Download Orbit

Diseases of Orbit
Anatomical considerations
• Walls
• Apex
• Openings
• Spaces
• Relations
• Blood vessels
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Orbital Cavity
• Dimensions- conical in shape
• Depth- 40 mm
• Height- 35 mm
• Width- 40mm
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Anatomy of Orbit
Frontal
Optic Foramen
Lesser and Greater
wing of Sphenoid
Lacrimal
Sup Orbital Fissure
Ethamoid
Palatine
Zygomatic
Maxillary
Sketch of orbit by Dr Sanjay Shrivastava
Anatomy of Apex of Orbit
LPS
Sup Orbital Fissure
Sup Oblique Mus
Optic Nerve
Med Rectus Muscle
Annulus of Zinn
Lat Rectus Mus
Inf Rectus Muscle
Sketch of Apex of Orbit by Dr Sanjay Shrivastava
Walls
• Roof- is formed by the orbital plate of frontal
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bone and lesser wing of sphenoid
Floor- is formed by the maxillary bone- orbital
plate and maxillary process of zygomatic bone
and orbital process of palatine bone
Medial wall- is formed by the lacrimal and
ethamoidal bone, frontal process of maxillary
bone and body of sphenoid
Lateral wall- is formed by the greater wing of
sphenoid and zygomatic bone
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Apex
• Annulus of zinn giving rise to origin to
extra ocular muscles
• Optic canal
• Part of superior orbital fissure
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Openings
• Optic canal- optic nerve with meninges and
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ophthalmic artery
Superior orbital fissureOutside tendinous ring – structures passing
outside are:
Lacrimal nerve –V1
Frontal nerve -V2
Trochlear nerve
Superior and inferior veins
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Opening
• Inside tendinous ring- structures passing
inside the ring are Oculomotor (3rd cranial nerve) upper division
Nasociliary nerve
Abducent nerve (6th cranial nerve)
Oculomotor lower division (3rd cranial nerve)
Inferior orbital fissure-inferior ophthalmic
vein
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Opening
• Foramen rotandum - maxillary nerve
• Superior orbital notch-supraorbital nerve
and vessels
• Infra orbital foramen-infraorbital nerve
and artery
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Spaces
• Subperiostial space
• Peripheral orbital space
• Central space
• Tenons space
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Relations
• Frontal sinus
• Sphenoidal sinus
• Maxillary sinus
• Ethamoidal air cells
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Common lesions
• Proptosis
• Exophthalmos- endrocrinal
• Enophthalmos
• Pseudoproptosis-slight prominence of eyes
like myopia, paralysis of extra ocular
muscles, obese people, mullers stimulation
by cocain
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Proptosis and Exophthalmos
• Abnormal protrusion of eye ball is called
proptosis or exophthalmos.
• The term exophthalmos is reserved for
prominence of the eye secondary to
thyroid disease
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Proptosis
• Abnormal protrusion of globe
• It may be Unilateral or Bilateral
• Unilateral – caused by orbital cellulitis, idiopathic
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orbital inflammatory disease, thrombosis of
orbital vein, arterio-venous aneurysms, tumors
of structures of orbit , orbital haemorrahge ,
emphysema.
Bilateral – endocrine exophthalmos , cavernous
sinus thrombosis , symmetrical orbital tumors,
oxycephaly - diminished orbital volume
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Proptosis
Proptosis
Proptosis in children
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Dermoid and epidermoid cyst
Capillary haemangioma
Optic nerve glioma
Rhabdomyosarcoma
Leukaemias
Metastatic neuroblastoma
Plexiform neurofibromatosis
Lymphomas
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Mass lesion in Left orbit
Due Retinoblastoma Stage III
Proptosis in adults
• Metastases – (of malignancy) from breast,
lung, GIT
• Cavernous haemangiomas
• Mucocele
• Lymphoid tumors
• Meningiomas
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Types of Proptosis
• Axial proptosis - eye is pushed directly
forwards – lesions situated in optic
nerve and central space
• Non axial- situated elsewhere in orbit
pushes eye in opposite direction
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Causes of proptosis in different in
different locations
Extra conal lesions
Intra conal lesions
Muscular disorders
Dermoid cyst
Cavernous haemangioma
Thyroid
ophthalmopathy
Rhabdomyosarcoma
Optic nerve glioma
Pseudo tumor
Extension of nasal
/sinus diseases
Meningioma
Cysticercosis
A-V malformations
Lymphoproliferative
disorder
Rhabdomyosarcoma
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Clinical presentation
• Static- as seen usually in congenital causes
• Increasing – fast- as in cases of
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Rhabdomyosarcoma, neuroblastoma,
haemopoetic
Gradual- as in cases of meningiomas
Pulsatile- as in cases of carotid cavernous
fistula
Intermittent- as in cases of orbital varicosity
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Clinical signs
• Impaired mobility
• Diplopia
• Papilloedema
• Optic atrophy
• Hertel exophthalmometry – measures
more than 18 mm
• Difference in two eyes of more than 2 mm
is considered positive
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Investigations
• Careful history recording
• Systemic examination
• ENT examination
• Biochemical and haematological
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investigations
Imaging of bony structures- plain x ray
Imaging of soft tissues –CT scan, MRI
Vascular study- orbital venography, carotid
angiography, MR angiography, digital
subtraction angiography
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Orbital cellulitis
• Definition: Purulent inflammation of the cellular
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tissue of the orbit
Causes of Orbital Cellulitis:
Spread of infection from neighbouring structures
like nasal sinuses, eyelids, eyeball (like in case
of panophthalmitis) facial erysiplas etc
Also due to deep penetrating injuries (specially
in cases of retained Foreign body) and
metastatic infection in cases of pyaemia
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Types of Orbital Cellulitis
• Two types- pre septal cellulitis and orbital
cellulitis
• Pre septal –structures anterior to orbital
septum, characterized by erythema,
chemosis, conjunctival discharge without
restriction of ocular movements and visual
impairment
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Types of Orbital Cellulitis
• Orbital
–
behind
orbital
septum,
characterized severe pain, fever, diminution
of vision (due to retrobulbar neuritis or
compression of optic nerve and /or its blood
supply), massive swelling of lids, chemosis,
proptosis, restriction of ocular movements,
diplopia, an abscess may form pointing
somewhere in the skin of the lid near the
orbital margin or fornix
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Complications
• Panophthalmitis
• Extension into brain through meninges ,
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cavernous sinus thrombosis may develop
In diabetic patients fungal superinfection may
develop
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Management
• Culture and sensitivity of pus, if present
and of blood
• Treatment –Broad spectrum Intravenous
antibiotics , and anti inflammatory
• If abscess has formed – Incision and
Drainage under cover of antibiotics
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Cavernous sinus thrombosis
• Due to extension of thrombosis from various
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feeding vessels
Superior and inferior ophthalmic vein enter in
front
Superior and inferior Petrosal sinus leave from
behind
Cavernous sinus communicates with facial veins,
lateral sinus, jugular vein, Mastoid emmisary veinlateral sinus- superior petrosal sinus
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Cavernous sinus thrombosis
• Cavernous sinus on one side communicates with
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other side through transverse sinus
Because of connection with mastoid through
mastoid emmisary vein, mastoid tenderness is
diagnostic feature of cavernous sinus thrombosis
Source of infection
• Orbital veins - as in cases of eryiepelas,
septic lesion of face, orbital cellulitis ,
infective condition of face, mouth, nose,
sinuses
• Furuncle of upper lip – dangerous area of
face
• Metastatic infection or septic condition
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Symptoms and Signs
• Patient may present with symptoms and signs of
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Orbital cellulitis, there is sever supra-orbital pain
Systemic features – headache, fever ,altered
sensorium, vomiting and cerebral symptoms
Transference of symptoms and signs to other
eye (bilateral orbital cellulitis with which it may
be confused is very rare clinical condition).
Mastoid edema and tenderness is present.
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Symptoms and Signs
• In case of infection spreading to other eye,
the first sign is involvement of lateral
rectus of other eye
• Papilloedema
Treatment
• Emergency
• Broad spectrum Intra Venous antibiotics
• Anti coagulants
• Neurophysicians to be consulted
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Exophthalmos
• Endocrine exophthalmos : Graves
Ophthalmopathy (dysthyroid eye disease)
is the commonest cause of uniocular or
bilateral proptosis in age groups between
25 and 50 years
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Graves Disease
• Consists of Exophthalmos, and all signs of
thyrotoxicosis (i.e. tachycardia, muscular
tremors and raised BMR)
• In early stage the presentation may be
unilateral, becomes bilateral. Palpabral
aperture is wide open due to lid retraction
(Dalrymple sign). Upper lid fail to follow
downward movement of eye (von Graefe
sign)
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Summary of signs in Graves disease
• Lid retraction
• Lid lag (upper and lower
• Infrequent blinking and incomplete closure of lids (Stellwag
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sign)
Lid edema
Exophthalmos
Conjunctival congestion over the insertion of recti muscles
and chemosis
Convergence insufficiency (Mobius sign) and Diplopia
Raised intraocular tension may be present
Superior limbic keratopathy
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Werner classification of signs (NO
SPECS)
• Grade 0 – No signs or symptom
• Grade 1 – Only sign (lid retraction)
• Grade 2 – Soft tissue involvement
(Chemosis)
• Grade 3 – Proptosis (which may be
minimum <23, moderate , marked >28)
• Grade 4 – Extraocular muscle involvement
• Grade 5 – Corneal involvement
• Grade 6 – Sight loss
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Exophthalmic Ophthalmoplegia
• Is proptosis with external ophthalmoplegia
• Usually seen in middle aged people , it is
of insidious onset, typically assymetrical
limiting upward movement and abduction
due to swollen, pale edematous, infiltrated
ocular muscles . There is irreducible
exophthalmos with risk of exposure
keratitis , globe dislocation mechanical
compression of optic nerve and
ophthalmic vessels
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Exophthalmic Ophthalmoplegia
• Disease is self limiting with intermissions
and relapses, usually not affected by any
treatment . Spontaneous resolution may
take place which rarely is complete
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Treatment of Exophthalmic Ophthalmoplegia
• Short term oral steroid therapy (with dose of 40•
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60 mg) with radiotherapy (1000 rad ) are
effective in controlling soft tissue inflammation
Exposed cornea should be protected by doing
tarsorrhaphy in less severe cases , by orbital
decompression in more severe cases. Lateral
tarsorrhaphy may also be needed.
Residual muscle palsy is dealt with muscle
adjustment surgery.
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Types
• Type – I : Characterized by symmetrical
mild proptosis with lid retraction usually
associated with thyrotoxicosis
• Type – II : Characterized by extreme
exophthalmos, compressive neuropathy
and extraocular muscle involvement. This
form may be associated with any state of
thyroid function, but usually with
hypothyroidism, seen after thyroidectomy.
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Cause of exophthalmos
• Due to edema, lymphocytic infiltration anf
fibrosis of orbital contents and extraocular muscles
• Lid retraction is due to contraction of
Muller muscle
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