Teratomas account for 6.6% of childhood tumors, most commonly occurring in the testes, ovaries, and retroperitoneum [7–8]. The orbit represents an infrequent site for this type of tumor [9–11]. The tumor shows progressive growth and is characterized by clinical features such as severe unilateral exophthalmos, incomplete palpebral fissure, bulbar conjunctival edema, and eyeball displacement. Compression of the eye can produce corneal exposure and visual loss. When the mass contains bone or cartilage tissue, the imaging findings have specific characteristics. Computed tomography (CT) scans revealed a well-outlined cystic mass with a focal bone-like structure (or calcific densities) in their lumens. Ultrasonic and MRI scans demonstrated a cystic mass with a high internal echo within the cyst. However, the mass does not necessarily contain bone or cartilage tissue, and the imaging findings lack characteristics at this time, making the diagnosis difficult. Due to the lack of specificity in clinical manifestations and imaging findings, it is easy to confuse orbital cystic lesions, such as dermoid cysts, epidermoid cysts, congenital cystic eye, parasitic cyst, meningoceles, and cystic change of schwannoma. Pathologic diagnosis is the gold standard for the diagnosis of teratomas. The child's pathological examination included the following tissue components: (1) stratified squamous epithelium from the ectoderm and brain tissue from the neuroectoderm. (2) Cartilage from the mesoderm. (3) The glandular epithelium from the endoderm. The diagnosis of teratoma was confirmed by histopathology and immunohistochemistry.
Currently, the primary treatment for teratomas is surgically removing diseased tissue. Due to the tumor being usually large and the orbital surgical field being narrow and limited, complete resection of the tumor may be extremely difficult. During the operation, we can first aspirate the fluid from a giant cyst to decrease the size of the mass and facilitate complete removal. Previous studies have shown The liquid component was then aspirated and replaced with fibrin glue, which can sclerose the small adjacent vessels, reduce the risk of bleeding, and also decrease the risk of rupture of surrounding epithelium, and increase the chances of wholly and radically removing the lesion [12–14]. However, the patient was reviewed one month after surgery, and the patient had enophthalmos, conjunctival hyperemia, and keratitis on ocular examination, which was considered to be due to the greater size of the mass causing the patient's orbital cavity to enlarge, postoperative eye concavity, the cornea not adhering to the eyelids, and a certain space, causing inflammation of the cornea. For this reason, a second operation was performed, with the implantation of an allogeneic sclera into the orbit to increase the orbital volume, improve the pitting of the fossa, and restore keratitis to normal. On the selection of orbital implants, I looked through the literature and found autologous dermal fat grafts, hydroxyapatite, Medpor plates, titanium mesh, etc. [15–16]. That had been previously used in clinical practice. Different implants have advantages and disadvantages. Autologous dermal fat has been highly appreciated in many implants but requires fat extraction from the periocular region. We chose allogeneic sclera because they do not cause new trauma to the patient and because our unit has an eye bank and access to allogeneic sclera.
In conclusion, giant orbital teratomas in children are rare. This clinical case suggests that larger orbital masses occurring in childhood may result in markedly increased orbital volume and the possibility of postoperative enophthalmos and keratitis and that we need to increase the orbital volume and reduce the incidence of complications by timely implantation in orbit after excising the mass and defining its nature.