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Diseases of Orbit Anatomical considerations • Walls • Apex • Openings • Spaces • Relations • Blood vessels 11/27/2014 2 Orbital Cavity • Dimensions- conical in shape • Depth- 40 mm • Height- 35 mm • Width- 40mm 11/27/2014 3 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 • • • 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 11/27/2014 6 Apex • Annulus of zinn giving rise to origin to extra ocular muscles • Optic canal • Part of superior orbital fissure 11/27/2014 7 Openings • Optic canal- optic nerve with meninges and • ophthalmic artery Superior orbital fissureOutside tendinous ring – structures passing outside are: Lacrimal nerve –V1 Frontal nerve -V2 Trochlear nerve Superior and inferior veins 11/27/2014 8 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 11/27/2014 9 Opening • Foramen rotandum - maxillary nerve • Superior orbital notch-supraorbital nerve and vessels • Infra orbital foramen-infraorbital nerve and artery 11/27/2014 10 Spaces • Subperiostial space • Peripheral orbital space • Central space • Tenons space 11/27/2014 11 Relations • Frontal sinus • Sphenoidal sinus • Maxillary sinus • Ethamoidal air cells 11/27/2014 12 Common lesions • Proptosis • Exophthalmos- endrocrinal • Enophthalmos • Pseudoproptosis-slight prominence of eyes like myopia, paralysis of extra ocular muscles, obese people, mullers stimulation by cocain 11/27/2014 13 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 11/27/2014 14 Proptosis • Abnormal protrusion of globe • It may be Unilateral or Bilateral • Unilateral – caused by orbital cellulitis, idiopathic • 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 11/27/2014 15 Proptosis Proptosis Proptosis in children • • • • • • • • Dermoid and epidermoid cyst Capillary haemangioma Optic nerve glioma Rhabdomyosarcoma Leukaemias Metastatic neuroblastoma Plexiform neurofibromatosis Lymphomas 11/27/2014 18 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 11/27/2014 20 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 11/27/2014 21 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 11/27/2014 22 Clinical presentation • Static- as seen usually in congenital causes • Increasing – fast- as in cases of • • • Rhabdomyosarcoma, neuroblastoma, haemopoetic Gradual- as in cases of meningiomas Pulsatile- as in cases of carotid cavernous fistula Intermittent- as in cases of orbital varicosity 11/27/2014 23 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 11/27/2014 24 Investigations • Careful history recording • Systemic examination • ENT examination • Biochemical and haematological • • • 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 11/27/2014 25 Orbital cellulitis • Definition: Purulent inflammation of the cellular • 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 11/27/2014 26 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 11/27/2014 27 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 11/27/2014 28 Complications • Panophthalmitis • Extension into brain through meninges , • cavernous sinus thrombosis may develop In diabetic patients fungal superinfection may develop 11/27/2014 29 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 11/27/2014 30 Cavernous sinus thrombosis • Due to extension of thrombosis from various • • • 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 11/27/2014side ssss 31 Cavernous sinus thrombosis • Cavernous sinus on one side communicates with • 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 11/27/2014 33 Symptoms and Signs • Patient may present with symptoms and signs of • • 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. 11/27/2014 34 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 11/27/2014 36 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 11/27/2014 37 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) 11/27/2014 38 Summary of signs in Graves disease • Lid retraction • Lid lag (upper and lower • Infrequent blinking and incomplete closure of lids (Stellwag • • • • • • 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 11/27/2014 39 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 11/27/2014 40 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 11/27/2014 41 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 11/27/2014 42 Treatment of Exophthalmic Ophthalmoplegia • Short term oral steroid therapy (with dose of 40• • 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. 11/27/2014 43 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. 11/27/2014 44 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 11/27/2014 45