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   Table of Contents      
ARTICLES
Year : 1976  |  Volume : 24  |  Issue : 1  |  Page : 26-31

Lymphoid pseudotumours or pseudolymphomas of the orbit


M.U. Institute of Ophthalmology, Aligarh, India

Correspondence Address:
R Gogi
M.U. Institute of Ophthalmology, Aligarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 1031381

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How to cite this article:
Gogi R, Nath K, Khan A A, Tyagi S P. Lymphoid pseudotumours or pseudolymphomas of the orbit. Indian J Ophthalmol 1976;24:26-31

How to cite this URL:
Gogi R, Nath K, Khan A A, Tyagi S P. Lymphoid pseudotumours or pseudolymphomas of the orbit. Indian J Ophthalmol [serial online] 1976 [cited 2019 Dec 13];24:26-31. Available from: http://www.ijo.in/text.asp?1976/24/1/26/31105

A pseudotumour is an inflammatory lesion of orbital tissue of unknown etiology, clinically simulating an tumour. The term pseudotumour is misleading, as the condition presents quite often as a true tumour though it is an inflammatory mass and not a neoplastic one[5]. Alternatively the term "nonspecific granuloma" has been used[9]. Since the granuloma is characterised by the presence of epithelioid cells and giant cells and such a histological picture is not always present, there­fore, this term is also not correct. Hence, in the absence of an appropriate name and exact etiology of this clinical entity the term pseudo­tumour remains in use[5].

Hartung[11] in 1845 reported the first case of orbital pseudotumour in a suspected case of malignancy. Host ever, the term pseudotumour was introduced by Birch-Hirschfeld[2] in 1905.

Birch-Hirsclhfeld[3] reviewed thirty cases of orbital pseudotumours from the literature. He included some of his own cases and divided them into the following three groups;[4]

(a) Tumours which subsided spontaneously or following medical treatment with potassium iodide, mercury, arsenic or quinine.

(b) Cases of proptosis in which no tumour was found on operation and micro­scopic examination revealed chronic inflammatory tissue.

(c) Cases of proptosis in which an orbital mass was detected, removed and the histological examination revealed a chronic nonspecific inflammatory mass containing diffuse follicular areas.

Thereafter, pseudotumours had been classi­fied in different ways by Dunnington and Berke[8], Hogan and Zimmerman,[12] Reese,[16] and Agarwal et al.[1] However, it was the classical description of Hogan and Zimmerman[12] and Zimmerman[18],[19] which gave the pseudotumours its present status.


  Material and Methods Top


In the present report clinico-pathological features of fifteen cases of lymphoid pseudotumours from a study of one hundred and twenty primary orbital tumours are described. Each case was thoroughly examined and fully investigated. Only histo-pathologically proved cases are included in this article. Macro- and microscopic appearances of these new growths were studied in each case.


  Observations Top


I-Clinical Features

Amongst the fifteen cases, six cases belonged to second decade, three cases each to third and fourth, one to fifth and two cases to sixth decade of life. There were eleven male and four female cases. Apart from protrusion of the eyeball in all the patients, there was history of pain in the orbit (8 cases), gradual diminution of vision (7 cases), watering (5 cases) and ptosis (3 cases). All the cases were uni­lateral and the duration of proptosis varied from three months to two and a half years.

On examination, proptosis was found to be slightly eccentric in eleven cases [Figure - 1],[Figure - 2] and axial in the other four [Figure - 3]. The maximum amount of proptosis was upto 20.0 mm. in one case. All cases manifested increased intraorbital pressure and varying amount of limitation of ocular movements. The tumour mass was palpable in twelve cases. Other features such as diminution of vision (7 cases), defective pupillary reaction (6 cases), lid oedema and chemosis (3 cases), ptosis (3 cases), fund us changes in the form of early papilloedema and corresponding visual field defects were also noted in two cases. On radiological examina­tion there was increased soft tissue shadow in the orbital region in all the cases. Orhito­venogram showed displacement of the first and second parts of superior ophthalmic vein in six cases when the tumour either occupied the upper inner quadrant or roof of the orbit [Figure - 4].

General systemic examination and labora­tory tests were all normal.

The tumour mass was removed in all the cases either by lateral (11 cases) or anterior (1 case), or transfrontal orbitotomy (I case) and in two cases of pseudotumours excision of pseudotumours alongwith enucleation of the eyeball was done. The tumours occupied floor of the orbit (7 cases), upper medial quadrant (3 cases), roof of the orbit (3 cases) and filled whole of the orbit behind the eyeball in two cases

[Figure - 5]. Often the tumours which insinuated in between the orbital tissues were removed in pieces.

II-Pathological Features

(a) Gross appearance : It varied greatly. None of the lymphoid pseudotumours was encapsulated. They were well circumscribed with nodular surface in eight cases [Figure - 6], in another six the mass was irregular without any specific shape [Figure - 7]. In one case there was a small stone impacted in the pseudotumour [Figure - 8]. It was roughly biconvave and measured 6 x 4 x 4 mm [Figure - 9]. On chemical analysis, the stone consisted of calcium, phosphate and carbonate.

Consistency of the tumour mass varied from soft to firm and colour from grey to creamy white or greyish white. Cut surface was homo­genous in all except two cases where the appea­rance was granular.

(b) Microscopic appearance : All the cases were characterized by the presence of lymphoid follicle formation with fibrous tissue prolifera­tion in between [Figure - 10]. In the follicles there were pale and deeply staining areas [Figure - 11]. Dark areas consisted mainly of lymphocytes and pale areas contained a large number of reticulum cells [Figure - 12]. There was no evidence of malignancy. In one case there was no follicle

formation but there was diffuse proliferation of lymphocytes, reticulum cells, polymorph, eosi­nophils and plasma cells without any evidence of malignancy. General systemic examination and haematological investigations did not show anything positive in these cases.


  Discussion Top


More than three-fourths of the cases (12 cases) in the present report have occurred in the second, third and fourth decades. Silva[17] also found these cases to be more frequent under thirty years of age. On the contrary Blodi and Gass[5] reported this to be more during fourth, fifth and sixth decades. Coop[6], and Blodi & Gass[5] observed that the cases are almost evenly distributed in both the sexes, whereas Ingalls[13], and Silva[17] reported that pseudotumours occur almost twice in females. In the present series, males are more commonly affected.

Lid oedema and chemosis was noticed only in three cases whereas diminution of vision and defective pupillary reaction were common find­ings along with the proptosis. Ingalls[13], Coop[6] and Blodi & Gass[5] reported, that oedema of lids and conjunctiva are common clinical findings. The low incidence of changes in the lids and conjunctiva may be due to the fact that our cases reported very late and by that time orbital circulation get adjusted to the new environ­ment. Similarly visual changes are due to deviation of the eyeball with resultant ambly­opia and pupillary changes and as a result of direct pressure by the tumour mass on the nerve fibres.

To distinguish a benign from malignant lymphoid lesion elsewhere in the body, the integrity of the architecture of lymph node is an important criterion. In the orbit, however, lymph nodes are not present and histological distinctions between lymphocytic infiltrations from benign and malignant lym­phatic tumours is often difficult. Perhaps this is the reason that in the past such lesions have been diagnosed as cases of lymphomas or lymphosarcomas by Forrest,[10] Das[7] and Mohan et at[15] Hogan and Zimmerman[12] pointed out that any such lesion of the orbit without any general systemic manifestation and with normal haematological investigations, should be labelled as "Lymphoid Pseudotu­mour". A similar lesion takes place in the lungs and is labelled as "Pseudolymphoma". Liebow et al[14] suggested that the absence of a widespread disease is the best criterion for distinguishing pseudolymphoma from lympho­mas. Further, the former is largely composed of mature lymphocytes and regional lymph nodes are not involved. We feel that this ap­proach of lung pathology can be well adopted for orbital pseudolymphomas, i.e., lymphoid pseudotumours of the orbit.


  Summary Top


In a study of 120 cases of primary orbital tumours, fifteen cases of lymphoid pseudotu­mours have been reported. Clinical and patho­logical features of these lesions have been des­cribed in detail. The term "Pseudolymphomas" in place of lymphoid pseudotumours of the orbit is suggested.

 
  References Top

1.
Agrawal, P. K., Dayal, Y., and Agarwal, L. P. 1967, Orient. Arch. Ophthal., 5, 263.  Back to cited text no. 1
    
2.
Birch-Hirschfeld, A. 1905, Ber. Dtsch. Ophthal. Ges., 32, 127.  Back to cited text no. 2
    
3.
IBID 1915 Graefe-Saemisch Hb. D. ges. Augen­heilk, 2nd Ed., Leipzig. 9 (1). P. 556.   Back to cited text no. 3
    
4.
IBID 1930, Quoted Coop, M.E. (1961).  Back to cited text no. 4
    
5.
Blodi, F.C., and Gass, J.D.M. 1967, Trans. Amer. Acad. Ophthal. Otolaryng., 71, 303.  Back to cited text no. 5
    
6.
Coop, M.E. 1961; Brit. J. Ophthal., 45, 513.  Back to cited text no. 6
    
7.
Das, S.P. 1963; J. All India Ophthal. Soc., 11, 38.  Back to cited text no. 7
    
8.
Dunnington, J.H. and Berke, R.N. 1943; Arch. Ophthal., 30, 446.  Back to cited text no. 8
    
9.
Easton, J.A., and Smith, W.T. 1961, Jour. Path. Bact„ 82, 345.  Back to cited text no. 9
    
10.
Forrest, A.W. 1949, A.M.A. Arch. Ophthal., 41,198.  Back to cited text no. 10
    
11.
Hartung, 1845; Ann. Oculist, Paris, 14, 164.  Back to cited text no. 11
    
12.
Hogan, M.J., and Zimmerman, L.E. 1962; "Ophthalmic Pathology-An Atlas and Text Book", P. 763, W.B. Saunders Company, Phila­delphia and London.  Back to cited text no. 12
    
13.
Ingalls, R.C. 1953, "Tumours of the Orbit and Allied Pseudotumours". Thomas, Springfield, iii, Blackwell Scientific Publications, Oxford.  Back to cited text no. 13
    
14.
Liebow, A.A., Carrington, C.R.B., and Fried­man, P.J. 1972; Hum. Path., 3,457,  Back to cited text no. 14
    
15.
Mohan, H., Sen, D.K., and Gupta, D.K. 1968, Orient. Arch. Ophthal., 6, 271.  Back to cited text no. 15
    
16.
Reese, A.B. 1963, "Tumours of the Eye", Ed. 2nd, P. 538, Hoeber, N.Y.  Back to cited text no. 16
    
17.
Silva, D. 1968, Amer. J. Ophthal., 65, 318.  Back to cited text no. 17
    
18.
Zimmerman, L.E. 1964, Lymphoid tumours. In ocular and adnexal tumours: New and contro­versial Aspects. pp. 429-446. Kimpton, London, Mosby, St. Louis.  Back to cited text no. 18
    
19.
Zimmerman, L.E. 1967, Arch. Ophthal., 78,166  Back to cited text no. 19
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12]



 

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