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CASE REPORT  
Year : 2011  |  Volume : 4  |  Issue : 1  |  Page : 45-47
Extended lateral orbitotomy, an effective procedure to excise large orbital hydatid cyst: A rare case


1 Department of Ophthalmology, I.G.M.C. Shimla, Himachal Pradesh, India
2 Department of Neurosurgery, I.G.M.C. Shimla, Himachal Pradesh, India

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Date of Web Publication7-May-2011
 

   Abstract 

Echinococcosis is an infection of humans by the larval stage of Echinococcus granulosus, Echinococcus multilocularis or Echinococcus vogeli. Orbital hydatid cyst is extremely rare and has an incidence of 1% of all the hydatid cysts. We report a case of a 6-year-old boy presenting with a large orbital hydatid cyst causing abaxial proptosis with compressive optic neuropathy and a cyst in the liver. The cyst was successfully removed from the orbit through a combined anterio-superior trans-periosteal lateral orbitotomy. Following surgery, there was immediate reduction of proptosis and healing of exposure keratopathy. The role of computerized tomography (CT) scan in early diagnosis and advantages of the lateral orbitotomy approach are discussed.

Keywords: Hydatid cyst, Lateral Orbitotomy, Orbit

How to cite this article:
Sharma RL, Thakur RC, Sud C, Sareen A. Extended lateral orbitotomy, an effective procedure to excise large orbital hydatid cyst: A rare case. Ann Trop Med Public Health 2011;4:45-7

How to cite this URL:
Sharma RL, Thakur RC, Sud C, Sareen A. Extended lateral orbitotomy, an effective procedure to excise large orbital hydatid cyst: A rare case. Ann Trop Med Public Health [serial online] 2011 [cited 2018 Aug 15];4:45-7. Available from: http://www.atmph.org/text.asp?2011/4/1/45/80536

   Introduction Top


Hydatid cyst is the larval stage of Echinococcus granulosus, Echinococcus multilocularis or Echinococcus vogeli, a dog tape worm. Although it has a worldwide distribution, it is most commonly found in those countries where sheep and cattle are reared simultaneously. The cysts are commonly found in liver and the lungs but the larvae may spread to various parts of the body like brain, bones, orbit, [1] etc. The route of spread to these sites is mainly hematogenous. Orbital hydatid cyst is rare and has an incidence of 1% of all the hydatid cysts. [2],[3] The most frequent clinical findings of orbital cysts are exophthalmos, chemosis, lid edema, visual impairment and restriction of ocular motility. [4] Ultrasonography reveals a circumscribed cystic structure and computerized tomography (CT) scan shows a cyst of water having cerebrospinal fluid density. [5]


   Case Report Top


A 6-year-old boy presented with painless progressive protrusion of left eye for 3 months. It was associated with diminution of vision in the left eye. There was coincidental history of blunt trauma head, 1 year prior to the onset of this illness.

The general physical examination was normal. The visual acuity in the left eye was hand movement and in the right eye, it was normal. The consensual pupil reactions in the right eye and direct reactions in the left eye were sluggish. The left eye was proptosed with the eyeball protruding downward and laterally. The distance of apex of cornea from lateral orbital margin was 28 mm in the left eye and 17 mm in the right eye on Hertel's exophthalmometry [Figure 1]. There was no palpable thrill or bruit; neither the proptosis increased on straining. Ocular movements were restricted and there was lagophthalmos with incomplete closure of the eye. The left cornea had features of exposure keratitis in the inferior part. Fundus examination of the left eye showed optic disc pallor and attenuation of retinal vessels.
Figure 1: Photograph of patient at presentation, showing abaxial proptosis and exposure keratitis

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The X-rays of the skull and paranasal sinuses were normal. The ultrasonography of orbit showed a well-defined hypoechoic cystic mass in left retrobulbar area with clear contents. Computerized axial tomography of orbits (plain and contrast) confirmed the cystic nature of the mass measuring 3.1 × 2.1 cm, involving left retrobulbar region and pushing the eyeball anteriorly and inferiorly [Figure 2] and [Figure 3]. There was minimal enhancement of the cyst wall after contrast. There was evidence of gliosis in left parietal lobe due to old head trauma but no cyst. The blood profile showed mild leukocytosis and chest X-ray was normal. Abdominal ultrasonography showed a well-defined cystic mass measuring 4.5 × 3.1 cm, occupying left lobe of the liver. The enzyme-linked immunoassay (ELISA) test for hydatid disease was positive with a value of 0.667.
Figure 2: Photographs of CT showing the large orbital hydatid cyst occupying almost whole of the orbit and pushing the eyeball out of the orbit

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Figure 3: Photographs of CT showing the large orbital hydatid cyst coronal section

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The child was put on oral Albendazole (400 mg BD) and surgical excision was planned under general anesthesia through an extended lateral orbitotomy approach (the incision extended anteriorly till the middle of eye brow) because the size of cyst was large. Peroperatively, the cyst was outside the muscle cone but extending medially. The pericyst had a thick wall and was firmly adherent to the surrounding structures including the lateral rectus muscle. The clear fluid of the cyst was aspirated using a 23-gauge needle and through the same needle, a scolicidal solution (0.5% Cetrimide) was injected. On incising the pericyst, a bilobed cyst [Figure 4] with pearly white, shiny wall was isolated and removed, taking care to prevent any spillage of the cyst contents and any injury to the optic nerve. The daughter cyst was seen within the cyst, suggesting the diagnosis of hydatid cyst, which was confirmed later on histopathology.
Figure 4: Intraoperative photograph showing hydatid cyst along with daughter cyst being removed through lateral orbitotomy

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A drain was placed in the residual orbital cavity and a loose tarsoraphy suture was applied to prevent exposure keratopathy and to reposition the globe into the orbit. Postoperatively, the child was put on oral Prednisolone (1.5 mg/kg) and systemic antibiotics along with Albendazole (400 mg BD) for 2 weeks. The proptosis resolved and ocular movements recovered almost completely after 2 weeks. [Figure 5]. Because the patient already had features of early optic atrophy at the time of presentation, visual recovery was counting fingers at 2 ft on 3 months and remained the same at 1 year follow-up.
Figure 5: Postoperative photograph after 6 months

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   Discussion Top


Hydatid disease is commonly seen in endemic areas but orbital involvement is rare, with only 1% of the cases involving the orbit. [2],[3] A detailed study conducted on central nervous system hydatidosis in Turkey by Altinors et al. revealed that 22 of 336 cases had orbital cyst. [6] An orbital hydatid cyst may be intraconal in location or may lie outside the muscle cone either superomedially or superolaterally. [2]

Hydatid disease of the orbit is often associated with significant morbidity. The complications are generally related to proptosis and compressive effects of enlarging cyst on orbital contents. The main complications are optic atrophy and exposure keratitis as was seen in this case due to the delayed presentation. The diagnosis can be made easily with the help of investigations like ultrasonography and CT scan. [7]

Definitive treatment of orbital hydatid cyst is complete surgical excision. Two main routes to expose the intraorbital lesion have been described - transcranial and extracranial. The transcranial approach is suitable for lesions with intracranial extension and superior lesions extending behind the optic nerve. Ahmet Selcuklu et al. have reported removal of intraorbital hydatid cyst located within the muscle cone inferiorly through a trans-maxillary approach. [8] The lateral orbital approach is the procedure most commonly used to treat intraorbital lesions located in the lateral compartment of the orbit, such as lacrimal gland tumors. Arai et al. [9] recommended the use of the lateral orbital approach for lesions located inferolaterally to the optic nerve, but they stressed that the ciliary ganglion and its nerve roots could be easily damaged. The lateral rectus muscle must be retracted, and this maneuver can cause lateral gaze palsy. Removal of the lateral wall of the orbit could result in endophthalmos or exophthalmos with mastication. Forehead movement palsy can develop if the frontal branch of the facial nerve is transected. In this patient, the cyst was occupying almost whole of the orbit. The standard lateral orbitotomy incision was extended in a curved manner to the lateral one-third of the eye brows anteriorly to enhance the exposure. This approach was effective in removing the large hydatid cyst which was extending medial to the optic nerve and there were no complications as described above because extensive dissection was not done as cyst was deflated before removal. Albendazole is a useful adjuvant therapy to prevent relapse and to cure other systemic hydatid cysts as was followed in the present case who had small hydatid cyst of liver as well.

We conclude that ultrasonography and CT scan of orbit are important tools for diagnosis of orbital hydatid cyst and surgical excision through the extended lateral orbitotomy approach is an effective modality for the treatment of such large hydatid cyst of the orbit.

 
   References Top

1.Braunwald E, Fauci, Kasper DL, Hauser SL, Longo DL, Jameson JL: Cestodes. In: Harrison's Principles of Internal Medicine.New York: 15 th ed. McGraw-Hill Medical Publishing Div; p 1248-1251   Back to cited text no. 1
    
2.Gomez MA, Craxatto JO, Cravetto L, Ebner R. Hydatid cyst of the orbit. A review of 35 cases. Ophthalmology 1988;8:1027-32.  Back to cited text no. 2
    
3.Ergün R, Ökten A, Yüksel M, Gül B, Evliyaoðlu C, Ergüngör F, Taþkýn Y. Orbital hydatid cysts: Report of four cases. Neurosurg Rev 1997;20:33-7.  Back to cited text no. 3
    
4.Sami A, Achouri M, Harouch M, Choukry M, Ouboukhlik A, Elkamar A, et al. Intra-orbital hydatid cysts 10 cases. Neurochirurgie 1995;41:398-402.   Back to cited text no. 4
    
5.Kars Z, Kansu T, Ozcan OE. Orbital echinococcosis: Report of two cases studied by computerised tomography. J Clin Neuroophthalmol 1982;2:197-9.  Back to cited text no. 5
    
6.Altinörs N, Bavbek M, Caner HH, Erdogan B. Central nervous system hydatidosis in Turkey: A cooperative study and literature survey analysis of 458 cases. J Neurosurg 2000;93:1-8.   Back to cited text no. 6
    
7.Alparslan L, Kanberogðlu K, Peksayar G, Çokyüksel O. Orbital hydatid cyst: Assessment of two cases. Neuroradiology 1990;32:163-5.  Back to cited text no. 7
    
8.Selçuklu A, Öztürk M, Külahlý I, Doðan H. Successful surgical management of an intraorbital hydatid cyst through a transmaxillary approach. Skull Base 2003;13:101-5.  Back to cited text no. 8
    
9.Arai H, Sato K, Katsuta T, Rhoton AL Jr. Lateral approach to intra-orbital lesions: Anatomic and surgical considerations. Neurosurgery 1996;39:1157-63.  Back to cited text no. 9
    

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Correspondence Address:
Ram Lal Sharma
Department of Ophthalmology, I.G.M.C. Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.80536

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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