vinit orbit

Presenter

Dr. Vinit Kamble

Moderator

DR. B.P.SINHA

Walls

Apex

Openings

Spaces

Relations

Blood vessels

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Dimensions- conical or quadrangular bony

pyramidal in shape which connect ACF and

maxillary sinus below

Depth- 42 mm on medial ,50 mm on lateral

side

Height- 35 mm

Intermargimal dist.-25mm on medial wall

100mm on lateral

Width- 40mm parts- Apex /notch of pyramid

Base- ante. Most quadrangular11/24/2014 3

Sketch of orbit by Dr Sanjay Shrivastava

Frontal

Ethamoid

Zygomatic

Lesser and Greater

wing of Sphenoid

Maxillary

Lacrimal

Palatine

Optic Foramen

Sup Orbital Fissure

7 BONES USED IN FORMATION OF

ORBITAL CAVITY

ROSTRUM OF SPHENOID

,PERPEND..PLATE OF ETHMOID, FRONTAL

, MAXILLA ,PALATINE, ZYGOMATIC,

LACRIMAL BONES

24-Nov-14 5

Orbital index - height/width x 100

It is 83 to 89 in CAUCASIANs and

<83 in NIGROEs , >89 in orientals

Ratio of orbital vol/globe vol=4.1: 1

Vol 29 ml

Ant- quadrangular called BASE

Post -notch called APEX

24-Nov-14 Dr. Kavita Kumar 6

Lateral wall of each orbit lies at angle 45

degree to medial wall

Lateral wall of both orbit 90 degree to

each

other

lateral wall seprate orbit from from MCF and

muscular temporal foss ante.

WALLS – medial , lateral , floor, roof


4 walls meet at SUP. INTERNAL, SUP.

EXTERNAL, INF. INTERNAL , INF. EXTERNAL


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

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Trangular in shape, formed by frontal bone

Anteriorly and behind by lesser wing of

sphenoid

Ante.ro lateral- fossa for lacrimal gland

Above – frontal lobe of cerebrum+ meninges

Below – LPS, SR,SO,LACRIMAL GLAND, 4th

CN , FRONTAL NERVE , PERIORBITAL

TISSUE.


M/C - involved in blow out fracture and

invaded by tumour of maxillary antrum

Seen in X ray orbit P/A view.


Quadrilateral

Formed by- from front to back frontal

process of maxilla , lacrimal bone, body of

sphenoid, orbital plate of ethmoid,

Lacrimal fossa anteriorly with ant. Lacrimal

crest of maxillary bone and post lacrimal

crest of lacrimal bone infe. By NASO

LACRIMAL CANAL


Medial to lacrimal fossa lie – ant. Ethmodal

sinus in upper part , middle meatus of nose

in lower part ,

Lacrimal fossa consist – sac + fascia

Post.- to post lacrimal crest consist Horners

muscle , septum orbitale, ligament of medial

rectus


Consist that is towards nose Ethmoid air

sinus , middle meatus of nose , sphenoid

air sinus

Orbital surface of medial wall- superior

obligue in upper part , MR- middle part

In bet. Superior obligue muscle and MR

consist ant ethmoidal nerve , post ethmoidal

nerve, infratrochler nerve


Thinnest wall , ethmoiditis, with orbital or

preseptal cellulitis in child , eroded by cyst,

Neoplasm, fracture during orbitomy operation

or surgery, injury

Haemorrhage m/c due to injury to ethmoidal

vessels

Xray P/A view recquired for diagnosis


Trangular , ant. relation- zygomatic bone

with groove which transmit zygomatic

nerve and vessels

Post . Relation – greater wing of sphenoid,

Origin to LR muscle , seprated from roof

by sup orbital fissure and from floor

by infe orbital fissure


Protect post half of eyeball

Palpation of retro orbital mass is eazy

through lateral wall


Annulus of zinn giving rise to origin to extra

ocular muscles

Optic canal- 6 to 11 mm at 4to 5 yr

Part of superior orbital fissure

Optic canal -transmit optic nerve and

ophthalmic artery , lateral wall is shortest

Gret. And lesser wing of sphenoid form sup

orbital fissure..divided in to lateral,

medial,inferior

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It is post notch of pyramid types-

1] orbital end is vertically oval

2] center- circular

3] cranial end- horizontally oval

Optic nerve glioma and meningioma show

Enlargement of optic canal seen best in x

ray

P/A VIEW


IN ORBITAL APEX SYNDROME - IT IS

VISUAL LOSS FROM OPTIC

NEUROPATHY, OPHTAHLMOPLEGIA,

MULTIPLE CRANIAL NERVE

INVOLVEMENT consist

SOFS/Rohon Duvigneaud syndrome,

THS/unilateral, CST/bilateral diag. from

HRCT,MRI

Involve 3,4,5,6 CN with optic nerve

dysfunction


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

Optic canal- optic nerve with meninges and

ophthalmic artery connect orbit to MCF

Superior orbital fissure-

Outside tendinous ring – structures passing

outside are:

Lacrimal nerve –V1

Frontal nerve -V2

Trochlear nerve

Superior and inferior veins

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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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Foramen rotandum - maxillary nerve

Superior orbital notch-supraorbital nerve and

vessels

Infra orbital foramen-infraorbital nerve and

artery

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Subperiostial space

Peripheral orbital space

Central space

Tenons space

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Space bet orbital bone and periorbita

Tumour arising from bone seprate periorbita

to orbital rim

Dermoid, epidermoid cyst,mucocele,myeloma,

hematoma, fibrous dysplasia are seen in this

space


Bounded peripherally by periorbita, 4 extra

Ocular muscle, with intermuscular septa

Tumour in this space produse proptosis

E.g malig lymphoma, capiilary haemangioma,

Pseudotumour, neoplasm of lacrimal gland

Contents- SO,IO,LPS, LACRIMAL FRONTAL,

TROCHLEAR, LACRIMAL GLAND


RETROBULBAR SPACE/ MUSCULAR CONE

Ant- by tenons capsule or fascia bulbi

Periphery-rectus muscles and intramus. Septa

Contents- optic nerve , meninges, 3RD ,6th

,opthalmic artery, ciliary ganglion, central

Fat, sup ophtha. Vein

Cavernous haemangioma,neurofibroma,neuro-

-lemoma ,meningioma,optic nerve glioma

Treat- lateral orbitomy


Tenons capsule, envelop globe from limbus

To optic disc , inner face lies in contact with

sclera

outer face of fascia bulbi lies in contact with

orbital fat, subconjuctival space anter.

Lower part of fascia bulbi is thick takes in

Formation of sling / hammcock on which globe

rest called as suspensory liga of

LOCKWOOD


Frontal sinus

Sphenoidal sinus

Maxillary sinus

Ethamoidal air cells

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Eyeball, extra ocular muscles, muller muscles

Optic nerve, occulomotor,trochlear,abducent,

Trigeminal,fat,fascia, lacrimal sac gland

Ophthalmic artery, and its branches

Orbital fascia, reticular tissue


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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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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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

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Dermoid and epidermoid cyst

Capillary haemangioma

Optic nerve glioma

Rhabdomyosarcoma

Leukaemias

Metastatic neuroblastoma

Plexiform neurofibromatosis

Lymphomas

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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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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

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

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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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• 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

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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

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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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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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Panophthalmitis

Extension into brain through meninges , cavernous sinus thrombosis may develop

In diabetic patients fungal superinfection may develop

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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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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 vein-

lateral sinus- superior petrosal sinus

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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

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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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.

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In case of infection spreading to other eye, the

first sign is involvement of lateral rectus of

other eye

Papilloedema

Emergency

Broad spectrum Intra Venous antibiotics

Anti coagulants

Neurophysicians to be consulted

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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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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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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

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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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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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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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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.

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• 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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Due to edema, lymphocytic infiltration anf

fibrosis of orbital contents and extra-ocular

muscles

Lid retraction is due to contraction of Muller

muscle

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vinit orbit

Education

lacrimal fossa

kavita kumarmedial

kavita kumarconsist

kavita kumarmc

kavita kumarroof

kavita kumarthinnest

kavita kumarlateral

orbital plate of frontal