Orbital cysts are rare and, clinically, often present diagnostic problems.The following case with bilateral giant orbital cysts is presented because no similar case can be found in the literature

Skapinker, S

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S.A. MEDICAL JOURNAL278Gay-Prieto. J. A. (1932): Derm. Wschr., 95, 1056.Graham, W. E. and 'orris, E. W. (1941): Vener. Dis. Inform.,Supp., 13, 18.Hellerstrom, S. and Wassen, E. (1930): Proc. Verh. 8th. Int.Kongr. Derm. Syph., 1147.Robinson, H. M. et af. (1949): Amer. J. Syph., 33, 389.19 March 1955Schamberg, I. L. (1941): Amer. J. Med. Sci., 201, 67.Shaffer, B. et al. (1938): J. Uro!., 40, 863.Stein, R. O. (1940): Amer. J. Syph., 24, 254.Wassen, W. (1935): Acta path. microbiol. scand., Supp. XXII.Wong, S. C. and Cox, H. R. (1948): Ann. T.Y. Acad. Sci., 51, 290.Wright, L T. et al. (1948): Ibid., 51, 318.BILATERAL ORBITAL CYSTS OCCURRING IN A BANTU INFANTS. SKAPI 'KER, M.B., RCH. (RAND), ER.CS.E.and1. R TAYLOR, M.R, RCH. (RAND), D.O.M.S. (R.CP. AND S.), F.R.CS. (ENG.)Department of Surgery, University of the Witwatersrand, JohannesburgOrbital cysts are rare and, clinically, often presentdiagnostic problems.The following case with bilateral giant orbital cystsis presented because no similar case can be found in theliterature.CASE REPORTJ.R., African child aged 8 months, admitted to BaragwanathHospital, 2 September 1952.The mother noticed a swelling over the bridge of the nose 6months ago. At first the swelling was firm, but gradually it spreadacross the mid-line on both sides of the nasal bridge and becamecystic. As the growth progressed it involved both eyes in turn,pushing them upwards and outwards. The child has to move itswhole head in order to see an image.Birth was normal. Since birth the general condition has beensatisfactory and progress otherwise normal.Examination revealed a well-behaved c1ll1d, with prominentbilateral proptosis. The eyeballs were displaced laterally andthere was a marked divergency of the visual axes. There was alsoa swelling in the midline, which bulged on coughing (see Figs.I and 2).The ophthalmologist's report (T.B.T.) was as follows:Orbits. Clinically the orbits appear slightly enlarged. There ismllrked swelling of the orbital tissues which is bulging· the lidsforwards and has caused the eyeballs to be pushed markedlylaterally and forwards.Figs. I and 2. Child as it appeared before operation. otethe large cysts medially with the marked displacement of theeyeballs.Eyeballs. There is an extreme divergent strabismus due to dis-placement and rotation of the eyeballs laterally. The cornea isclear on both sides. The pupils are equal and react well. The fundishow bulging masses under the retinae on the nasal sides, givingthe appearance of detachment of the retina, but due to indentationof the sclera. The discs are slightly distorted and show evidenceof stretching of the optic nerves.Aspiration of CystsOn 9 September the cyst in the mid-line between the nasal boneswas aspirated and cerebrospinal fluid was obtained. This wasreplaced by 10 C.c. of air, which on X-ray was found to be in thesubarachnoid space. This central cyst was diagnosed as ameningocele.On 15 September the orbital cysts were aspirated. The removalof 28 c.c. of clear yellowish fluid from the right cyst caused nodeflation or softening of the left cyst. The left cyst contained20 c.c. Air was inserted and the patient was X-rayed. The report(16 September) of the South African Institute for Medical Researchon the cyst fluid was as follows:'Total protein 0·9 g. per 100 c.c. Microscopic examinationof the centrifuged deposit from this specimen showed a moderatenumber of erythrocytes and a few polymorphonuclears perhigh-power field.'After aspiration the eyes were normal on examination but weresomewhat sunken in large fat-free orbits. The cysts rapidly filledup and on the next day they were as tense as before the aspiration.Operations for Removal of Cysts (S.S.)The left cyst was removed under general anaesthesia on16 October 1952. Anterior orbitotomy. Left medial cantbotomy.The conjunctiva was cut on the nasal side, exposing a tense cystictumour. The cyst tracked medially to the eyeball, between themuscle cone and the medial orbital wall, and was attached to theoptic nerve. It extended as far posteriorly as the optic fora men.No defect of the orbital walls could be detected. The cyst wasenucleated. The inferior oblique muscle was cut and re-suturedlater. The conjunctiva was sewn and a dental dam drain wasinserted.. The canthotomy was repaired. The drain was removed on18 October.The right cyst was removed on 3 November 1952 by a proceduresimilar to that on the left side.Except for slight orbital oedema the post-operative period wasuneventful.Histology. The cyst-wall showed the structure of oedematousgranulations and fibrous tissue. No epithelial lining was observed.The origin of the cyst could not be determined.Progress. After the operation the eyes resumed their normalstraight position,' but were somewhat unsupported owing to thelack of orbital fat. Vision appears normal, as the child is able topick up small objectS even with one eye occluded.Duke-Elder 1 classifies orbital cysts as follows:1. Congenital cysts: (a) Dermoids, (b). Cephaloceles,(c) Congenital cystic eyeball.2. Implantation cysts: following penetrating orbital trauma.3. Haematic cysts: following an intra-orbital haemorrhage.4. Parasitic cysts: e.g. hydatid, cysticercus, filaria.c19 Maart 1955 S.A. TYDSKRIF VIR GENEESKUNDE 279Figs. 3 and 4. Post-operative appearance of the child. Theeyes are somewhat unsupported in the large fat-free orbits.5. Serous cysts: hygromata.6. Mucous cysts: from the para-nasal sinuses.7. Dental cysts: invading the orbit from the antrum.8. Cysts of intra-orbital organs: lacrimal gland (dacryops).The case presented here in a Bantu infant appearedto be one of bilateral haematic cysts, most probablyfollowing haemorrhagic disease of the newborn.The first description of haemorrhagic disease of thenewborn, was that of Minot 2 (1852). The disease ischaracterized by an unusual tendency to spontaneoushaemorrhage during the first week of life, usually2nd-5th day. Townsend 3 in 1894 used the term'haemorrhagic disease' to describe all cases ofhaemorrhage in the newborn in which no obvious causecould be found. This excluded cases due to trauma,sepsis, congenital syphilis, and blood dyscrasias such ashaemophilia, congenital leukaemia and congenitalthrombocytopenia.Two cases ofhaemorrhagic disease of the newborn,presenting as unilateral proptosis, were described byKessel and Williams.4 In one of their cases there was alow prothrombin index, but the other case had normalhaematological findings. The proptosis became lessmarked after a few days, and in one case had completelydisappeared by the end of the third week.Bilateral exophthalmos in the newborn followingspontaneous delivery was reported as a rare occurrenceby Kundert. 5 Fracture of the orbit with strangulationof the ophthalmic vein in the superior orbital fissure,retro-bulbar haemorrhage, subperiosteal haemorrhage,and injury of the cavernous sinus, hav~ been consideredas aetiological factors in previously reported cases(Edgerton,6 Windham,7 Harley S). Trauma producedby moulding of the head in its passage through the birthcanal was believed to be a primary factor in all cases.The proptosis usually disappears as the haemorrhageabsorbs, but may persist or even increase if thehaemorrhage becomes encysted.Pathology of Haematic Cysts. Retro-bulbar haemorr-hage usually absorbs slowly owing to the poor blood-supply of the orbital fat. Another factor retardingabsorption is the increased, pressure in a closed space,which prevents the normal capillary dilatation so essentialfor hastening absorption. Very rarely the haematomadevelops into an encapsulated cyst, remaining as anorbital tumour, which is known as a haematic cyst.The characteristic feature of this kind of orbital cystis the absence of epithelial and endothelial lining.Structurally they have two coats, an outer fibrous layer,and an inner layer of granulation tissue, rich in capillariesand in which there may be foam cells loaded with lipoids.They contain yellowish or reddish-green fluid anddegenerated erythrocytes. The cysts may be situatedsubperiosteally or in the orbital tissue-spaces.Similar cysts occur in the breast in localized areas offat necrosis.SUMMARYBilateral orbital cysts, in themselves, are extremely rare.The condition affecting this child is difficult to classifysince it does not fall in with the normal classification ofthese cysts. The lack of an epithelial lining makes ahistological diagnosis difficult. In the absence of areliable history we feel that the most probable diagnosisis bilateral haemorrhagic cysts; the lack of endotheliallining tends to support this contention. The cystic fluidis most likely a transudate from the granulation tissue,mixed with break-down products of the haemorrhage.An anterior meningocele, itself a rare finding, waspresent as well.We should like to thank Dr. E. Kahn and Dr. S. Wayburne, ofBaragwanath Hospital, Johannesburg, for the cooperation andgreat help they gave us in the care and management of this caseand Dr. Wayburne especially for his excellent photographs, whichwe have used in this paper. Thanks are also due to Dr. R. Tropeand the staff of Si. John's Ophthalmic Hospital for their co-operation. We also wish to thank Dr. J. D. Allan, Medical Super-intendent of Baragwanath Hospital, for allowing us to publishthis paper.REFERE TCESI. Duke-Elder, S. (1952): Text-book of Oplllhalmology, p. 5524,Vo!. V. London: H. Kimpton.2. Minot, F. (J 852): Amer. J. Med. Sci., 24, 310.3. Townsend, -c. W. (1894): Arch. Pediai., 11, 559.4. Kessel, 1. and Williams, C. G. (1951): S. Afr. Med. J., 25, 126.5.· Kundert, K. F. (1951): Amer. J. Ophtha!., 39, 1173.6. Edgerton, A. C. (1934): Arch. Ophtha!., 11,836.7. Windham, R. E. (1942): Amer. J. Ophtha!., 25, 1236.8. Harley, R. D. (1943): Ibid., 27, 1314.UNION DEPARTMENT OF HEALTH BULLETINrReport for the 7 days ended 3 March 1955:Plague, Smallpox: itTyphus Fever. Transvaal: 0 further cases have been reportedfrom the Heidelberg district since the notification of 3 February1955. This area is now regarded as free from infection.Epidemic Diseases in Other Countries:Plague: Nil.Cholera in Dacca, Chalna (Pakistan).Smallpox in Kabul (Afghanistan); Moulmein, Rangoon(Burma); Phnom-Penh, Allahabad, Bombay, Calcutta, _Delhi,Kanpur, Lucknow, Madras, agpur, Tellicherry (India); Karachi(Pakistan); Nhatrang, Phanthiet, Saigon-Cholon (Viet- am).Typhus Fever: Nil.

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Bilateral orbital cysts occurring in a Bantu infant

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Bilateral orbital cysts occurring in a Bantu infant

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