Diseases of Orbit

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Diseases of Orbit

• Dr Kavita Kumar
• Associate Professor
• Dr Sanjay Shrivastava
• Professor
• Department of Ophthalmology
• Gandhi Medical College
• Bhopal

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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
Ethamoid
Sup Orbital Fissure
Palatine
Zygomatic
Maxillary
Sketch of orbit by Dr Sanjay Shrivastava
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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
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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

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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
  ophthalmic artery
• 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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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 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
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Proptosis
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Proptosis in children

• 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
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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
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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

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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 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
  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 , 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
  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 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

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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
  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

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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 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 lt23,
  moderate , marked gt28)
• 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
  40-60 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 extra-ocular
  muscles
• Lid retraction is due to contraction of Muller
  muscle