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BRIEF COMMUNICATION
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 98-100

Angiographic guided sclerotherapy as a treatment modality of an orbital mass


Department of Ophthalmology, Mahatma Gandhi Mission Medical College, Kamothe, Navi Mumbai, Maharashtra, India

Date of Submission05-Mar-2014
Date of Acceptance14-Nov-2014
Date of Web Publication7-May-2015

Correspondence Address:
Saurabh Shrivastava
N-601, Haware Slpendor, Sector 20, Kharghar - 410 210, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.156601

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  Abstract 

We report a case of a 6-year-old child who presented with an orbital mass, in which invasive and non-invasive radiological investigations were used for diagnosis and its subsequent management with angiographic guided intralesional sclerotherapy using 3% sodium tetradeclysulphate. Angiographic guided sclerotherapy prevents accidental injection into major vessel and its extravasation into surrounding tissue. The use of sclerosing agents in the treatment of lymhangiomas of the orbit and other parts of body is known but angiographic guided sclerotherapy in the treatment of a vascular orbital mass is still not well-known.

Keywords: Diagnostic angiography, orbital hemangioma, sclerotherapy


How to cite this article:
Shrivastava S, Ramakrishnan R, Agrawal AS, Loomba A, Patel C. Angiographic guided sclerotherapy as a treatment modality of an orbital mass . J Clin Ophthalmol Res 2015;3:98-100

How to cite this URL:
Shrivastava S, Ramakrishnan R, Agrawal AS, Loomba A, Patel C. Angiographic guided sclerotherapy as a treatment modality of an orbital mass . J Clin Ophthalmol Res [serial online] 2015 [cited 2022 Jun 28];3:98-100. Available from: https://www.jcor.in/text.asp?2015/3/2/98/156601

Hemangiomas are benign congenital tumors comprising of proliferating endothelium and are the most common tumor of infancy with incidence of 3-12%. [1] Angiographic guided sclerotherapy in the treatment of a vascular orbital mass is still in its primitive stage, but we have known the use of sclerosing agents in the treatment of lymhangiomas of the orbit and other parts of body. We report a case of an orbital mass in which invasive and non invasive radiological investigations helped us reach a confirmed diagnosis and its subsequent management with angiographic guided intralesional sclerotherapy.


  Case Report Top


A 6-years-old male child presented to us with a swelling in the left upper lid noticed since 3 months. The mass was small to begin with, a size of a pea, which progressively increased to present size 2.5 × 1 cm [Figure 1]. Patient complaint of bluish discoloration of the skin above the mass. Patient did not complaint of diminution of vision or pain associated with the mass. There was no associated significant history of trauma or any past surgery done. There was no history of any systemic illness or any congenital abnormality.

On examination the visual acuity was 6/6 both eyes. There was a well-localized swelling measuring 2.5 × 1 × 1 cm in the left upper eyelid extending posteriorly into supero-medial quadrant of the orbit. Swelling was soft and cystic in consistency. Fluctuation was positive and transillumination negative. It showed no impulse on coughing or bending forward. No bruit or thrill was found. Swelling was not reducible. Eyes were orthophoric with full and free extra ocular movements. Moderate mechanical ptosis was present There was bluish discoloration of the skin above it. A contrast magnetic resonance imaging (MRI) was done to see its posterior extension and a provisional diagnosis was made of a cavernous hemangioma or arterio-venous malformation communicating with superior ophthalmic vein. Contrast computed tomography (CT) scan [Figure 2], [Figure 3], [Figure 4] and ultrasonography (USG) B scan were also done. All the routine investigations like complete blood count, serum electrolytes, liver function test, renal function test, urine routine and microscopy, coagulation profile, serology, X-ray chest were done. USG abdomen was also done to rule out visceral and cutaneous hemangiomas. Pediatric consultation was done and any congenital, cardiovascular or bony abnormalities were ruled out. We planned for a digital subtraction diagnostic angiography to see if the mass had any communication with a vein or an artery. A radio opaque dye (Iohexol) was injected through the femoral vein [Figure 5] which showed an isolated swelling in the supero medial quadrant of the orbit without any communication with a major vessel. The dye was then injected into the mass delineating the mass [Figure 6]. After confirmation of the diagnosis as an isolated vascular mass, angiographic guided puncture and subsequent injection of 3 cc 3% sodium tetradecylsulphate (sclerosing agent) was given into the mass [Figure 7].
Figure 1: Swelling in the left upper lid at presentation

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Figure 2: Contrast CT Scan showing the orbital mass

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Figure 3: Contrast CT Scan showing isolated orbital mass

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Figure 4: Contrast CT Scan showing posterior extension of the mass into the supero- medial quadrant of the orbit

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Figure 5: Dye in the arterial system

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Figure 6: Dye delineating the mass

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Figure 7: Sclerosing agent into the mass

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The capillary hemangioma reduced in size one week post operatively to measure 1.5 × 0.5 × 0.5 cm [Figure 8]. A second dose of the sclerosant, repeating the same procedure was injected in the mass after 6 weeks.
Figure 8: Swelling post intervention

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Post operatively the child is doing well with significant decrease in the mass size. Patient has completed the whole course of treatment and is under regular follow-up every 3 months for 9 months.


  Discussion Top


Vascular lesions of the orbit may be classified on the basis of their natural history, growth pattern and histologic composition as capillary hemangiomas, venous vascular malformations, venous lymphatic malformations, arterial and arteriovenous lesions or neoplasms. Most follow a characteristic pattern of clinical development, and have one or more specific imaging features that allow diagnosis. Hemangioma typically manifest at or soon after birth and subsequently involutes, they are non encapsulated, poorly circumscribed, lobulated and largely extraconal in location. [2] Direct intralesional injection of a sclerosing agent is established as treatment of choice for low-flow malformations. The sclerosing agent causes a slugging of erythrocytes and a rapid subsequent thrombosis of the injected vessels followed by fibrosis within several weeks. There is also an initial peri vascular inflammatory reaction. Several sclerosing agents are available, most commonly used are hypertonic saline, 3% sodium tetradecylsulfate, polidocanol, and chromate glycerin. Sodium tetradecylsulfate is a mild sclerosing agent that has been used for both head and neck and orbital malformations. [3] The role of sclerotherapy in treatment of vascular swelling of the orbit is still not well-reported. Angiographic guided sclerptherapy prevents accidental injection into major vessel and its extravasation into surrounding tissue thus making the treatment safe and effective.

 
  References Top

1.
Vaidya S, Cooke D, Kogut M, Stratil PG, Bittles MA, Sidhu M. Imaging and percutaneous treatment of vascular anomalies. Semin Intervent Radiol 2008;25:216-33.  Back to cited text no. 1
    
2.
Smoker WR, Gentry LR, Yee NK, Reede DL, Nerad JA. Vascular lesions of the orbit: More than meets the eye. Radiographics 2008;28:185-204.  Back to cited text no. 2
    
3.
Ernemann U, Westendorff C, Troitzsch D, Hoffmann J. Navigation-assisted sclerotherapy of orbital venolymphatic malformation: A new guidance technique for percutaneous treatment of low-flow vascular malformations. AJNR Am J Neuroradiol 2004;25:1792-5.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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