, Tiwari B, et al. Gossypiboma, varied presentations: a report of two cases. J Clin Imaging Sci 2013;3:11.
“Tag-Team” Orbital and Strabismus Surgeries with Immediate Reconstruction After Tumor Excision Metastatic to the Inferior Rectus Chris Y. Wu, Steven M. Archer, M.D, and Alon Kahana, M.D., Ph.D Abstract: Carcinoid tumors are rare, slow-growing, lowgrade neuroendocrine tumors with a propensity for orbital metastatic spread. The typical treatment paradigm for localized orbital disease involves excision, adjuvant radiotherapy, and/or receptor-targeted chemotherapy, followed by delayed evaluation for reconstructive strabismus surgery. We present a 58-year-old female patient with carcinoid tumor metastatic to the right inferior rectus muscle who presented with worsening binocular diplopia. The patient underwent coordinated “tag-team” orbital and strabismus surgeries that included excision of the right inferior rectus muscle to the annulus of Zinn followed immediately by reconstructive strabismus surgery. The patient required 1 additional strabismus surgery 1 year later. Follow up revealed no tumor recurrence at 4 years, and excellent binocular vision with good function. Deep orbital and strabismus surgeries, when performed simultaneously in a “tag-team” approach, may offer superior functional outcomes and improved patient quality of life, with expedited functional recovery. This approach may become a new treatment paradigm for surgical disease processes localized to the extraocular muscles.
C
arcinoid tumors are rare neuroendocrine malignancies with a disproportionate propensity for orbital metastasis. The current treatment paradigm of localized orbital carcinoid metastasis to the extraocular muscles involves excision, adjuvant radiotherapy and/or receptor-targeted chemotherapy, followed by delayed evaluation for strabismus reconstructive surgery.1 We present a case of a patient with metastatic carcinoid tumor of the right inferior rectus muscle who underwent immediate reconstructive strabismus surgery after excision.
CASE REPORT Case History. A 58-year-old woman was referred to the Eye Plastic and Orbital Surgery clinic by a general ophthalmologist for Accepted for publication December 11, 2014. Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor, MI The authors have no financial or conflicts of interest to disclose. Institutional Review Board approval was received for this study, IRB# HUM00040783. Address correspondence and reprint requests to Alon Kahana, M.D., Ph.D. Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor, MI. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000399
Case Reports
evaluation of recent-onset diplopia secondary to restrictive strabismus, with concern for Graves’s ophthalmopathy. Review of systems revealed nausea, diarrhea, and shortness of breath. On past medical history, she was treated for carcinoid tumor of the ileum with liver metastasis 6 years prior to presentation, and underwent segmental ileal resection and right hepatectomy with subsequent metastatic recurrence in the left liver lobe, for which she underwent radiofrequency ablation. She had also been treated for Graves’s disease, and was on hormone replacement therapy for iatrogenic hypothyroidism. Ophthalmic Exam and Diagnostics. Visual acuity with correction was 20/20 OU. No deficits noted in pupillary exam or in color vision. Extraocular motility exam revealed limitation of supraduction of the right eye consistent with restriction (Fig. A) and mild hypotropia and esotropia in primary gaze. The rest of the exam was noncontributory. Orbital MRI with gadolinium contrast showed asymmetric enlargement with enhancement of the right inferior rectus muscle (Fig. B). No abnormalities were noted in the other extraocular muscles or optic pathways. Pentetreotide scan with 111Indium labeling showed increased radiotracer uptake in the right inferior orbit (Fig. C), corresponding to the right inferior rectus muscle. Additional uptake was noted in a right periaortic lymph node, left hepatic lobe, left posterolateral T8 vertebral body, and left distal femur, consistent with metastatic disease. Treatment. Following medical and oncologic evaluations, and treatment of her carcinoid syndrome and congestive heart failure, she was taken to the operating room for treatment of her strabismus. From the outset, a coordinated surgical approach was planned between the orbital and strabismus surgeons. The goal was to establish and preserve the surgical planes around the extraocular muscles (strabismus surgeon), perform a combined lateral and inferior fornix orbitotomy for complete excision of the right inferior rectus muscle from origin at the annulus of Zinn to insertion on the globe (orbital surgeon), followed immediately by strabismus surgery which consisted of inferior transposition of the horizontal rectus muscles (inverse Knapp procedure). The inferior pole of the medial rectus muscle was placed to overlap 2 mm with the nasal border of the IR insertion, and inferior pole of the lateral rectus muscle placed 2 mm with the temporal border of the IR insertion; both medial and lateral rectus muscle insertions were kept parallel and concentric with the limbus. No complications were encountered during the operation and blood loss was minimal. Pathology. The surgical specimens showed well-differentiated glandular tumor configuration formed of redundant cells showing a finely stippled chromatin pattern (Fig. F,G). The tumor was confined to the middle segment of the excised inferior rectus muscle (Fig. D). Histopathologic carcinoid features were confirmed by immunohistochemical positivity for Chromogranin A. Postoperative Course. Due to a small right hypotropia in primary position, right hypertropia in reading position and intorsion, a second strabismus surgery was performed 1 year after the initial operation, consisting of a 3.5 mm left inferior rectus muscle resection with a posterior fixation suture and bilateral superior oblique anterior tenotomies. No other operations, strabismus or otherwise, were indicated after additional 3 years of follow-up. The most recent follow-up exam (4 years) was positive for mild limitation of the right eye in up- and down-gaze with diplopia in extreme gazes (Fig. E). The patient was able to fuse in primary gaze at distance and at near with prism glasses. She experienced no metastatic carcinoid recurrences in her orbit and her systemic disease has remained stable on systemic octreotide.
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e7
In an article by Gil et al.,22 various approaches for anterior skull base reconstruction after oncological resection are discussed, including the use of a temporalis muscle flap to cover the orbital socket in cases of exenteration, as was performed in our patient. They report a 5% incidence of CSF leak, intracranial infection, and tension pneumocephalus in their series, concluding that double-layer fascial graft alone for repair of skull base defects was adequate in prevention of these complications in the majority of cases. Although rare, tension pneumocephalus should be considered in any patient experiencing headache or altered mental status following orbital exenteration.
REFERENCES 1. Sweni S, Senthilkumaran S, Balamurugan N, et al. Tension pneumocephalus: a case report with review of literature. Emerg Radiol 2013;20:573–8. 2. Finch MD, Morgan GA. Traumatic pneumocephalus following head injury. A complication of general anaesthesia. Anaesthesia 1991;46:385–7. 3. Reasoner DK, Todd MM, Scamman FL, et al. The incidence of pneumocephalus after supratentorial craniotomy. Observations on the disappearance of intracranial air. Anesthesiology 1994;80:1008–12. 4. Pitts LH, Wilson CB, Dedo HH, et al. Pneumocephalus following ventriculoperitoneal shunt. Case report. J Neurosurg 1975;43:631–3. 5. DelGaudio JM, Ingley AP. Treatment of pneumocephalus after endoscopic sinus and microscopic skull base surgery. Am J Otolaryngol 2010;31:226–30. 6. Michel SJ. The Mount Fuji sign. Radiology 2004;232:449–50. 7. Campanelli J, Odland R. Management of tension pneumocephalus caused by endoscopic sinus surgery. Otolaryngol Head Neck Surg 1997;116:247–50. 8. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care 2010;13:152–8. 9. Pepper JP, Lin EM, Sullivan SE, et al. Perioperative lumbar drain placement: an independent predictor of tension pneumocephalus and intracranial complications following anterior skull base surgery. Laryngoscope 2011;121:468–73. 10. Ishiwata Y, Fujitsu K, Sekino T, et al. Subdural tension pneumocephalus following surgery for chronic subdural hematoma. J Neurosurg 1988;68:58–61. 11. Markham J. Pneumocephalus. In: Vinken PJ, Bruyn GW, ed. Handbook of Clinical Neurosurgery. Amsterdam: North Holland Publishing Co; 1976:201–13. 12. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: a retrospective analysis of 488 cases. Neurosurgery 1984;14:649–58. 13. Eljamel MS, Foy PM. Acute traumatic CSF fistulae: the risk of intracranial infection. Br J Neurosurg 1990;4:381–5. 14. Bernal-Sprekelsen M, Bleda-Vázquez C, Carrau RL. Ascending meningitis secondary to traumatic cerebrospinal fluid leaks. Am J Rhinol 2000;14:257–9. 15. Kang BS. Disseminated head and neck emphysema with pneumocephalus due to air compressor injury into orbit. Am J Emerg Med 2007;25:223–5. 16. Yuksel M, Yuksel KZ, Ozdemir G, et al. Bilateral orbital emphysema and pneumocephalus as a result of accidental compressed air exposure. Emerg Radiol 2007;13:195–8. 17. Williams TR, Frankel N. Intracerebral air caused by conjunctival laceration with air hose. Arch Ophthalmol 1999;117:1090–1. 18. Walrath JD, Kazim M. Compressed helium injury to the or bit resulting in pneumocephalus. Ophthal Plast Reconstr Surg 2006;22:234–5. 19. Koenig RP. Traumatic eye and intracranial air-movement from a subconjunctival to an intracranial position. Am J Ophthalmol 1977;83:915–7. 20. Detorakis ET, Drositis I, Drakonaki EE, et al. Pneumocephalus and presumed meningitis following inconspicuous penetrating periocular trauma. Acta Ophthalmol Scand 2004;82:603–5.
Case Reports
21. Esson MD, Blanco-Guzman M, Douglas PS. Delayed tension pneumocephalus complicating orbital exenteration. Br J Oral Maxillofac Surg 2005;43:123–5. 22. Gil Z, Abergel A, Leider-Trejo L, et al. A comprehensive algorithm for anterior skull base reconstruction after oncological resections. Skull Base 2007;17:25–37.
Forget Me Not: A Case of Gossypiboma (Textiloma) Mimicking an Orbital Tumor Kaustubh Mulay*, Vishal Sharma†, and Santosh G. Honavar† Abstract: Retained foreign bodies are not infrequent following surgical procedures and are associated with medico-legal issues. Gossypiboma following ocular surgeries is rare but should be included in the differential diagnosis of a postoperative patient presenting with pain or mass. We report on one such case of gossypiboma following surgical excision of lacrimal gland.
A
surgical sponge is the most frequently encountered retained foreign-body (RFB). Gossypiboma (textiloma) is a rare surgical complication resulting in the formation of a mass around a surgical swab retained inside the body following a surgery. The term “gossypiboma” is derived from 2 words, “gossypium” (Latin) meaning “cotton” and “boma” (Swahili) meaning “place of concealment.” “Textiloma” is derived from the words “textilis” (Latin = weave) and “oma” (Greek = disease, tumor).The earliest report on “gossypiboma” was by Wilson in 1884.1 The actual incidence of gossypiboma is difficult to estimate because of the low reporting rates due to medico-legal complexities associated. Gossypiboma occurs most commonly following intraabdominal surgery, the reported rate of occurrence being 1 in 1000 to 1500 interventions.1 Gossypiboma in the eye or orbit is rare. We report a case of orbital gossypiboma in a 63-year-old female following excision of lacrimal gland.
CASE REPORT Eleven months after surgical excision of left lacrimal gland for a suspected adenoid cystic carcinoma, a 63-year-old female presented to our clinic with a burning sensation and stickiness in the left eye since the surgery. On examination, proptosis (2 mm) of the left eye (Fig. 1A) was observed with restriction of left eye movements in the lateral gaze. Schirmer test showed wetting of 35 mm and 1 mm of paper strip in the right and left eyes, respectively. A soft mass was palpable in the temporal orbit. CT scan showed a homogenously enhancing, diffuse mass involving the lateral, superior and inferolateral orbit (Fig. 1B,C). Per-operatively, a surgical gauze (Fig. 1D) was found at the center of a firm mass in the inferotemporal orbit. Microscopy showed granulation tissue composed of proliferating vascular channels, fibrocollagenous stroma, and dense
Accepted for publication December 8, 2014. *National Reporting Centre for Ophthalmic Pathology; and †Oculoplastic, Facial Aesthetic and Ocular Oncology, Centre For Sight, Hyderabad, India The authors have no financial or conflict of interest to disclose. Address correspondence and reprint requests to Kaustubh Mulay, Centre For Sight, Ashoka Capitol Building, Banjara Hills, Road No. 2, Hyderabad 500034. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000406
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e5
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
Case Reports
FIG. 1. A, 63-year-old female without any inflammatory signs. B, CT scan (coronal section) showing a diffuse mass in the superotemporal and inferotemporal orbit. C, CT scan (axial view) showing a homogenous and well-defined mass in the orbit with central enhancement. D, Surgical gauze found in the orbital mass. E, Microscopy of the mass showing lymphoplasmacytic infiltrate and fibrosis (hematoxylin-eosin; ×40). F, Cotton fibers (arrows) engulfed and surrounded by multinucleate, foreign-body type giant cells ( hematoxylin-eosin; ×400).
lymphoplasmacytic infiltrate (Fig. 1E). Numerous foreign-body giant cells were seen, some with engulfed cotton fibers (Fig. 1F).
DISCUSSION Gossypiboma has been reported after phacoemulsification cataract surgeries and external dacryorhinostomy.2,3 Emergency surgeries, unplanned change in operation, body mass index, surgical counts, involvement of more than 1 surgical team, change in nursing staff during procedure, volume of blood loss, and female gender are risk factors for RFB.4 Cotton fibers are inert and do not incite biochemical reactions without granuloma formation. Hence, gossypiboma may remain undetected for several years and may be an incidental finding during radiologic evaluations. Gossypiboma may evoke an aseptic, fibrotic reaction resulting in formation of a mass or may trigger an inflammatory and exudative reaction with formation of an abscess in which case it may be detected early. Retained foreign-body should be a differential diagnosis in any patient who postoperatively presents with infection, pain, or mass. Radiology is the cornerstone in the diagnosis of a gossypiboma. Surgical gauzes impregnated with radio-opaque threads may be easily detected in a plain x-ray. However, they may be distorted due to twisting, folding,
e6
or deterioration with time thus making detection by a plain x-ray difficult.5 No such markers were seen in our case. CT scan shows a rounded mass with a dense central part and an enhancing wall. MRI is not helpful as the radio-opaque marker is not magnetic or paramagnetic and thus not visible in MRI. Surgical removal of the RFB is the treatment of choice in gossypiboma. To conclude, an RFB is an uncommon complication following ocular surgeries. Gossypiboma should be included in the differential diagnoses of an explained mass in a postoperative patient. CT scan is the investigation of choice in suspected cases. A careful approach in high risk cases will help avoid this embarrassing complication.
REFERENCES 1. Manzella A, Filho PB, Albuquerque E, et al. Imaging of gossypibomas: pictorial review. AJR Am J Roentgenol 2009;193(6 Suppl):S94–101. 2. McPherson ZE, Jung-Yeon Ku J, Chong E, et al. Fibres found in the eye during and after phacoemulsification cataract surgery. Eye (Lond) 2014;28:958–61. 3. Shoaib KK. An enlarging mass due to a retained gauze piece-an unusual complication of dacryocystorhinostomy. Can J Ophthalmol 2011;46:372–3.
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
4. Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229–35. 5. Kohli S, Singhal A, Tiwari B, et al. Gossypiboma, varied presentations: a report of two cases. J Clin Imaging Sci 2013;3:11.
“Tag-Team” Orbital and Strabismus Surgeries with Immediate Reconstruction After Tumor Excision Metastatic to the Inferior Rectus Chris Y. Wu, Steven M. Archer, M.D, and Alon Kahana, M.D., Ph.D Abstract: Carcinoid tumors are rare, slow-growing, lowgrade neuroendocrine tumors with a propensity for orbital metastatic spread. The typical treatment paradigm for localized orbital disease involves excision, adjuvant radiotherapy, and/or receptor-targeted chemotherapy, followed by delayed evaluation for reconstructive strabismus surgery. We present a 58-year-old female patient with carcinoid tumor metastatic to the right inferior rectus muscle who presented with worsening binocular diplopia. The patient underwent coordinated “tag-team” orbital and strabismus surgeries that included excision of the right inferior rectus muscle to the annulus of Zinn followed immediately by reconstructive strabismus surgery. The patient required 1 additional strabismus surgery 1 year later. Follow up revealed no tumor recurrence at 4 years, and excellent binocular vision with good function. Deep orbital and strabismus surgeries, when performed simultaneously in a “tag-team” approach, may offer superior functional outcomes and improved patient quality of life, with expedited functional recovery. This approach may become a new treatment paradigm for surgical disease processes localized to the extraocular muscles.
C
arcinoid tumors are rare neuroendocrine malignancies with a disproportionate propensity for orbital metastasis. The current treatment paradigm of localized orbital carcinoid metastasis to the extraocular muscles involves excision, adjuvant radiotherapy and/or receptor-targeted chemotherapy, followed by delayed evaluation for strabismus reconstructive surgery.1 We present a case of a patient with metastatic carcinoid tumor of the right inferior rectus muscle who underwent immediate reconstructive strabismus surgery after excision.
CASE REPORT Case History. A 58-year-old woman was referred to the Eye Plastic and Orbital Surgery clinic by a general ophthalmologist for Accepted for publication December 11, 2014. Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor, MI The authors have no financial or conflicts of interest to disclose. Institutional Review Board approval was received for this study, IRB# HUM00040783. Address correspondence and reprint requests to Alon Kahana, M.D., Ph.D. Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor, MI. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000399
Case Reports
evaluation of recent-onset diplopia secondary to restrictive strabismus, with concern for Graves’s ophthalmopathy. Review of systems revealed nausea, diarrhea, and shortness of breath. On past medical history, she was treated for carcinoid tumor of the ileum with liver metastasis 6 years prior to presentation, and underwent segmental ileal resection and right hepatectomy with subsequent metastatic recurrence in the left liver lobe, for which she underwent radiofrequency ablation. She had also been treated for Graves’s disease, and was on hormone replacement therapy for iatrogenic hypothyroidism. Ophthalmic Exam and Diagnostics. Visual acuity with correction was 20/20 OU. No deficits noted in pupillary exam or in color vision. Extraocular motility exam revealed limitation of supraduction of the right eye consistent with restriction (Fig. A) and mild hypotropia and esotropia in primary gaze. The rest of the exam was noncontributory. Orbital MRI with gadolinium contrast showed asymmetric enlargement with enhancement of the right inferior rectus muscle (Fig. B). No abnormalities were noted in the other extraocular muscles or optic pathways. Pentetreotide scan with 111Indium labeling showed increased radiotracer uptake in the right inferior orbit (Fig. C), corresponding to the right inferior rectus muscle. Additional uptake was noted in a right periaortic lymph node, left hepatic lobe, left posterolateral T8 vertebral body, and left distal femur, consistent with metastatic disease. Treatment. Following medical and oncologic evaluations, and treatment of her carcinoid syndrome and congestive heart failure, she was taken to the operating room for treatment of her strabismus. From the outset, a coordinated surgical approach was planned between the orbital and strabismus surgeons. The goal was to establish and preserve the surgical planes around the extraocular muscles (strabismus surgeon), perform a combined lateral and inferior fornix orbitotomy for complete excision of the right inferior rectus muscle from origin at the annulus of Zinn to insertion on the globe (orbital surgeon), followed immediately by strabismus surgery which consisted of inferior transposition of the horizontal rectus muscles (inverse Knapp procedure). The inferior pole of the medial rectus muscle was placed to overlap 2 mm with the nasal border of the IR insertion, and inferior pole of the lateral rectus muscle placed 2 mm with the temporal border of the IR insertion; both medial and lateral rectus muscle insertions were kept parallel and concentric with the limbus. No complications were encountered during the operation and blood loss was minimal. Pathology. The surgical specimens showed well-differentiated glandular tumor configuration formed of redundant cells showing a finely stippled chromatin pattern (Fig. F,G). The tumor was confined to the middle segment of the excised inferior rectus muscle (Fig. D). Histopathologic carcinoid features were confirmed by immunohistochemical positivity for Chromogranin A. Postoperative Course. Due to a small right hypotropia in primary position, right hypertropia in reading position and intorsion, a second strabismus surgery was performed 1 year after the initial operation, consisting of a 3.5 mm left inferior rectus muscle resection with a posterior fixation suture and bilateral superior oblique anterior tenotomies. No other operations, strabismus or otherwise, were indicated after additional 3 years of follow-up. The most recent follow-up exam (4 years) was positive for mild limitation of the right eye in up- and down-gaze with diplopia in extreme gazes (Fig. E). The patient was able to fuse in primary gaze at distance and at near with prism glasses. She experienced no metastatic carcinoid recurrences in her orbit and her systemic disease has remained stable on systemic octreotide.
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
e7
