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Late Implant Hemorrhage Masquerading as an Orbital Mass

Chamberlain, Paul D. M.D.; Sweeney, Adam R. M.D.; Shetlar, Debra J. M.D.; Yen, Michael T. M.D.

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Ophthalmic Plastic and Reconstructive Surgery: March/April 2021 - Volume 37 - Issue 2 - p e81
doi: 10.1097/IOP.0000000000001667
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A 69-year-old woman presented with 12 months of progressively worsening painless proptosis and a firm mass protruding from the left superior orbit. She had a history of enucleation for a traumatic blind painful eye 3 years prior with implantation of a porous polyethylene implant. There was no history of trauma following the enucleation, and she was not on any anticoagulant medications. Axial MRI revealed a large, circumscribed mass consisting of hyperintense complex fluid on T2-weighted imaging (Fig. 1A) with enhancing capsule on sagittal postcontrast T1 imaging (Fig. 1B) surrounding the implant and displacing it posteriorly and inferiorly. Intraoperatively, when the capsule of the mass was entered, an abundance of viscous yellow-colored fluid was expressed. Within this capsule, the porous polyethylene implant was floating freely without any integration of blood vessels, connective tissue, or muscle. The capsule containing the implant was excised in its entirety, and a silicone sphere implant was placed in the orbit. Histology of the excised capsule showed benign epithelium with dense fibrous tissue and numerous cholesterol clefts (asterisk) admixed with red blood cells, lipid laden histiocytes, and chronic inflammation (Fig. 2, hematoxylin and eosin, ×200). These findings are consistent with changes seen with chronic hemorrhage. While porous polyethylene implants are typically used to allow for fibrovascular ingrowth, chronic or late bleeding in the orbit may prevent or disrupt such integration from developing. Retained intracapsular hemorrhage may mimic an orbital mass, and if symptomatic, may necessitate removal of the implant, capsule, and hemorrhage. Definitive diagnosis requires tissue for pathologic evaluation.

FIG. 1.
FIG. 1.:
Axial (A) and sagittal (B) magnetic resonance imaging demonstrating a large, circumscribed mass with enhancing capsule.
FIG. 2.
FIG. 2.:
Histology demonstrating dense fibrous tissue and cholesterol clefts (asterisk) admixed with red blood cells, lipid laden histiocytes, and chronic inflammation (hematoxylin and eosin, x200).
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