Orbits, eyelids and lacrimal pathways

Many tumours and pseudotumors (inflammatory disorders) can affect the orbit. Managing these conditions involves multiple medical fields, with Ophthalmology playing a pivotal role. As a Maxillofacial Surgeon, my responsibilities include performing biopsies, tumour removal, orbital decompression, and orbital and eyelid reconstruction.

Orbital tumours and inflammatory diseases do not have specific symptoms. They may manifest as proptosis (eye bulging), eye redness, eye pain, visual impairment, diplopia (double vision), eyelid ptosis, epiphora (constant tearing), headaches or nasal obstruction.

Imaging techniques such as CT scans and MRIs are crucial for evaluation. While fine needle biopsy may provide a faster and more cost-effective means of obtaining a diagnosis and differentiating between benign and malignant orbital masses, a definitive diagnosis often requires an open biopsy, especially for bone, neural tumours, and lymphomas.

The most common types of orbital tumours include:

• Vascular malformations: are benign tumours that frequently involve the orbital tissues. Surgery can be a solution when the lesion causes symptoms. In specific cases, interventional (neuro)radiology may help in vascular diagnostic angiography or therapeutic vascular embolization.
• Mesenchymal tumours: this category encompasses a wide variety of usually benign tumours, such as lipomas. Solitary fibrous tumours within this group are locally aggressive and require removal, although distant metastases are rare.
• Schwannoma or neurilemmomas are benign tumours that originate from neural cells. Asymptomatic cases should be monitored regularly, but surgical intervention is necessary for gliomas and meningiomas, often in collaboration with Neurosurgery.
• Tumours originating from the orbital bone: Benign symptomatic tumours are surgically removed while preserving the eye structure. Malignant cases require prompt and radical excision.
• Lymphoma, particularly MALT lymphomas, are not uncommon and require a biopsy for confirmation. Treatment is managed by a Hematologist using appropriate drugs.
• Eyelid and facial skin tumours can invade the orbit and should be surgically removed. A new drug (vismodegib) enlarges the treatment options for selected patients with unresectable or potentially eye-threatening basal cell carcinoma. Still, its prescription must be approved and directed by an oncology board. Radiotherapy is a valid option for certain orbital-invading skin tumours.
• Lesions originating from the lacrimal sac and nasal sinus can also invade the orbit and should be referred to a surgeon.
• Lacrimal gland tumours: Although rare, these tumours must also be surgically removed.

Graves’ disease involves abnormal thyroid function due to an autoimmune response. Approximately 25% to 30% of individuals with Graves’ disease develop Graves’ orbitopathy, characterized by inflammatory changes in the orbit and eyes. The disease severity ranges from mild and moderate to sight-threatening, with negative impacts on quality of life even in mild and moderate cases.

In Graves’ orbitopathy, there is an abnormal growth of adipose (fat) and muscle tissues within the non-distensible bony cavity of the orbit. This growth leads to proptosis (eye bulging), eyelid retraction, and an inability to close the eyelids properly, resulting in corneal dryness and potential corneal ulcers. Additionally, it can alter light refraction and optical power and increase the risk of severe eye infections.

Muscle dysfunction and misalignment of the eyes may cause double vision. Compression of the optic nerve by the surrounding tissues can lead to vision loss and requires urgent medical and surgical intervention.
Patients with Graves’ disease may also experience other symptoms of hyperthyroidism, such as tachycardia, excessive sweating, diarrhoea, and an enlarged neck.

General recommendations: 

The first and most essential action patients can take is to quit smoking and adopt a healthy lifestyle to reduce cholesterol levels.

Optimal control of thyroid hormones is crucial. Eye ointments with artificial tears and gels alleviate dry eye symptoms. Therefore, prompt consultation with an Endocrinologist and an Ophthalmologist is essential.

Depending on the disease activity and severity, the multidisciplinary medical team may recommend corticosteroid treatment, immunomodulatory drugs, or, in selected cases, radiotherapy.

In sight-threatening Graves’ orbitopathy that does not respond adequately to medication, prompt referral to a surgeon is necessary for orbital decompression to relieve pressure on the optic nerve. Endoscopic approaches through the nose can treat mild cases. Severe ones may require a skin incision to access the lateral (external) orbital wall.

For inactive or stable disease, rehabilitative surgery may include eyelid surgery and orbital decompression.

If you suspect you have Graves’ disease or an orbital tumour, don’t hesitate to contact us for a comprehensive multidisciplinary evaluation.