|Year : 1977 | Volume
| Issue : 1 | Page : 5-10
R Gogi, K Nath
A. M. U. Institute of Ophthalmology, Aligarh, India
A. M. U. Institute of Ophthalmology, Aligarh
|How to cite this article:|
Gogi R, Nath K. Orbital pseudotumours. Indian J Ophthalmol 1977;25:5-10
Pseudotumours are diverse space occupying lesions clinically manifesting as neoplasias. The term pseudotumour was coined by BirchHirchfeld in 1905.  Garner  has reviewed this controversial subject by accepting the classification of Hogan and Zimmerman.  There is probably no subject in ophthalmic pathology so confusing, even in hands of experienced pathologists, than the lymphoid tumours and lymphoid pseudotumours of the orbit. ,,, Gogi et a1  reviewing the clinicopathological features in fifteen cases or lymphoid pseudotumours stressed the general systemic examination, haematological investigation and lymph node biopsy to differentiate between lymphomas and benign lymphoid pseudotumours. The term "pseudolymphoma" in place of "lymphoid pseudotumour" was also suggested. 
Apart from lymphoid group there is another group of pseudotumours that covers a variety of chronic inflammatory lesions.  In the present paper thirteen such cases are presented that clinically simulated a neoplasm but histologically were classified as pseudotumours.
| Material and Methods|| |
In a consecutive study of 120 primary orbital tumours studied at A.M.U. Institute of Ophthalmology Aligarh, thirteen cases of non-lymphoid pseudotumours were diagnosed histopathologically. Detailed observation on these cases appear below.
| Observations|| |
1. Clinical Features
Maximum number of cases belonged to first decade (5 cases) followed by three each in the third and fourth decades and two in the fifth. There was history of slowly progressive protrusion of the eyeball, the duration varied from six months to one year. This was associated by pain (6 cases), diplopia (5 cases) and diminution of vision (1 case). There was history of dull aching pain behind the eyeball in all the cases.
On examination eccentric proptosis [Figure - 1],[Figure - 2] varying from 4.0 to 9.0 mm, presented in all the cases. Markedly increased intraorbital pressure with a varying degree of limitation of ocular movements was also present. Swelling could be palpated in 10 cases. There was diminution of vision (1 case), defective pupillary reactions (2 cases), chemosis and lid oedema (2 cases). General systemic examination, radiological examination and laboratory tests did not suggest any systemic disease. In to elve cases the tumour was taken out either through lateral orbitotomy (8 cases) or anterior orbitotomy (4 cases). In one case the diagnosis was made entirely on the basis of needle biopsy. All the tumours were subjected to gross and histopathological examination.
2 Pathological Features
On the basis of histological diagnosis following six types of lesions were seen [Table - 1].
(a) Orbital Myositis (3 cases)
In two cases the tumour mass was greyish white, firm in consistency and measured 2.7x2.0 x 1.5 cm [Figure - 3] and 2.0x1.5xl.0 cm. In the third case it vas a soft firm white mass. On microscopic examination, there was lymphocytic infiltration of muscle fibres with follicle formation [Figure - 4]. There were few plasma cells but adjacent orbital tissues were normal.
(b) Tuberculosis like lesions (3 cases)
In two cases the tumour masses measured, 2.0 x 1.0 x 1.0 cm and 1.5 x 1.5 x 1.0 cm while in the third case only needle biopsy was taken. The masses were firm in consistency and cut surface was homogeneously white [Figure - 5]. Histopathology revealed the presence of epithelioid cells lymphocytes and Langhan's type of giant cells [Figure - 6],[Figure - 7] however, the caseation was absent.
(c) Sarcoid like lesion (3 cases)
In all cases the circumscribed mass was covered by thin fibrous capsule the size which varied from 2.0 x 1.0 cm [Figure - 8] to 2.5 x 1.5 x 1.0 cm. Histology consisted of noncaseating aggregations of ephitheliod cells, surrounded by fibrous tissue. The giant cells were centrally placed with numerous nuclei and minimal lymphocytic infiltration [Figure - 9].
(d) Foreign body granulomas (2 cases)
The mass measure 1.5 x 1.0 x 1.0 cm and 2.0 x 1.Ox 1.0 cm. These were soft, friable and greyish white in colour [Figure - 10]. The tumour comprised of loosely placed epithelioid-cells, lymphocytes, few plasma cells and numerous foreign body type of giant cells containing a number of nuclei varying from three to forty [Figure - 11].
(e) Plasma cell pseudotumour (1 case)
In one case an irregular greyish mass was found. There was marked infiltration by plasma cells with a few lymphocytes [Figure - 12].
(f) Chronic Dacryoadcnills (1 case)
In one case a small mass measuring 1.0 x 1.0 x 0.5 cm was recovered from lacrimal gland area. On histopathology, there were numerous gland ductules with intense lymphocytic and few plasma cell infiltration [Figure - 13],[Figure - 14]. Similarly the adjacent lacrimal gland area was also affected. However, the normal architecture of the lacrimal gland was maintained.
| Comments|| |
Clinically it was difficult to differentiate these pseudotumours from a true neoplasm. Reese  pointed out a relatively sudden onset of the lesion and oedema as features of pseudotumours. However, in our cases the onset of the disease was gradual and progressive where oedema was also not a common finding. Although lymphoid group constitutes a major bulk of the pseudotumours, , yet other lesions such as plasma cell tumour, orbital myusitis, lipogranuloma, vasculitis, sclerosing pseudotumour dacryoadenitis and other specific pseudotumours are also not rare. ,
In orbital myositis, sometimes it is difficult to differentiate this lesion from changes in extraocular muscles in thyrotropic disease. , In our cases there was no evidence of thyroid dysfunction. However, the thyroid functions may be  normal in initial stages when patient presents orbital pathology and thyroid dysfunction may manifest at a later stage. ,, In such cases the differentiation is based on the fact that in orbital myositis the extraocular muscles are involved without involving the other orbital tissue. , This point was a highlight in all cases to clinch the diagnosis. Rarely, in some cases the inflammatory process may spill over to the adjacent adipose and connective tissue. , In such difficult cases the follow up of the case can only be the answer.
Other lesions in this study include three cases each of tuberculosis like and sarcoidosis like lesions. Even a thorough general systemic examination, radiological and laboratory investigations could not support a tubercular or a sarcoid lesion. Therefore, the presence of a non-caseating granuloma in these cases can only suggest a chronic inflammatory process which may occur in response to some fungi , or bacteria or parasite  or even by a virus  . Sarcoid like lesions have also been described by other workers. ,
In two cases typical foreign body granuloma was present, yet there was no history of trauma or a foreign body or operation in these cases. A foreign body granuloma in the orbit can occur following a previous injury with a retained foreign body which is long forgotten by the patient ,, or a post-traumatic granuloma, , or following a ruptured orbital dermoid. ,,
In plasma cell tumour there was pure plasma cell proliferation without any evidence of malignancy. Sometime a similar situation may arise from multiple myeloma that infiltrates the orbit as a first clinical sign. However, differentiation was never a problem in the presence of normal radiological and laboratory findings. Such plasma cell pseudotumours have been named as plasmocvtoma. , Lymphocytic infiltration in the lacrimal gland was present in one case of chronic dacryoadenitis and in the past similar cases have been recorded. ,,
| Summary|| |
In a consecutive study of 120 histologically proved cases of primary orbital tumours, thirteen non lymphoid pseudotumours are described. These include cases of orbital myositis (3 cases), tuberculosis like lesions (3 cases), sarcoid like lesions (3 cases), foreign body granulomas (2 cases), plasma cell tumour (1 case) and one case of chronic dacryoadenitis. Clinical and pathological features of these cases are discussed.
| Acknowledgement|| |
We are thankful to Mr. A.Y. Khan, Senior technician of Institute, for processing the tissue for histopathological examination. We are also grateful to Mr. U. C. Gupta, senior photo-technician of Institute for carrying out photography work for us.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14]
[Table - 1]