eMedicine Specialties > Ophthalmology > Orbit

Hemangioma, Cavernous

Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota; David A Weinberg, MD, FACS, Director, Oculoplastic and Orbital Surgery, Assistant Professor of Neurology and Ophthalmology, Department of Surgery, Division of Ophthalmology, Fletcher Allen Health Care

Updated: May 13, 2009

Introduction

Background

Cavernous hemangiomas are the most common intraorbital tumors found in adults. These benign, vascular lesions are slow growing and can manifest as a painless, progressively proptotic eye. Most of these tumefactions are exceedingly unilateral. Bilateral cases have been reported but are rare.

Pathophysiology

Orbital cavernous angiomas can increase intraorbital volume with a resultant mass effect. Although cavernous hemangiomas are histologically benign, they can encroach on intraorbital or adjacent structures and can be considered anatomically or positionally malignant. Visual acuity or field compromise, diplopia, and extraocular muscle or pupillary dysfunction can result from compression of intraorbital contents by the angioma. Lagophthalmos can result in exposure keratopathy, keratitis, and corneal perforation.

Frequency

International

Henderson reported an incidence of 4.3% among orbital neoplasms.¹

Mortality/Morbidity

The morbidity associated with cavernous hemangiomas is the threat of compressive optic neuropathy, extraocular muscle dysfunction, and cosmetic disfigurement.

Mortality can result from intraoperative complications, such as bleeding and the risk of general anesthesia.

Race

No predilection exists for race or ethnicity.

Sex

Harris and Jakobiec found a 7:3 occurrence ratio of women to men, while Henderson reported an almost equal ratio, 8:7 in women and men.^2,1

Age

Patients usually manifest symptomatically during the third to fifth decades of life.

Clinical

History

Patients who present with clinically significant cavernous hemangiomas usually are middle-aged. Some of the more salient clinical symptoms are listed below.

• Patients commonly describe a painless, slowly progressive protrusion or bulging of their globe accompanied by mild eyelid fullness.
• A change in visual acuity secondary to induced hyperopia or reduction of the myopic refractive error can result from an anteriorly directed mass effect. In some cases, a compressive optic neuropathy can be the etiological basis for the visual acuity or field disturbance.
• Extraocular muscle dysfunction and the resultant diplopia secondary to extraocular muscle impingement can cause a patient to seek consultation.
• Some patients may describe the feeling of something next to or behind their eye and describe swelling or fullness of their upper lid.
• Rarely, a patient harboring a cavernous angioma may describe gaze-evoked amaurosis fugax or headache.
• Zauberman and Feinsod described a pregnancy-induced increase in symptomatology.³

Physical

Performing a complete ophthalmologic examination on patients is beneficial.

• As with any examination, a thorough history and review of symptoms is paramount in formulating a comprehensive list of differential diagnoses.
• Examination of patients should commence with an observation of facial features, noting any asymmetry or scarring. Palpation of the lids and globes allows one to assess differences in lid fullness and increased resistance to retropulsion. Hertel exophthalmometry can detect axial proptosis and should be documented for comparison on follow-up visits.
• Visual and color acuities, as well as visual fields, should be assessed, followed by testing of pupillary and extraocular muscle function. Decreased color vision, visual field deficits, and relative afferent pupillary defects warrant immediate imaging to rule out a compressive optic neuropathy. Additionally, any extraocular motility disturbance should be quantitated with prismatic measurements.
• Rarely, slit lamp or penlight evaluation may find dilated and tortuous epibulbar vessels, an epibulbar cherry-red spot, or a darkening over insertions of extraocular muscles.
• Dilated funduscopic examination may elucidate choroidal folds secondary to compression of the globe by the mass. If the tumefaction is in close proximity to the optic nerve, visible changes may include edema, elevation, pallor, and even atrophy in severe cases.

Differential Diagnoses

Other Problems to Be Considered

Fibrous histiocytoma
Hemangiopericytoma
Neurolemmoma

Workup

Imaging Studies

• CT scan detects an oval or round shaped, sharply marginated, homogenous lesion. Uptake of contrast medium by this tumefaction is highly variable and has limited diagnostic value. Computerized tomography should not be solely relied upon since it does not allow one to make a definitive diagnosis.
• Ultrasound study can find a uniform high-echogenicity on A-scan. These reflections are secondary to the septae found within the lesion. Doppler flow study may reveal subdued blood flow within the angioma.

Histologic Findings

Histopathologic study finds engorged vascular channels, which are tightly knit and separated by fibrous septae. These channels can have diameters measuring 1 mm and are lined by a single layer of endothelial cells.

Treatment

Surgical Care

Most cavernous angiomas require no intervention. If surgical extirpation is indicated, the surgical approach to the orbit is dictated by tumor location within the orbit.

• Most cavernous angiomas are found between the optic nerve and extraocular muscles within the intraconal space. A lateral orbitotomy, or a variant thereof, is a typical approach. Tumefactions within the medial aspect of the orbit are approached best through an upper eyelid or a transcaruncular-based medial orbitotomy.
• After adequate exposure, a well-circumscribed, purple, encapsulated lesion is seen with distinct vessels on its surface. Gentle blunt dissection allows for en-bloc removal after all vessels have been identified and cauterized with bipolar cautery.
• The cryoprobe allows for removal of well-circumscribed lesions, reducing the incidence of capsular rupture and bleeding, making it an ideal tool for hemangioma extirpation. A disadvantage of the cryoprobe is that adjacent orbital structures also may be frozen, as is the case with deep orbital tumors.
• Use of the carbon dioxide laser or Nd:YAG laser is another modality for the surgeon faced with the task of tumor removal.

Consultations

If the cavernous hemangioma has an intracranial component or extends to facial structures outside the orbit, neurosurgical or otolaryngologic consultation should be sought.

Follow-up

Further Outpatient Care

• Most patients with cavernous hemangiomas can be observed clinically with semiannual or annual formal visual field testing and dilated funduscopic examinations.

Complications

• Complications are related to the angiomas mass effect within the orbit. Axial proptosis, extraocular muscle dysfunction, and compressive optic neuropathy are the sequelae that can transpire secondary to enlarging cavernous hemangiomas.

Prognosis

• Most cavernous hemangiomas remain stable throughout a patient's life and cause no visual compromise.
• If surgical intervention is warranted, most lesions excised in the hands of an experienced surgeon have an excellent prognosis and result in a low morbidity. There is no recurrence following excision or risk of malignant transformation.

Patient Education

• Patients should have a clear understanding of the immediate need for follow-up care if a visual disturbance occurs or if proptosis increases significantly.

Miscellaneous

Medicolegal Pitfalls

• Documentation of the patient's understanding for immediate follow-up care if visual compromise or diplopia occurs is prudent.

Multimedia

Media file 1: Extirpation of an orbital cavernous hemangioma. Note en bloc removal and preservation of capsule. Courtesy of Robert Alan Goldberg, MD.

Media file 2: MRI demonstrates enhancing mass in apex of left orbit. White arrow points to the superior portion of the optic nerve, showing its deviation. Mass was pressing on superotemporal optic nerve and displacing it inferomedially at apex. Patient had 6 months of progressive decreased vision and visual field loss. Courtesy of M. Duffy, MD, PhD.

Media file 3: In A, final preoperative visual field of same patient as in Media file 2, demonstrating significant inferior altitudinal field loss; in B, postoperative visual field at approximately 3 weeks after orbital apex decompression and removal of mass; and in C, postoperative visual field at approximately 6 months.

Media file 4: Intraoperative photo of same patient as in Media file 2. Neurosurgical service performed craniotomy and decompression of the superior orbital fissure and optic canal (yellow arrows) at request of ophthalmology service. Orbital surgery service then opened the periorbita over a bulge (double black arrows) between optic nerve and cranial nerves (single black arrow) and bluntly dissected out mass. Pathology confirmed mass as a cavernous hemangioma. Cranial nerves V and IV were adhered, and careful blunt separation was performed. Postoperatively, a small left hypertropia resolved over 6 weeks. Courtesy of M. Duffy, MD, PhD.

References

1. Henderson GW. Vascular hamartomas, hyperplasias, and neoplasms. In: Henderson GW, ed. Orbital Tumors. New York: Raven Press; 1994:94-100.

2. Harris GJ, Jakobiec FA. Cavernous hemangioma of the orbit: a clinicopathologic analysis of sixty-six cases. In: Jakobiec, ed. Ocular and Adnexal Tumors. Birmingham, Ala: 1978:741-81.

3. Zauberman H, Feinsod M. Orbital hemangioma growth during pregnancy. Acta Ophthalmol (Copenh). 1970;48(5):929-33. [Medline].

4. Dortzbach RK, Kronish JW. Orbital disease. In: Dortzbach RK, ed. Ophthalmic Plastic Surgery Prevention and Management of Complications. New York: Raven Press; 1994:312-25.

5. Harris GJ, Jakobiec FA. Cavernous hemangioma of the orbit. J Neurosurg. Aug 1979;51(2):219-28. [Medline].

6. Mercandetti M, Cohen AJ. Exophthalmos. eMedicine Journal [serial online]. February 7, 2007;Available at http://www.emedicine.com/oph/topic616.htm.

7. Mercandetti M, Cohen AJ. Tumors, orbital. eMedicine Journal [serial online]. February 7, 2007;Available at http://www.emedicine.com/oph/topic758.htm.

8. Rodgers IR, Grove AS. Vascular lesions of the orbit. In: Principles and Practice of Ophthalmology. Philadelphia: WB Saunders; 1994:1970-1.

9. Shields JA, Shields CL. Vascular and hemorrhagic lesions. In: Atlas of Orbital Tumors. Philadelphia: Lippincott, Williams and Wilkins; 1999:50-56.

10. Yan J, Wu Z. Cavernous hemangioma of the orbit: analysis of 214 cases. Orbit. Mar 2004;23(1):33-40. [Medline].

Keywords

cavernous hemangioma, cavernous angiomas, orbital cavernous angiomas, vascular lesions, intraorbital tumors, protrusion, bulging

Contributor Information and Disclosures

Author

Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society
Disclosure: Nothing to disclose.

David A Weinberg, MD, FACS, Director, Oculoplastic and Orbital Surgery, Assistant Professor of Neurology and Ophthalmology, Department of Surgery, Division of Ophthalmology, Fletcher Allen Health Care
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

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