Cavernous Hemangioma of the Orbital Apex: Pathogenetic Considerations in Surgical Management

PURPOSE: To consider the pathogenesis and growth of cavernous hemangioma, particularly within the crowded orbital apex, in decisions regarding surgical indications, timing, and technique. DESIGN: A perspective based on analysis of the microanatomic relationships and growth potential of apical cavernous hemangiomas, with representative case studies illustrating management recommendations. METHODS: Analysis of microscopic findings in typical and vision-loss cases; review of tumor growth patterns as reported in observational and interventional studies; consideration of surgical approaches and reported functional outcomes. RESULTS: An ongoing, local hemodynamic imbalance may drive the proliferation of a cavernous hemangioma. Extension into neighboring tissue induces a fibrous capsule, which is continually reconstituted as the lesion expands, and which may incorporate visually critical structures in the confines of the apex. The extent of this microanatomic intimacy is not detectable preoperatively. The tumor's remaining growth potential at the time of diagnosis or following incomplete resection is not predictable. CONCLUSIONS: Patients without significant vision deficits should be observed for progression. Those with significant deficits or signs of progression should be offered timely surgery, with recognition of the risks. The surgical approach should be individualized based on macroanatomic relationships. The decision to intervene should not be a commitment to complete resection at any cost; intraoperative recognition of "inoperable" attachments may dictate modifications in order to preserve vision. (Am J Ophthalmol 2010;150:764-773. (C) 2010 by Elsevier Inc. All rights reserved.)