Diseases of OrbitDiseases of Orbit

Anatomical considerations Anatomical considerations

• WallsWalls

• ApexApex

• OpeningsOpenings

• SpacesSpaces

• RelationsRelations

• Blood vesselsBlood vessels

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Orbital CavityOrbital Cavity

• Dimensions- conical in shapeDimensions- conical in shape

• Depth- 40 mmDepth- 40 mm

• Height- 35 mmHeight- 35 mm

• Width- 40mmWidth- 40mm

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Anatomy of OrbitAnatomy of Orbit

Sketch of orbit by Dr Sanjay Shrivastava

Frontal

Ethamoid

Zygomatic

Lesser and Greater wing of Sphenoid

Maxillary

Lacrimal

Palatine

Optic Foramen

Sup Orbital Fissure

Anatomy of Apex of OrbitAnatomy of Apex of Orbit

Sketch of Apex of Orbit by Dr Sanjay Shrivastava

Sup Orbital Fissure

Annulus of Zinn

Med Rectus Muscle

Inf Rectus Muscle

Lat Rectus Mus

LPS

Sup Oblique Mus

Optic Nerve

WallsWalls

• Roof- is formed by the orbital plate of frontal Roof- is formed by the orbital plate of frontal bone and lesser wing of sphenoidbone and lesser wing of sphenoid

• Floor- is formed by the maxillary bone- orbital Floor- is formed by the maxillary bone- orbital plate and maxillary process of zygomatic bone plate and maxillary process of zygomatic bone and orbital process of palatine boneand orbital process of palatine bone

• Medial wall- is formed by the lacrimal and Medial wall- is formed by the lacrimal and ethamoidal bone, frontal process of maxillary ethamoidal bone, frontal process of maxillary bone and body of sphenoidbone and body of sphenoid

• Lateral wall- is formed by the greater wing of Lateral wall- is formed by the greater wing of sphenoid and zygomatic bonesphenoid and zygomatic bone

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ApexApex

• Annulus of zinn giving rise to origin Annulus of zinn giving rise to origin to extra ocular musclesto extra ocular muscles

• Optic canalOptic canal

• Part of superior orbital fissurePart of superior orbital fissure

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OpeningsOpenings

• Optic canal- optic nerve with meninges and Optic canal- optic nerve with meninges and ophthalmic arteryophthalmic artery

• Superior orbital fissure-Superior orbital fissure-

Outside tendinous ring – structures passing Outside tendinous ring – structures passing outside are:outside are:

Lacrimal nerve –V1Lacrimal nerve –V1

Frontal nerve -V2Frontal nerve -V2

Trochlear nerveTrochlear nerve

Superior and inferior veinsSuperior and inferior veins

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Opening Opening

• Inside tendinous ring- structures passing Inside tendinous ring- structures passing inside the ring are -inside the ring are -

Oculomotor Oculomotor (3(3rdrd cranial nerve) cranial nerve) upper divisionupper division

Nasociliary nerveNasociliary nerve Abducent nerve Abducent nerve (6(6thth cranial nerve) cranial nerve)

Oculomotor lower division Oculomotor lower division (3(3rdrd cranial nerve) cranial nerve)

Inferior orbital fissure-inferior Inferior orbital fissure-inferior ophthalmic veinophthalmic vein

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OpeningOpening

• Foramen rotandum - maxillary nerveForamen rotandum - maxillary nerve

• Superior orbital notch-supraorbital Superior orbital notch-supraorbital nerve and vesselsnerve and vessels

• Infra orbital foramen-infraorbital Infra orbital foramen-infraorbital nerve and arterynerve and artery

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SpacesSpaces

• Subperiostial spaceSubperiostial space

• Peripheral orbital spacePeripheral orbital space

• Central spaceCentral space

• Tenons spaceTenons space

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RelationsRelations

• Frontal sinusFrontal sinus

• Sphenoidal sinusSphenoidal sinus

• Maxillary sinusMaxillary sinus

• Ethamoidal air cellsEthamoidal air cells

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Common lesionsCommon lesions

• ProptosisProptosis

• Exophthalmos- endrocrinalExophthalmos- endrocrinal

• EnophthalmosEnophthalmos

• Pseudoproptosis-slight prominence of Pseudoproptosis-slight prominence of eyes like myopia, paralysis of extra eyes like myopia, paralysis of extra ocular muscles, obese people, ocular muscles, obese people, mullers stimulation by cocain mullers stimulation by cocain

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Proptosis and ExophthalmosProptosis and Exophthalmos

• Abnormal protrusion of eye ball is Abnormal protrusion of eye ball is called proptosis or exophthalmos.called proptosis or exophthalmos.

• The term exophthalmos is reserved The term exophthalmos is reserved for prominence of the eye secondary for prominence of the eye secondary to thyroid disease to thyroid disease

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Proptosis Proptosis

• Abnormal protrusion of globeAbnormal protrusion of globe• It may be Unilateral or BilateralIt may be Unilateral or Bilateral• Unilateral – caused by orbital cellulitis, Unilateral – caused by orbital cellulitis,

idiopathic orbital inflammatory disease, idiopathic orbital inflammatory disease, thrombosis of orbital vein, arterio-venous thrombosis of orbital vein, arterio-venous aneurysms, tumors of structures of orbit , aneurysms, tumors of structures of orbit , orbital haemorrahge , emphysema.orbital haemorrahge , emphysema.

• Bilateral – endocrine exophthalmos , Bilateral – endocrine exophthalmos , cavernous sinus thrombosis , symmetrical cavernous sinus thrombosis , symmetrical orbital tumors, oxycephaly - diminished orbital orbital tumors, oxycephaly - diminished orbital volumevolume

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ProptosisProptosis

ProptosisProptosis

Proptosis in childrenProptosis in children

• Dermoid and epidermoid cystDermoid and epidermoid cyst

• Capillary haemangiomaCapillary haemangioma

• Optic nerve gliomaOptic nerve glioma

• Rhabdomyosarcoma Rhabdomyosarcoma

• LeukaemiasLeukaemias

• Metastatic neuroblastomaMetastatic neuroblastoma

• Plexiform neurofibromatosisPlexiform neurofibromatosis

• Lymphomas Lymphomas

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Mass lesion in Left orbit Mass lesion in Left orbit Due Retinoblastoma Stage IIIDue Retinoblastoma Stage III

Proptosis in adultsProptosis in adults

• Metastases – (of malignancy) from Metastases – (of malignancy) from breast, lung, GITbreast, lung, GIT

• Cavernous haemangiomasCavernous haemangiomas

• MucoceleMucocele

• Lymphoid tumors Lymphoid tumors

• MeningiomasMeningiomas

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Types of ProptosisTypes of Proptosis

• Axial proptosis - eye is pushed Axial proptosis - eye is pushed directly forwards – lesions situated directly forwards – lesions situated in optic nerve and central spacein optic nerve and central space

• Non axial- situated elsewhere in Non axial- situated elsewhere in orbit pushes eye in opposite orbit pushes eye in opposite directiondirection

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Causes of proptosis in different Causes of proptosis in different in different locations in different locations

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Extra conal lesionsExtra conal lesions Intra conal lesionsIntra conal lesions Muscular disordersMuscular disorders

Dermoid cystDermoid cyst Cavernous haemangiomaCavernous haemangioma Thyroid Thyroid ophthalmopathyophthalmopathy

RhabdomyosarcomaRhabdomyosarcoma Optic nerve gliomaOptic nerve glioma Pseudo tumorPseudo tumor

Extension of nasal Extension of nasal /sinus diseases/sinus diseases

MeningiomaMeningioma CysticercosisCysticercosis

A-V malformationsA-V malformations Lymphoproliferative Lymphoproliferative disorderdisorder

RhabdomyosarcomaRhabdomyosarcoma

Clinical presentationClinical presentation

• Static- as seen usually in congenital causes Static- as seen usually in congenital causes

• Increasing – fast- as in cases of Increasing – fast- as in cases of Rhabdomyosarcoma, neuroblastoma, Rhabdomyosarcoma, neuroblastoma, haemopoetichaemopoetic

• Gradual- as in cases of meningiomasGradual- as in cases of meningiomas

• Pulsatile- as in cases of carotid cavernous Pulsatile- as in cases of carotid cavernous fistulafistula

• Intermittent- as in cases of orbital varicosityIntermittent- as in cases of orbital varicosity

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Clinical signsClinical signs

• Impaired mobilityImpaired mobility

• DiplopiaDiplopia

• PapilloedemaPapilloedema

• Optic atrophyOptic atrophy

• Hertel exophthalmometry – measures Hertel exophthalmometry – measures more than 18 mmmore than 18 mm

• Difference in two eyes of more than 2 Difference in two eyes of more than 2 mm is considered positivemm is considered positive

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Investigations Investigations

• Careful history recordingCareful history recording• Systemic examinationSystemic examination• ENT examinationENT examination• Biochemical and haematological Biochemical and haematological

investigations investigations • Imaging of bony structures- plain x rayImaging of bony structures- plain x ray• Imaging of soft tissues –CT scan, MRIImaging of soft tissues –CT scan, MRI• Vascular study- orbital venography, carotid Vascular study- orbital venography, carotid

angiography, MR angiography, digital angiography, MR angiography, digital subtraction angiographysubtraction angiography

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Orbital cellulitisOrbital cellulitis

• Definition: Purulent inflammation of the cellular Definition: Purulent inflammation of the cellular tissue of the orbittissue of the orbit

• Causes of Orbital Cellulitis: Causes of Orbital Cellulitis:

Spread of infection from neighbouring structures Spread of infection from neighbouring structures like nasal sinuses, eyelids, eyeball (like in case like nasal sinuses, eyelids, eyeball (like in case of panophthalmitis) facial erysiplas etcof panophthalmitis) facial erysiplas etc

Also due to deep penetrating injuries (specially Also due to deep penetrating injuries (specially in cases of retained Foreign body) and in cases of retained Foreign body) and metastatic infection in cases of pyaemiametastatic infection in cases of pyaemia

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Types of Orbital Cellulitis Types of Orbital Cellulitis

• Two types- pre septal cellulitis and Two types- pre septal cellulitis and orbital cellulitisorbital cellulitis

• Pre septal –structures anterior to Pre septal –structures anterior to orbital septum, characterized by orbital septum, characterized by erythema, chemosis, conjunctival erythema, chemosis, conjunctival discharge without restriction of discharge without restriction of ocular movements and visual ocular movements and visual impairmentimpairment

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Types of Orbital Cellulitis Types of Orbital Cellulitis • Orbital – behind orbital septum, Orbital – behind orbital septum,

characterized severe pain, fever, diminution characterized severe pain, fever, diminution of vision (due to retrobulbar neuritis or of vision (due to retrobulbar neuritis or compression of optic nerve and /or its blood compression of optic nerve and /or its blood supply), massive swelling of lids, chemosis, supply), massive swelling of lids, chemosis, proptosis, restriction of ocular movements, proptosis, restriction of ocular movements, diplopia, an abscess may form pointing diplopia, an abscess may form pointing somewhere in the skin of the lid near the somewhere in the skin of the lid near the orbital margin or fornixorbital margin or fornix

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Complications Complications

• PanophthalmitisPanophthalmitis• Extension into brain through meninges , Extension into brain through meninges ,

cavernous sinus thrombosis may developcavernous sinus thrombosis may develop• In diabetic patients fungal superinfection In diabetic patients fungal superinfection

may developmay develop

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ManagementManagement

• Culture and sensitivity of pus, if Culture and sensitivity of pus, if present and of bloodpresent and of blood

• Treatment –Broad spectrum Treatment –Broad spectrum Intravenous antibiotics , and anti Intravenous antibiotics , and anti inflammatoryinflammatory

• If abscess has formed – Incision and If abscess has formed – Incision and Drainage under cover of antibiotics Drainage under cover of antibiotics

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Cavernous sinus Cavernous sinus thrombosisthrombosis

• Due to extension of thrombosis from various Due to extension of thrombosis from various feeding vesselsfeeding vessels

• Superior and inferior ophthalmic vein enter in Superior and inferior ophthalmic vein enter in frontfront

• Superior and inferior Petrosal sinus leave from Superior and inferior Petrosal sinus leave from behindbehind

• Cavernous sinus communicates with facial Cavernous sinus communicates with facial veins, lateral sinus, jugular vein, Mastoid veins, lateral sinus, jugular vein, Mastoid emmisary vein-lateral sinus- superior petrosal emmisary vein-lateral sinus- superior petrosal sinus sinus

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Cavernous sinus thrombosisCavernous sinus thrombosis

• Cavernous sinus on one side Cavernous sinus on one side communicates with other side through communicates with other side through transverse sinustransverse sinus

• Because of connection with mastoid Because of connection with mastoid through mastoid emmisary vein, mastoid through mastoid emmisary vein, mastoid tenderness is diagnostic feature of tenderness is diagnostic feature of cavernous sinus thrombosiscavernous sinus thrombosis

Source of infectionSource of infection

• Orbital veins - as in cases of Orbital veins - as in cases of eryiepelas, septic lesion of face, eryiepelas, septic lesion of face, orbital cellulitis , infective condition orbital cellulitis , infective condition of face, mouth, nose, sinuses of face, mouth, nose, sinuses

• Furuncle of upper lip – dangerous Furuncle of upper lip – dangerous area of facearea of face

• Metastatic infection or septic Metastatic infection or septic condition condition

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Symptoms and SignsSymptoms and Signs

• Patient may present with symptoms and signs of Patient may present with symptoms and signs of Orbital cellulitis, there is sever supra-orbital painOrbital cellulitis, there is sever supra-orbital pain

• Systemic features – headache, fever ,altered Systemic features – headache, fever ,altered sensorium, vomiting and cerebral symptomssensorium, vomiting and cerebral symptoms

• Transference of symptoms and signs to other Transference of symptoms and signs to other eye (bilateral orbital cellulitis with which it may be eye (bilateral orbital cellulitis with which it may be confused is very rare clinical condition). Mastoid confused is very rare clinical condition). Mastoid edema and tenderness is present.edema and tenderness is present.

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Symptoms and SignsSymptoms and Signs

• In case of infection spreading to other eye, In case of infection spreading to other eye, the first sign is involvement of lateral the first sign is involvement of lateral rectus of other eyerectus of other eye

• PapilloedemaPapilloedema

Treatment Treatment

• Emergency Emergency

• Broad spectrum Intra Venous Broad spectrum Intra Venous antibioticsantibiotics

• Anti coagulantsAnti coagulants

• Neurophysicians to be consultedNeurophysicians to be consulted

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Exophthalmos Exophthalmos

• Endocrine exophthalmos : Graves Endocrine exophthalmos : Graves Ophthalmopathy (dysthyroid eye Ophthalmopathy (dysthyroid eye disease) is the commonest cause of disease) is the commonest cause of uniocular or bilateral proptosis in age uniocular or bilateral proptosis in age groups between 25 and 50 years groups between 25 and 50 years

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Graves Disease Graves Disease

• Consists of Exophthalmos, and all signs of Consists of Exophthalmos, and all signs of thyrotoxicosis (i.e. tachycardia, muscular thyrotoxicosis (i.e. tachycardia, muscular tremors and raised BMR)tremors and raised BMR)

• In early stage the presentation may be In early stage the presentation may be unilateral, becomes bilateral. Palpabral unilateral, becomes bilateral. Palpabral aperture is wide open due to lid retraction aperture is wide open due to lid retraction (Dalrymple sign). Upper lid fail to follow (Dalrymple sign). Upper lid fail to follow downward movement of eye (von Graefe downward movement of eye (von Graefe sign) sign)

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Summary of signs in Graves Summary of signs in Graves disease disease • Lid retractionLid retraction

• Lid lag (upper and lowerLid lag (upper and lower

• Infrequent blinking and incomplete closure of lids Infrequent blinking and incomplete closure of lids (Stellwag sign) (Stellwag sign)

• Lid edema Lid edema

• ExophthalmosExophthalmos

• Conjunctival congestion over the insertion of recti Conjunctival congestion over the insertion of recti muscles and chemosismuscles and chemosis

• Convergence insufficiency (Mobius sign) and Convergence insufficiency (Mobius sign) and DiplopiaDiplopia

• Raised intraocular tension may be presentRaised intraocular tension may be present

• Superior limbic keratopathy Superior limbic keratopathy 04/11/23 39

Werner classification of signs (NO Werner classification of signs (NO SPECS)SPECS)

• Grade 0 – No signs or symptomGrade 0 – No signs or symptom

• Grade 1 – Only sign (lid retraction)Grade 1 – Only sign (lid retraction)

• Grade 2 – Soft tissue involvement (Chemosis)Grade 2 – Soft tissue involvement (Chemosis)

• Grade 3 – Proptosis (which may be minimum Grade 3 – Proptosis (which may be minimum <23, moderate , marked >28)<23, moderate , marked >28)

• Grade 4 – Extraocular muscle involvement Grade 4 – Extraocular muscle involvement

• Grade 5 – Corneal involvement Grade 5 – Corneal involvement

• Grade 6 – Sight loss Grade 6 – Sight loss

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Exophthalmic Exophthalmic Ophthalmoplegia Ophthalmoplegia • Is proptosis with external ophthalmoplegia Is proptosis with external ophthalmoplegia

• Usually seen in middle aged people , it is of Usually seen in middle aged people , it is of insidious onset, typically assymetrical insidious onset, typically assymetrical limiting upward movement and abduction limiting upward movement and abduction due to swollen, pale edematous, infiltrated due to swollen, pale edematous, infiltrated ocular muscles . There is irreducible ocular muscles . There is irreducible exophthalmos with risk of exposure exophthalmos with risk of exposure keratitis , globe dislocation mechanical keratitis , globe dislocation mechanical compression of optic nerve and ophthalmic compression of optic nerve and ophthalmic vessels vessels

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Exophthalmic Exophthalmic Ophthalmoplegia Ophthalmoplegia

• Disease is self limiting with Disease is self limiting with intermissions and relapses, usually intermissions and relapses, usually not affected by any treatment . not affected by any treatment . Spontaneous resolution may take Spontaneous resolution may take place which rarely is complete place which rarely is complete

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Treatment of Exophthalmic Treatment of Exophthalmic OphthalmoplegiaOphthalmoplegia

• Short term oral steroid therapy (with dose of Short term oral steroid therapy (with dose of 40-60 mg) with radiotherapy (1000 rad ) are 40-60 mg) with radiotherapy (1000 rad ) are effective in controlling soft tissue inflammation effective in controlling soft tissue inflammation

• Exposed cornea should be protected by doing Exposed cornea should be protected by doing tarsorrhaphy in less severe cases , by orbital tarsorrhaphy in less severe cases , by orbital decompression in more severe cases. Lateral decompression in more severe cases. Lateral tarsorrhaphy may also be needed. tarsorrhaphy may also be needed.

• Residual muscle palsy is dealt with muscle Residual muscle palsy is dealt with muscle adjustment surgeryadjustment surgery. .

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TypesTypes

• Type – I : Characterized by symmetrical Type – I : Characterized by symmetrical mild proptosis with lid retraction usually mild proptosis with lid retraction usually associated with thyrotoxicosis associated with thyrotoxicosis

• Type – II : Characterized by extreme Type – II : Characterized by extreme exophthalmos, compressive neuropathy exophthalmos, compressive neuropathy and extraocular muscle involvement. and extraocular muscle involvement. This form may be associated with any This form may be associated with any state of thyroid function, but usually state of thyroid function, but usually with hypothyroidism, seen after with hypothyroidism, seen after thyroidectomy. thyroidectomy.

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Cause of exophthalmos Cause of exophthalmos

• Due to edema, lymphocytic Due to edema, lymphocytic infiltration anf fibrosis of orbital infiltration anf fibrosis of orbital contents and extra-ocular muscles contents and extra-ocular muscles

• Lid retraction is due to contraction of Lid retraction is due to contraction of Muller muscle Muller muscle

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