Diseases of Orbit

Dr. I Gede Suparta SpM

Bag. Mata FK UNRAM/SMF Ilmu Penyakit Mata RSU
Prop. NTB Mataram
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

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 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
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 (3
rd
cranial nerve) upper division
Nasociliary nerve
Abducent nerve (6
th
cranial nerve)
Oculomotor lower division (3
rd
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
Proptosis
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
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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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
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


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

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
<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 40-60
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
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