From the Guidelines
A bulge on the lateral side of the eyeball causing pressure is highly suggestive of an orbital mass, and given the firm nature of the bulge, an MRI with contrast is strongly indicated to characterize the mass and guide management. The most common benign orbital masses include cavernous hemangiomas, dermoid cysts, and lacrimal gland tumors, while malignant possibilities include lymphoma, metastatic tumors, and lacrimal gland carcinomas 1. The overall risk of cancer for orbital masses varies by location, with lateral orbital masses having a significant risk of malignancy, particularly if associated with the lacrimal gland. Lacrimal gland tumors have about a 50% chance of being malignant. Since thyroid ophthalmopathy has been ruled out with normal thyroid function tests, other etiologies must be investigated promptly.
Key Considerations
- The patient's presentation of a firm bulge on the lateral side of the eyeball is concerning for an orbital mass, and the risk of cancer cannot be ignored.
- An MRI of the orbits without and with contrast is the optimal imaging modality to localize and characterize the primary lesion, especially when a mass lesion is suspected within the globe, optic nerve, or adjacent orbital soft tissues 1.
- The MRI should include thin cuts through the orbit and be performed with and without contrast to best visualize the mass and its relationship to surrounding structures.
- Early diagnosis is crucial as orbital masses can threaten vision through compression of the optic nerve or globe, regardless of whether they are benign or malignant.
Next Steps
- An ophthalmologist, preferably one specializing in oculoplastics or orbital disease, should evaluate the patient as soon as possible after imaging is obtained.
- The patient should undergo an MRI with contrast to characterize the mass and guide management.
- Further management will depend on the findings of the MRI and the clinical evaluation by the ophthalmologist.
From the Research
Description of the Bulge
- The bulge in the orbit of the eye on the lateral side of the eyeball that is firm and has put pressure on the eyeball can be described as a mass lesion in the orbit 2.
- The symptoms of such a mass lesion can vary considerably according to the nature, location, and extent of the disease and include common signs of proptosis, globe displacement, eyelid swelling, and restricted eye motility 2.
Most Common Masses in the Orbit
- Cavernous hemangiomas are the most frequently found primary tumors in the orbital region and are the most common benign orbital tumors in the orbit 3, 4, 5, 6.
- They normally appear in adults and diagnostic features in the majority of cases include protrusio bulbi and orbital enlargement 3.
Risk of Cancer
- The risk of cancer from a cavernous hemangioma is low, as they are typically benign tumors 3, 4, 5, 6.
- However, it is essential to obtain a pathological examination of a tissue biopsy to provide an accurate, specific, and sufficiently comprehensive diagnosis, to optimize clinical management and estimate prognosis 2.
Odds of Cancer
- The odds of cancer from a cavernous hemangioma are not explicitly stated in the provided studies, but it is mentioned that they are benign tumors 3, 4, 5, 6.
Indication for MRI
- MRI is indicated for the evaluation of orbital mass lesions, including cavernous hemangiomas, as it provides superior evaluation of the orbit and can help in differentiating them from other orbital tumors 4, 5, 6.
- However, the use of MRI is limited in differentiating fast-filling cavernous hemangiomas from other orbital tumors, and in such cases, contrast-enhanced CT would be helpful 4.