Orbital and adnexal tumours

Symptoms of orbital and adnexal tumours

1. Bulging Eyes:

The protrusion degree is more than 22mm and the difference of both eyes is greater than 2mm or the degree keeps increasing during the observation period. These are known as pathological bulging eyes. The reasons that lead to eye protruding include tumours, inflammation in eye sockets, Graves disease, vascular malformations and orbital trauma.

2. Prolapse of the Eye:

Orbital pressure increases due to trauma and tumours, so the eyeball protrudes outside eyelids. If eyeballs protrude a lot and with the symptom of eyelid twitch, it will be easy to have prolapse of the eye.

3. Sunken eyeball:

Sunken eyeball could be due to lack of fat tissue around the eyeball, after orbital tumour removal, old age, some blood vessels disease such as orbital varices and following orbital wall fracture.

Real and fake eye cancer

1. Eyelid cancer

Keratoacanthoma and squamous cell epithelioma are both related to prolonged exposure to ultraviolet rays. Since the distribution of skin pigmentation is different, the risk for Asians to have eye cancer is lower than white people. Squamous cell epithelioma is also related to HIV infection.

The typical appearance of both cancers is swollen bump that newly appears on eyelids. The bump grows fast and may develop ulceration. Sometimes it is hard to differentiate, so the tissue may need to be cut and examine in order to confirm the diagnosis and grading. Once it is confirmed, they can be treated by local chemotherapy, radiotherapy and cryotherapy based on the grading.

2. Ocular surface cancer

Both are closely related to gradual damage from ultraviolet rays. Pterygium is a benign chronic degeneration, the typical symptoms are the conjunctiva on the sclera becoming thicker and will become fleshy. The symptoms are not apparent in the early stage. Squamous cell carcinoma is also related to exposure to ultraviolet rays. It is usually not easy to be distinguished with pterygium. However, squamous cell carcinoma can invade the ocular structures and spread through blood vessels and lymphatics, so it must be treated seriously.

The general development of pterygium is slow, but usually in stationary phase. If there is no symptom or the size is smaller than 3mm, it is not needed to be treated, but observation; If it becomes active or the size is larger than 3mm, it is needed to consider receiving treatment.
Generally all pterygium does not need excision or treatment. However, it may cause discomfort to eyes and need to apply eye drops to relieve inflammation and discomfort if pterygium grows larger. If pterygium becomes larger and grows to the central area of cornea, lead to astigmatism and even cover pupils, it may damage visual function, so pterygium removal should be considered. The treatment is safe and effective. Pterygium removal can improve both appearance and astigmatism. For squamous cell carcinoma, it should be removed and sent for histopathological examination to look for margins and base clearance in order to decide further treatment.

3. Intraocular cancer

Both are degradations inside the eyes. There are usually no symptoms in the early stage. However, when it has progressed to the stage that affects visual function, the size of the swollen lump should be quite apparent.
Melanocytic tumor is rarer to be seen. Its typical symptom is to grow black swollen bump in retina and it is usually found in one eye; it is more common to be seen among dark skinned people and females. Melanocytic tumor is often to be grown in optic nerve. This tumour is usually benign, so generally treatment is not needed. However, this tumour can rarely have malignant transformation which requires treatment. If the tumour becomes malignant, radiation therapy or removal surgery should be considered.
Melanoma is malignant which will grow inside the eye, invade retina and vitreous. The malignant tumour cell may even spread to whole body and affect important organs. If melanoma is diagnosed, early treatment is required, so visual function can be retained and the possibility to spread to whole body can be reduced.

Both diseases are common to be seen among children. Parents usually identify them because their children have strabismus and white pupil. Coats' disease is also known as exudative retinitis or retinal telangiectasis. It can lead to decreases in visual acuity and even blindness. Coats' disease usually affects one eye and attacks before 10 years old. Its symptoms include abnormal expansion and growth of capillaries in retina. These will cause a series of symptoms as blood exudates to retina. Radiation therapy or cryotherapy can be considered in the early stage. These therapies can damage the abnormal capillaries in retina in order to prevent the disease from getting worse.

Tumour in the eyeball

Retinoblastoma is most found primary eye tumour among children. It is a malignant tumour grown from the retina. If retinoblastoma is not treated, it will quickly grow towards the retina and may spread to areas outside of the eyeball, follow the optic nerve and transfer to the brain or the whole body. However, treatment should be chosen according to patient’s situation and other conditions such as unilateral or bilateral tumour, residual visual function, the position of the tumour and if it is already spread to optic nerve, the brain or haematogenous spread.

Treatments of eye tumour

Prosthetic eye surgery

The round orbital implant can fill most of the space in the eye socket, then the ocular prosthesis will fill the remain space. The prosthesis is moved with the support of the orbital implant. Orbital implant is made by various materials:

Silicone orbital implant

Hydroxyapatite orbital implant

Porous polyethylene orbital implant

Traditional prosthetic eye surgery

Traditional ocular prosthesis aims at improving patient’s appearance and provide prosthetic eye with flexibility and comfort;
However, there is still limitation in terms of flexibility and comfort.

Modern prosthetic eye surgery

The technique of prosthetic eye surgery is greatly improved that advancement can be seen in every details.
Modern prosthetic eye surgery:
（1）After the orbital implant for 6 to 8 weeks, the patient will wear a temporary ocular prosthesis. The permanent one will be made according to the appearance of the other eye, as well as the size and the socket of the orbital implant.
（2）Then, iris, sclera and even the pattern of blood vessels will be drawn on the ocular prosthesis. It stimulates the appearance of the other eye. The ocular prosthesis will be then polished in order to make it comfortable for the patient and match the appearance of the other eye.
（3）After 2 to 3 weeks, patients can wear the tailor-made ocular prosthesis; local adjustment can be done if it is needed, so the ocular prosthesis looks like the real eye and to be ensure that it is comfortable for the patients who will gain back their confidence.

How to use ocular prosthesis

Steps to wear ocular prosthesis

Wash your hands before wearing it.

Use your thumb and middle finger to hold the ocular prosthesis. The side with marking faces upward. You can also use small rubber sucker to hold it.

Use the other thumb (or the other fingers of the same hand) to pull up the upper eyelid.

Use index finger to fix the ocular prosthesis and release the upper eyelid. Then, slide the bottom part of the ocular prosthesis into the lower eyelid while pulling it downward until it is fixed in appropriate position.

At the same time, prevent the ocular prosthesis rotates

Slide the top part of the ocular prosthesis softly until half of it is covered by the upper eyelid.

Blink your eyes for 2 to 3 times, so the position of ocular prosthesis is fixed.

Steps to remove ocular prosthesis

It is more convenient to remove ocular prosthesis by rubber sucker.

Wash your hands and rubber sucker.

Make the rubber sucker wet by water or sterile solution. Then, put the sucker on top of the ocular prosthesis.

Pull down the lower eyelid until you can see the bottom part of the ocular prosthesis while inclining the rubber sucker upward. The prosthesis can then be slide out over the lower lid

Press the sucker until it is attached firmly and completely on the ocular prosthesis. Then, you can release the rubber sucker.

Rubber sucker is put on the middle of the ocular prosthesis where the iris is. Press it softly, so it attaches the ocular prosthesis.

Press the rubber sucker until the ocular prosthesis is released from the orbital implant.

Note: Put the ocular prosthesis on clean and soft tissue paper after removing it.Avoid touching the ocular prosthesis.

Note: prosthetic implant is a strict medical treatment. It should be tailor made by ocularists with lots of experience according to patient’s eye socket size, appearance and colour of the healthy eye. It is made after accurate calculation. Generally, tailor made eye prosthetic needs to be ordered one day before. Individuals may need extra follow-ups for prosthesis adjustment. If there is no special situation after the implantation, follow-ups generally will be arranged every half year to one year. Since the size of eye socket and the facial shape of children are not mature after the enucleation, their eye prosthesis is needed to be replaced regularly. Therefore, follow-ups are important for them. For adult patients, they require to have adjustment around every 4 to 5 years.

Important note for ocular prosthesis

Ocular prosthesis can create a more natural appearance and fill the eye socket. It can be used for longer time if the ocular prosthesis has often and essential/ necessary care treatment. It can be more comfortable for the patient, look more shiny in appearance, so it has better wearing outcome. Therefore, care treatment is very important for ocular prosthesis. There are a few important notes for ocular prosthesis as below,

Cleaning frequency:

Ophthalmologist will evaluate patients’ eye and discharge condition. Please clean it regularly according to ophthalmologist’s advice;

Saline solution: Contact lens solution or ocular prosthesis cleaner. Alcohol cannot be used;

Steps to clean ocular prosthesis:

1. Clean eyelids and eyelashes regularly. Keep orbital implant clean and hygiene;

2. Wash your hands before putting it into the eye;

3. Apply 2 to 3 drops of saline solution on the ocular prosthesis. Lightly buff the surface. Use warm water to rinse the prosthesis thoroughly and dry it with soft tissue paper. Repeat same steps if there is any sediment on the prosthesis after check.

Additional important note:

1. No need to remove ocular prosthesis everyday;
2. Recommend to wear goggles to protect your healthy eyes;
3. Wear goggles while swimming and having water sports. Ocular prosthesis is needed to be removed while diving, water skiing and scuba diving;
4. Adults guidance is needed for children to prevent swallowing;
5. Consult ophthalmologist as soon as possible and do not continue to wear ocular prosthesis if there is apparent redness, pain or stinky discharge etc.