 I already showed you the lions and the bears, and so these are the tigers, so oh my. So here you can see the tiger that's there, and they try to at least now, they don't put them in a cage where they march back and forth, at least they kind of let them go around a little bit of an enclosure, so they're not totally caged up, and there he is, he just, he wouldn't, wouldn't pose for me, so. And of course, here's the lions, they give them a little platform, they just kind of sit up there and roar, it's pretty impressive when you hear them roar, I mean you can hear them at the other side of the zoo, and so I don't think I'd want to be out on the savannah somewhere when I heard that roar, so they're just kind of sitting up there surveying all that they own, and there they are again, I was trying to get mid roar there, she was trying to roar a little bit, okay, so we're going to talk about orbit. Alright, so first of all when we define the orbit, there are seven bones around the orbit. Brad, tell us the bones around the orbit. There's maxillary, sphenoid, ethmoid, lacrimal, palatine, frontal, zygomatic. I lost count, I think that's seven, okay, so also when we when we look at the orbit, we break it into different parts, so Tina what are the three main areas of the orbit when we talk about the orbit? How do we subdivide it? Yeah, subperiosteal, it's a potential space, it's not it's not a real space, so when we think of conal, I mean basically the muscles in the intramuscular septum forms a cone, and so when you look at it, you look at the orbit, you've got the tissue that is within the cone, the intraconal tissue that's there, and you know the muscles form the cone, and the muscles have intramuscular septate to go around them, and all around from the apex of the orbit to the back of the eye, the intramuscular areas is what we call the intraconal space, thus you know the name it shaped like a cone, because you know the orbit is a cone, so what's the most important thing that lives in the intraconal space? All right, so the optic nerve, anything else goes through there? So remember the optomic artery runs through there, all the branches of the optomic artery run through there, the vein runs through there, the optic nerve, and a lot of fat, all right, what's in the extraconal space? Yes, so really not a whole lot going on in the extraconal space, I mean a lot of fat, really not much else, and then of course we call the subperiosteal space a potential space, and so because we've got these sinuses right next to the orbit, you know below it you've got the maxillary, you've got the ethmoids, you've got the frontal above, you know the spaces between here, if you do have an infection in there, you have a tumor in there, you can get invasion into the orbit from something going on in the sinuses, and the problem is is this subperiosteal space can fill with blood, it can fill with pus with inflammatory cells, and so that is a potential space, and here we can see it just in a different view now, this is a sagittal type of view, and you can see right here the bones, the globe, the intraconal space with the optic nerve running through it, the vessels that are there, extraconal space, and then of course the subperiosteal space will be right along here, this just shows it on a scan as you show you that the closeness of the sinuses that are nearby, all right now there are other things that live in the orbit, Caleb, what are we looking at right here? So this is an anchoring gland, it's a bilayer cuboidal acid-art type of parents of these glands, so it could be a lacrimal gland, so lacrimal gland, where does the lacrimal gland sit? So it's a superior temporal gland, so superior temporal gland, so we've got a main lacrimal gland, we've also got a palpebral lobe of the lacrimal gland, and that's kind of split by what? The septum. Okay so the septum kind of splits the two, the two, so when you look at it this is just it's a straightforward lacrimal gland, it's a straightforward eccrine gland, it's got these acinar spaces here, if you look real closely there's the little pink granules, little secretory granules in the cytoplasm of the of the little acini, all right so the hardest part about the orbit now, the eye we're lucky in that when we have difficulties going on in the eye we can look in and see them, but the problem is the orbit you can't see the orbit, so I mean Boopy really pounds you hard about your examination and how you examine the orbit and how you can get information before you just jump in and do a you know do an MRI scan immediately, so what are we seeing right here? Okay so describe it, yes so look at where the light reflex is here and then look right here it's just a little bit higher the light reflex which means that that eye is actually coming down a little bit so subtle finding but important what else do you see there? Well if you look and you look at that just kind of the wrinkling that's going on right here if you look up here look at that you kind of lose the wrinkling and you get an idea that there is a subtle fullness in here, okay so obviously what did we just show prior to this? Lacrimal gland and so where does the lacrimal gland live? It lives appears so whenever you see someone when they've got a subtle fullness here superior temporarily it looks like they've got a little bit of hypoglobus maybe the eyes being pushed down you would be concerned about the possibility of some kind of a lesion in the lacrimal gland and when you look right here at this scan sure enough there's a lesion here what does this look like? Oh I'm sorry we're still coming around so back, yeah sorry. So we've got a pretty well circumscribed. And so the key is well circumscribed so it's not spread out all over the place it's not molding around the the globe the muscles the tissue it's the some people would call this a coin lesion and so you've got this well circumscribed coin lesion kind of in the superior temporal orbit what would your concern be? Pleomorphic adenoma. Right so indeed what is pleomorphic adenoma? Alright so the reason why they call it that it's got proliferation of both and so you look here's the glandular elements and they can even form little tubules of these glands and then in between though you have the little myo intimal cells proliferating either and so it's called a benign mixed it's a mixture of both the pleomorphic adenomas the proper word. Now when in the olden days when I was a resident we were taught the 50-50 rule and so we were taught that 50% of all lesions of the lacrimal gland are epithelial lesions and 50% of those are the benign mixed of pleomorphic adenoma. It turns out the first part of that is just not true if you really look at oh my battery is dying. Oh that's good. He used to tell me my battery is dying. Thank you. So it turns out when especially when you look at the data that the shields is have put together at wills that probably 80% of lacrimal you know lesions are really like lymphoid type lesions be they lymphoma be they I'm decorative adenitis and so it's really not 50-50 but if you look at actual tumors from the lacrimal gland 50% of them are the benign mixed and so the second part of the 50-50 rule is true and if we look at a little bit higher power here's the kind of ductile glandular elements and then in between you get proliferation of the cells. This must be one that Weisch took a picture of. Obviously a fellow took a picture of that. You know it's interesting on my screen it shows up pretty well and on the screen up there it's all washed down I'm sorry I'm not sure what the difference between the two is but if we look at close-up here what I'm trying to illustrate here is that most of these lesions are what we call benign mix but you can also have a malignant mix and the setting of a malignant mix is usually when the surgeon is not able to get all the tumor out and there's remnant tumor there and then that tumor can continue to keep re-growing and what happens in that setting is that the cells can get a little bit more aggressive and so you can even go from a benign mix to a malignant mix so when you look at these lesions when you look at them that first CT scan we showed these tend to almost be encapsulated. Now they don't have a really true capsule around but as they grow slowly and push out they tend to be pseudo-encapsulated and so when you're going to remove these you want to not do an excisional biopsy you want to do a not an incisional biopsy you want to do an entire excisional biopsy so you want to remove these in their entirety if you think it's a tumor you don't want to just do a little piece of it because if there's some left behind then they can start getting more aggressive and start to take on more malignant characteristics and what I was trying to show you here is there is more pleomorphism in here there's starting to be nucleoline here and so these cells are becoming more aggressive as they become from a benign mix to a malignant mix and here's a close-up here here's a nucleolus here's some clump chromatin and so these cells are getting more aggressive you still have that glandular pattern that's going on here but they're just becoming more aggressive so if you leave a benign mixed in there and you do some surgery you let it grow and come back and there's been a couple cases we've seen where there's actually they thought they had it all and then it came back and and it's actually been documented over time that these will become more malignant-looking and more aggressive-looking all right what do we see in here please so this just looks that it's a lot more dramatic than the previous one was but again what you're seeing is you've got an idea that there's still some fullness up here and there's still something pushing that eye down so you're still suspicious that something is going on in here and now you look at the scan it's still kind of coin like but you still got a little maybe some tails coming out here so not quite as circumscribes of the previous one what would your concern here be all right so let's say this was indeed a tumor in the lacrimal gland area what tumor would you be concerned about so we talked about you know benign mixed pleomorphic adenomas what's another type of tumor that can occur in the lacrimal gland adenoid cystic all right so adenoid cystic is another type of carcinoma that can occur from the lacrimal gland it's less common than the pleomorphic adenoma but it's more aggressive and these can be quite nasty tumors and when you look at them these are the tumors that people use the term disarmingly benign and what I mean by that is when you look at the actual cells they just don't look malignant you know usually look at cells and in malignancy they'll have nucleoline and they'll have mitotic figures they'll be really nasty looking you look at these these almost look benign and that's what's real difficult about this particular tumor is the cells themselves look benign but in reality they're not they can be quite aggressive I know I'm sorry I don't know you Mike I'm the new intern coming out oh welcome welcome Mike so when do you take over the VA starting yesterday I began the takeover hey break him in well so the new interns you get reprieve the first day so you don't get pimp today but next week you're still liable okay you can go for it I'm ready are you ready remember the last time someone said bring you pimp not ready to get it right remember last time somebody said bring it on that that you know big banner bringing that they really didn't work out well alright so what are we seeing funny here I mean tell me what you're seeing just describe it for me gosh so I think centrally you've got some collections there of cells that look like they're proliferating you've got those kind of cystic spaces right the white and then you've got the connective tissue kind of build up around the supporting tissue there what do we see even more than connective tissue what's this stuff bone exactly so this kind of disarmingly benign looking tissue is literally invading into bone and so there it's important that you realize there are different patterns to these tumors and sometimes you know you can get what they call it this is what we call the swiss cheese pattern you know so you get it looks like swiss cheese literally so you've got this kind of swiss cheese pattern that you can see and this is again this one this one Caleb took so a bit of a swiss cheese pattern here now there is one pattern of this tumor that I really want you to remember and it is called basaloid and the reason why you want to remember this is when you look at all of these tumors and they say okay this is an aggressive tumor this can metastasize this can invade into bone the basaloid variety is the worst so when you see this it almost looks like kind of like a basal cell carcinoma it's really highly cellular it's not that swiss cheese it's not that creeper form pattern that we normally see but it's this solid basilar pattern these are really aggressive so these are the ones you really want to watch out for because these can be particularly aggressive and particularly nasty so we like to try when we look at these tumors to subdivide them into what you know type what what particular subtype of tumor they have and so it's the basaloid variety of these that is the most aggressive so these are the ones you definitely don't want to see all right so so Catherine before you go back to medicine we go back to medicine here next week what do we see in here so you see also some bonus of the upper mostly the upper also looks like there's also some erythema and also loss of wrinkling okay and so we look at the scan on this one now this scan looks different than the last two what's different here so you don't have a well circumscribed or coin lesion you the infiltrate looks like it's wrapping more being more focal exactly so rather than being these coin or these really localized lesions this is more diffuse and people call these silly buddy and I don't know the silly buddy still exists you guys have silly buddy when your kids okay so you know you can you know you can mold it around all the stuff that you can do and it molds around everything and so the idea is when you see a lesion that's molding around things it molds around the globe it molds around the muscles what would you be concerned about here or concerned about like a lymphoma exactly or lymphoid lesion and that's what you'd be concerned about lymphoid lesion and then we do the pathology here and what do you see a low power so what's the first rule of pathology way back to the intro blue is bad okay so blue is bad so you see a lot of blue here but if you look what you can see is you can see that this is fairly uniform and so you're not seeing you know areas where there's like follicles or big cells or small cells or light cells or dark cells you've got these uniform kind of small to medium-sized dark cells and when we do some staining with a brown stain with an amino peroxidase stain what are we seeing here actually not quite sure well you know peroxidase stains certain antigens that are in the cytoplasm and so sometimes when they you're trying to do fresh tissue this turns out to be an old fresh one you lose the cellular detail but you see that all of this cytoplasm is staining brown and so basically what this tells us is that this is a lymphoma and so when you're looking at lymphomas lymphomas can occur in the lacrimal gland but they can also occur in the orbit that more commonly in the orbit they can also occur in the lacrimal gland just like in the orbit you don't have just one entity okay lymphoma sitting here you've got a spectrum so you've got an inflammatory lesion over here and atypical you know a mixed inflammation here you've got an atypical lymphoid hyperplasia in the middle and then you've got lymphoma on the other side and that spectrum occurs both in the lacrimal gland and in the orbit in general and so we do want to do amino peroxidase staining or if you have fresh tissue you can do what's called flow cytometry and you want to characterize these you want to say okay are these all B lymphocytes are they all T lymphocytes are they all Kappa or they all lambda and this will give you a hint of whether or not this is a lymphoma or lymphoid hyperplasia or even just a benign perforation. Alright back to Brad what do we see in here? So this is a color fundus photo kind of what we were looking at of like coroidal folds. Okay so what do coroidal folds tell you? So it could be one of two things I think the most worrisome would be some sort of posterior mass but then it could also be found in hyperps. Exactly and so what's really interesting when you look at some of the studies they've done on astronauts that are in the space station for a long time especially when Captain Kelly was up there for like a year these guys would get a hyperopic shift and their global literally flatten out posteriorly and they've even documented they took an OCT up there and they actually documented coroidal folds on there so you know the most common thing is just someone who's hyperopic and has a flat globe but what you don't want to miss is coroidal folds are a sign of a lesion behind the eye but more specifically where? Interconal. Exactly so when you start to see these coroidal folds you worry about an interconal mass lesion and so last week we talked about optic nerve and so obviously if you see an interconal lesion you want to worry about gliomas, meningiomas, even neurolimomas, schwannomas that we talked about last week but when you see this you worry about an interconal lesion. Tina we're looking at the CT what do we see in here? Okay this is a 28 year old vague symptoms of maybe pain around the eye maybe some episodes where the vision washes out a little bit periodically what would you think about a nice round lesion like this minimal proptosis. That first statement was half right. Cavernous hemangioomas. Exactly so yep so when you see a lesion that's well circumscribed like this capillary hemangioomas really aren't well circumcised so not the little amoebasic all over but cavernous hemangioomas again tend to have a pseudo capsule around them and they tend to be pretty well circumscribed and they can occur in the muscle cone most prominently so this would be a concern for possible cavernous hemangiooma we look at the pathology does this confirm it indeed it does so when you look at these at low power this is just gross microscopy they're surrounded by a pseudo capsule and you've got these large vascular spaces that's the name cavernous these cavernous vascular spaces now it's interesting in that they don't have a capsule around it we always say pseudo capsule pseudo capsule means the lesions grow slowly it pushes the connective tissue around it's when you go in and the the ocular plastic guys go in to take these out you could just shell these things right out these just pop out hold they look like a little grape in there and you just you can even put a cryoprobe on it just pop them right out once you get to this is what it looks like low power microscopy again large cavernous spaces filled with blood vessels little thin septae coursing through them all right what am I illustrating here so what does that tell you when the red blood cells separate from the serum exactly and that's a key thing to remember with these is their low flow so a capillary hemangioa so you've got capillary manju over the lid it's extending in the orbit you know again they've got all kinds of little blood vessels coming in and out of them they bleed like crazy when you try to take them out these are very very low flow and they're so low flow that you can see a gravity line here so the red blood cells have settled out this is like a hematocrit tube so the red blood cells have settled out you've got serum up here so this tells you that these are very low flow lesions they have these septae coursing through them they grow very slowly but again because they're in the muscle cone they can cause issues cause problems and so when you do take them out they come out quite easily which is good and these are benign so these are the cavernous type of hemangioas okay well this is a more subtle one and I know it's not 3d here but you almost get the idea that that right eye is coming towards you a little bit and so the hardest thing when someone shows you a picture like this especially when you guys take boards is you first thing you got to figure out okay what's the abnormal side and when you look at it just initially you say I don't even know what's abnormal but then like booby says you want to look carefully at these because you often don't know what's gone but if you look real carefully get the idea that maybe there's a little bit of increased scleral show inferiorly a little bit more fullness down get the idea that that right globe is coming towards you a little bit more and then we look at the pathology and what the heck is this so there's a lot of cells in here very cellular back on but you know these are the stag horn spaces you know stag horn like horns on it on a deer and so literally descriptive stag horn but if you look carefully there's all kinds of little spaces in here even at low power you see that they all have red blood cells within so there's all kinds of little vascular spaces in some big some little but in between there's this really dense cellular proliferation in between what do you think that could be exactly so you can get Heman Joe perisitomas of the orbit especially within the muscle cone and it's proliferation not only of the little blood vessel cells of the endothelial cells but also the surrounding perisites and when you look closely at it here's a little vascular space there's all kinds of them around here but then in between you have this proliferation of these little perisites now this is kind of like the you know the lacrimal gland tumors in that you can get people will call these kind of benign and intermediate and normal lignite but what's weird about these this is another one of those outliers you have to you have to realize even though we look at these and we try to grade them and we say okay this is intermediate it's got clear line in it even looks more benign it looks more malignant that hasn't correlated to the prognosis of these lesions so I find that really weird I don't understand that in that you can see some of these that look really aggressive on pathology and they just sit there for years you can see some that look more benign on pathology and they behave very aggressively so if they really ask you on board you know tell tell me about this you can say that there are some that are benign and more intermediate more aggressive but that doesn't necessarily correlate to their prognosis but what we have seen again in these just like some of the lacrimal tumors that these are tough to remove completely because they're not encapsulated and we have seen through the years some that have gone from benign to intermediate to malignant and so if you leave them in there long enough they can undergo a progression to a more aggressive looking cell these are tough to get out all the way and they can come back and grow even more when you see them so you can see this one tends to be an intermediate one look at the nucleolide the clumped chromatin in there when you see them but the key is it's this vascular network with the proliferation of the parasites in between now what's a what's a stain that we can do on these particular tumors that's helpful sorry I'm one off okay this just shows again the more malignant ones there you go there's the more malignant and there's a really malignant one there's the reticulum stain okay so why is the reticulum stain important exactly so remember the parasites you know really give the support to the blood vessels and so when you get proliferation and mangio perisitoma you get this reticular network people even call it net like so it looks like a little net so when you do a reticulum stain all that silvery black material is what you see so this is really helpful when you're not sure what's going on so you do the reticulum stain you can see the network so this is one that we were saying how it undergoes a progression here's a malignant looking mangio perisitoma here's an intermediate looking one you know some nucleolide some clump chromatin some pleomorphism and then this one looks a lot more malignant so they undergo that progression from kind of benign to intermediate to more malignant looking and then you do the reticulum stain and that helps you to differentiate this from other potential tumors all right what do we see in here all right so the key is it's heterogeneous it's not all uniform you look there's some areas that look kind of cystic some that look solid some that stain brightly some that stain dull and so it's kind of a mixture it's a hodge podge of stuff that's going on but significant proptosis here what if I told you this this person is 10th all right so one of things you'd be concerned about another lesion that can occur in the orbit is a lymph angioma and these tend to occur in young young people in kids and they can really be variable I mean what I find is sometimes these kids can get a really explosive proptosis or it can settle back in and it can wax and wane and even when these kids have an upper respiratory infection their proptosis can get worse or if they have hemorrhaging into one of these little cysts their proptosis can worsen all right so what do we characterize lymph angiomas bipathologically so these have these big spaces they're lined by kind of a flatten spindly endothelial lining there's lots of vessels in here so sometimes you can get bleeding in here but the key as you see these they almost look like little pyres patches of lymphocytes and when kids get an upper respiratory infection those can actually proliferate and swell and so that's where you can get the intermittent proptosis that you can have in these in these youngsters and then what can happen is here you can actually get bleeding into these large cystic spaces and again you'll get a very rapid increase in proptosis now when people go in there to try to drain these you know they'll even try to you know use the ultrasound or CT to guide a needle and get in there and drain them and so when you drain them because the blood in some of these has been sitting there for a while it breaks down and so they're called chocolate cysts so remember when red blood cells break down they almost take on a brown appearance to them so you don't want to try to go in there and take these things out because again they're like amoebas they have fingers everywhere these are very difficult to take out because they're not encapsulated and sometimes you take them out and the proptosis gets even temporarily works and so if you do get bleeding and a cyst that shows up on a scan you can actually go in there and try to drain it to you know relieve the pressure on the globe without having to go in and actually try to remove the tissue so these are the so-called chocolate cysts you get when you get hemorrhaging into these large spaces in the in this lymph angioma lesion there's a close-up there's the pyres patch lymphocytes there are the various spaces that are filled with red blood cells so the so-called chocolate cysts now this is showing you those lymphocytes and again these kids when they have an upper respiratory infection can get a pretty rapid increase in their proptosis all right what do we see in right here region all right so something something bad is going on in there I mean and this was pretty rapid in onset in this and you can see it's a younger person it's a young young child well not young child but you know you know great school aged child and you've got this rapid increase of proptosis hypoglobus inward turning of the globe and then you look at the scan and you do an oh my god so what do we see in here all right so very rapidly growing orbital tumor in a child what's the one thing you worry about most rabdo myosarcoma okay so this this child this was right when I came here this was 30 years ago I don't know if you guys remember leotril that was the miracle cure leotril would cure all cancer and cure everything and so this kid had a very very small lesion about the size of your fingertip Rick Anderson biopsy did it was a rabdo and so they started the kid on chemo at primary children's kids started losing their hair getting sick so mom grabbed the kid took him out of the hospital they went to Mexico to a leotril clinic you know where they were going to be cured because you know the evil medical industrial complex in the US wasn't letting this in and so they went to Mexico for this miracle cure well dad whose divorce hired a private investigator found where mom had taken the kid flew to Mexico re kidnapped the kid back and brought the kid here and this is what happened in three weeks so this went from a lesion the size of your fingertip to this in three weeks and so this kid needed an exenteration needed to take out the whole orbit noble contents really had a rough go of it but but you know was still alive last I knew and so this can really grow explosively and so this is what shows you in an untreated rabdo myosarcoma in three weeks what it can do all right now I was going to talk about some of the different types of rabdo myosarcomas and and these slides were made for a previous orbit conference and they're so pretty I actually left the you know the legends on the bottom of it but still this doesn't tell you exactly what kind this is and so what are the different varieties of rabdo myosarcoma that we need to think about which I've never seen by the way I'm there yeah so the to you really want to remember is you want to remember the embryo type that's the most common and that's the type that has these kind of strap like kind of tadpole looking cells multiple nucleo I let's go a little bit of a close-up here boy it's really interesting on my screen that shows up really nice and it washes out up there but what you see is you see these large kind of round to tadpole looking cells they've got a lot of clumped chromatone a lot of nucleo I pleomorphism some are really big some are really small and so this is what we call the embryo this is the most common type this is kind of in between in terms of prognosis but still that they all have relatively bad prognosis but this was the in between of all of them now why are we showing this picture here what do we see in here on this tadpole there's definitely nucleo I they're big exactly so remember these are embryologically derived muscle tumor cells and so you can sometimes see in these embryo ones a little bit differentiated you can actually see cross striations so sometimes in the tail of the tadpole you can see cross striations and if you do a special stain sometimes you can see these tadpoles better so this is a special stain this is a trichrome stain trichrome stain you see the little it looks like little stripes on the Cheshire cat there so you see these cross striations here so this is an embryo rhabdomyo sarcoma with the cross striations on a trichrome type stain there's a really nice one you can see the cross striations beautifully in there all right so these just show you some of the special stains we can do and so because this is a muscle derived tumor you get staining with some of the muscle stains and so if I meant in Desmond they will stay in their aminoperoxidase stains it's staying positively for muscle derived tumor cells and so you can see that they've got the brown background cytoplasmic staining that you see in the aminoperoxidase stains that are positive all right so Mike see how good your short-term memory is here what is what's this particular variation of this tumor it looks like kind of lung with little spaces in there I would guess yeah exactly so this is why it's named it almost looks like alveoli remember when you used to look at lung path and you see the alveolar spaces and so what you see is you see these little set day coming through here and then you got the cells in the middle of the little septic so thus it looks more alveolar and so this is one you need to remember because this is particularly aggressive so the alveolar variety although rare is very aggressive and so if you see these you really want to be careful when you're treating these kids because these can be aggressive they can spread very very rapidly so the alveolar is the bad one and you can tell it because it looks like alveoli and if you really use your imagination it looks like a long alveolus with tumor cells in it and there you see aminoperoxidase staining you know staining positive for one of the muscle muscle antibodies all right what do we see in here so the left eye looks very full you're at the evidence it almost it looks very inflamed yes we see the eyes almost shut and a younger person again it looks really I'm rad and inflamed what would your concern be here especially in a kid you worry about like an orbital cellulite okay so you worry about cellulitis what else could give you a picture like this well let's say something non-infectious so you could actually get a lesion that looks a lot like an orbital cellulitis in a kid that is actually what we used to call a pseudotumor now we call it idiopathic orbital inflammatory syndrome but you can sometimes get a non-infectious variety that looks like this and it's hard to tell the two apart and so you don't want to miss a cellulitis in a kid obviously but sometimes you can get a lesion that looks a lot like it and it's an inflammatory lesion rather than an infectious lesion and when you look at it what you'll see is you'll see clumps of lymphocytes in here scattered in between the connective tissue but it turns out that this was not infectious this was not a cellulitis this was an inflammatory lesion and so this is said we used to call this pseudotumor but the word tumor is bad I guess and so we can't call it that so now it's idiopathic orbital inflammatory syndrome but it's the same idea it is a proliferation of inflammatory cells mostly lymphocytes but what you'll see is you'll see some plasma cells mixed in there you'll see some it'll sometimes form even some follicles there'll be blood vessels growing through this and so not a lymphoma here's a close-up here's lymphocytes there's a plasma cell there are some vessels coursing through it and so this is that benign remember we said okay lymphomas over here idiopathic orbital inflammation is here so this is the idiopathic orbital inflammation arm of that of that particular lesion and again you can see scattered you know little multifocal clumps of inflammatory cells in here now sometimes if these lesions go on long enough and they're not well treated this can happen what do we see in right here so this looks like we have some fibrosis and scarring occurring so this was an entity we again used to call sclerosing pseudotumor so in the days before cortical steroids were around these were horrible because you could get an entire sock damn glow I mean it would be a sock damn globe it wouldn't move it would squeeze off the blood supply and so you can get a sclerosing a fibrosis response to these in orbital inflammatory syndromes long-term and so you want to hit them pretty hard to try to calm them down before they get to the fibrotic phase or the sclerotic phase and so if you don't you can again get a sclerosing a fibrosing pseudotumor in orbital patient syndrome what do we see in here Keena it's almost like maybe the eyes even pushing out a little bit so you know your concern is that maybe there's something going on behind there now again you do the scan here and what do you see right here looks like the extracular muscles are in large there I can't tell if that's actually in the muscle spacer if that's just the tissue around it but there's actually the tissue around it is really there but the key here is it's very diffuse there's not really a particular lesion it's very diffuse then we do the pathology and what does this show small cells here that would be concerning for right so this would be most most consistent with a lymphoma so now again this is the spectrum from benign you know pseudotumor to lymphoma on this side so when you look here these are all uniform lymphocytes there's no follicles in there there's no blood vessels going through there there's no plasma cells in there and then when we do the amino peroxidase stains this stains positive for you know monoclonal lymphocytes and it's interesting in the orbit most common are B lymphocytes and they're usually extra zonal you know extra no zonal B lymphocytes and so they're kind of a moderate grade B cell lymphoma very rare to have a T cell lymphoma of the of the orbit they're usually a moderate to low grade B cell lymphoma all right now this is a really ugly ugly looking first off what kind of surgery gives you a something that looks this ugly all right so you've taken out the entire orbital and orbital contents just what do you see in here with this diffuse coloration here bluish and dark what concern would that be for exactly and so your concern is remember the orbit is often a repository for tumor cells around it and so it's pretty rare that you get you know primary tumor the orbit except you know the vascular ones we talked about lymphomas but because you know the orbit what does it have in front of it's got lid it's got conge it's got sinuses around it so you can often get secondary tumors going into the orbit so malignant melanomas you know they usually will arise from either the lid or from the conge and then going to the orbs of this particular patient had a conge melanoma that then invaded into the orbit and so if you look right here you see all of this boy this tumor is just everywhere in the orbit and this is what it looks like a low-power path so you see again you can't tell what kind of tumor cells these are just a low power but you can see that they're diffusely invading into the orbital connective tissue so there's these big lobules of tumor cells everywhere and when we look at the close-up these turn out to be melanocytes so again when you look at a malignant tumor sometimes they just look like big you know atypical cells you can't tell what they are unless you do some amine peroxidase staining and so this particular one there are stains that can tell you that it is malanocytic derived so you see these big atypical looking cells here in the orbit and it turns out when you do the staining these turned out to be melanoma now there's other lesions that that can involve the eyes what the heck is this there's also some injection both nasally and temporally on both eyes but again worse on the left and the right so kind of seems consistent with the thyroid eye disease but this this is a very timely photograph from orbit conference last night so very timely photograph and so this is a classic thyroid picture and it's they've got the surprise stare you know kind of the look you guys have when I come around and ask you randomly so you see that they're supposed superior and inferior scleral show so proptosis you see the little inflammation in front of where the recti muscles insert that's a real tip off so you know pimp question again that you'll hear over and over again what's the most common cause of unilateral proptosis in an adult what's the most common cause of bilateral proptosis in an adult thyroid eye disease so thyroid eye disease you always answer that that's kind of like the you know herpes of the cornea no matter what question you're asked you always say herpes when they show your corneal lesion so whenever they show you proptosis well of course you know you say thyroid is in the differential so you say that offhandedly too well of course thyroid and you say that when you're thinking of what else is in the differential diagnosis so thyroid can give you this and now here we have again the classic picture tendon spared anteriorly body of the muscle now this one is a concern even though again they were showing those scans last night you know they're saying oh this isn't bad and I'm thinking God I'm scared that really scares me but look at these fat muscle bodies coming back and they're even going back to the orbital apex you'd be concerned about you know possible effect on the optic nerve when you've got large muscles like this especially posteriorly this is just one where they were doing a dissection on someone who passed away and see the tendon is spared and then you've got the muscle body that is involved and you know acutely you get this mix-away inflammation you can get some hyaluronic acid in there you get some mucopolysaccharide you get swelling and you get a mixed inflammation lymphocytes plasma cells mixture in there acutely but in the long term if this doesn't get treated well you can actually get fibrosis of the muscles just like you get in the orbit with an orbital inflammatory syndrome so initially you'll get the swelling you'll get the mix-away type of change you get the inflammation but as these settle down you get significant fibrosis and that's where that patients get a lot of problems with Diplopia all right what the heck is this this was removed from the orbit exactly it's blurry but I don't take gross photos it has to be the fellas maybe it's a cystic type or just kind of like a large kind of you know kind of a smooth-looking kind of nodule or sometimes what we were trying to show is what the light coming through here this does transilluminate a little bit so it is it is fairly cystic but there's not just clear liquid in there I mean there's some kind of material inside there and so this is a cystic structure then we cut it in half and it's kind of smelly and greasy and looks like this so like the keratin all right so it's all keratin filled so what lesion do you see that's this round like that and a child that's filled with keratin all right so remember we showed you the dermal limbo core stomas you know the kind so don't get the term dermoid confused this is when most people talk about dermoid this is what they're talking about is the dermoid cyst of the orbit and why do you why do we think this happens what do we think the etiology is well you yeah can but that's okay so again when your hoof beats you do horses not so that's a zebra so what's the most common they think that maybe this is some embryology embryological superficial ectoderm that gets pinched off because when you look these are often along where the bony sutures are and they think that there'll be some some surface ectoderm gets pinched off and then it just slowly grows over time and when you look at these like yeah I gotta get you guys you know LASIK trained you know it's some PRK is done on you guys so this is a that's right you guys are accommodating through the scope when you take these pictures so these lesions a dermoid cyst you've got this epithelial lining it's filled with keratin but the key is you have the dermal appendages and so that's the tip-off you can sometimes get dramatically placed epithelium into the orbit and you'll get an epithelioid cyst would just surface epithelium and keratin but when you have the dermal appendages here's a hair follicle here's a sebaceous gland that is what forms a dermoid an orbital dermoid in kids so it's not only that epithelium but it's the dermal appendages with it and we say goodbye to the Shonbrun Zoo at Vienna so next week is tumors so tumors know your tumors and then the week after that we'll do an OCAP review and then look on OCAPs