Posterior exam: Remarkable for congested and tortuous vessels OS
Figure 3: Fundus photos. Left eye vessels are congested and tortuous.
Differential Diagnosis
Benign growths (e.g. hemangioma)
Malignancies (e.g. lymphoma)
Idiopathic orbital inflammatory syndrome
Infectious (e.g. orbital abscess)
Cysts (e.g. mucocele)
Additional Investigations
Figure 4: CT scan. Left mass measures 3cm in diameter. Smaller mass is present in the right posterior ethmoid sinus. Mass effect is evident in the left orbit, affecting the medical rectus, inferior muscles as well as the optic nerve.Figure 5: MRI orbit, T2 axial. Left mass is uniform in texture, well contained within regular borders. Signal characteristics most consistent with mucocele. There is appreciable axial displacement of left globe.
Diagnosis
Ethmoid sinus mucocele
Pathophysiology
Benign cysts lined with ciliated columnar epithelial cells that secrete mucous
Typically occurs in 3rd to 4th decades of life
Commonly due to obstruction of sinus ostium ventilation (e.g. inflammation, allergy, trauma, mass, idiopathic)
65 percent frontal sinus, 30 percent ethmoidal sinus and 1-10 percent maxillary or sphenoid sinus
Treatment
Surgical evacuation
Figure 6: Surgical evacuation. Top left: mucocele wall. Top right: initial incision showing immediate drainage of mucopurulent material. Bottom left: mucocele evaculation. Bottom right: mucocele wall biopsy.
Biopsied left middle turbinate and mucocele wall: chronic inflammation. No significant eosinophils, fungal organisms or malignancy
After opening up the mucocele endoscopically and removing a lot of the lining of the mucocele, the eye and orbit was “pushed” externally to aid in evacuation of the mucocele
Watch a clip of the procedure below:
Prognosis and Future Directions
Post-op week 2: visual acuity now baseline at 20/25 OD, 20/25 OS
We expect long-term good prognosis for this patient
Figure 7: Post-op week 2. Proptosis OS resolved. Extraocular motility intact in both eyes.
References
Khan, S., Sepahdari, A.R. (2012) Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies Saudi J Ophthalmol. 26(4):373-383
Iannetti, G., Cascone, P., Valentini, V., Agrillo, A., 1997. Paranasal sinus mucocele: diagnosis and treatment. J Craniofac Surg 8, 391-398
Iliff, C.E., 1973. Mucoceles in the orbit. Arch. Ophthalmol. 89, 392-395
Loo, J.-L., Looi, A.L.-G., Seah, L.-L., 2009. Visual outcomes in patients with paranasal mucoceles. Ophthal Plast Reconstr Surg 25, 126-129.
Kim, Y.-S., Kim, K., Lee, J.-G., Yoon, J.-H., Kim, C.-H., 2011. Paranasal sinus mucoceles with ophthalmologic manifestations: a 17-year review of 96 cases. Am J Rhinol Allergy 25, 272-275.
Contact
Sandy Zhang-Nunes, MD, Assistant Professor of Clinical Ophthalmology; Director, Oculofacial Plastic Surgery Service, sandy.zhang-nunes@med.usc.edu
