ORBITAL DISORDERS

• PRIMARILY FROM WITHIN ORBIT

• ADJACENT STRUCTURE
• DISTANCE SOURSE VIA THE
VASCULAR PATHWAY
• PART OF SYSTEMIC DISORDER

ANTONIO SAY, MD
 Orbital Walls (7 bones)
• Ethmoid
• Frontal
• Lacrimal
• Maxillary
• Palatine
• Sphenoid
• Zygomatic

ANTONIO SAY, MD
• Relations
Above – frontal sinus
Below – maxillary sinus
Medially- ethmoid and
sphenoid sinus

• Orbital septum
- barrier between the
eyelids and the orbit
- anterior limit of the
orbital cavity

ANTONIO SAY, MD
 Roof of the Orbit
• Frontal bone and
lesser wing of
sphenoid

• Landmarks:
– Lacrimal gland fossa
– Fossa for the
trochlea of the sup
oblique tendon and
muscle
– Supraorbital notch or
foramen

• Adjacent to anterior
cranial fossa & frontal
sinus

ANTONIO SAY, MD
 Lateral Wall of the Orbit
• Zygomatic bone(strongest) and greater wing of
sphenoid
• Superior Orbital Fissure
- separates the lateral wall from the roof
- separates lesser from the greater wing
of the sphenoid
• Landmark:
– Lateral orbital tubercle of whitnall(lat canthal tendon, lat
palpebral tendon, check lig is attached
– Frontozygomatic suture located 1cm above the tubercle
• Adjacent to middle cranial fossa & temporal fossa
• Lateral orbital rim is usually at the equator of the eye
allowing wide peripheral vision
• Globe is vulnerable to trauma laterally (wall protect
posterior half of the ANTONIO
eye) SAY, MD
 Medial Wall
• Ethmoid bone
(paper-thin)
• Lacrimal bone
• Body of the
Sphenoid - most
posterior aspect
• Landmark:
– Frontoethmoid suture
(Ant & post ethmoid
arteries)
– Cribriform plate lies at
frontoethmoid suture

• Adjacent to ethmoid,
sphenoid sinus &
nasal cavity

ANTONIO SAY, MD
Lacrimal Crest
1. anterior lacrimal crest
frontal process of
the maxilla
2. posterior lacrimal
crest
formed by the
angular process of the
frontal bone
3. lacrimal groove
between the two crests
contains the
lacrimal sac

frequently fragmented result

from indirect blowout fracture
Infections of ethmoid sinuses
commonly extend through
lamina papyracea(ethmoid
foramen) to cause orbital
cellulitis & proptosis ANTONIO SAY, MD
 Superior Orbital Fissure
Frontal bone Inferior Ophthalmic vein
Lesser
Lateral
wing Superior ophthalmic vein
Greater w
e Lacrimal, Frontal and Trochlear nerves
lacrimal
Outside Annulus of Zinn
Medial
zygoma Superior and Inferior divisions of the
maxilla
oculomotor nerve
Abducens nerve
Nasociliary nerve
Within Annulus of Zinn

ANTONIO SAY, MD
 Floor of the Orbit
• Maxillary, palatine & zygomatic bones
• Form the roof of the maxillary sinus
• Landmark:
– Infraorbital groove & canal

ANTONIO SAY, MD
 Orbital Floor
• Inferior Orbital Fissure
- separates the lateral wall from the
orbital floor

• Orbital plate of the Maxilla

- central area of the floor
- most frequent site of blowout fracture

• Inferior Orbital Rim

- frontal process of the maxilla medially
- zygomatic bone laterally
ANTONIO SAY, MD
 Six P’s Orbital disorder evaluation
• Pain (inflammation, infection, hemorrhage,
malignant lacrimal gland tumors, NP CA)
• Proptosis (forward displacement of the eyeball)
• Progression
• Palpation
• Pulsation
• Periorbital changes

ANTONIO SAY, MD
• Proptosis
forward displacement of the eyeball

• Pseudoproptosis
obvious proptosis in the absence of
orbital disease

ANTONIO SAY, MD
 Proptosis

• Axial displacement (eyeball is displaced straight ahead , retrobulbar lesion)

• Non axial displacement (eyeball displaced sideways or vertically, outside
the muscle cone)
• Superior displacement (maxillary sinus tumors)
• Inferomedial displacement (dermoid cyst and lacrimal gland
tumors)
• Inferolateral displacement (frontoethmoid mucocoeles, abscess,
osteomas or sinus ca)

• Bilateral proptosis (graves, pseudotumor,

metastatic tumor etc.)

ANTONIO SAY, MD
• Pulsating Proptosis
- reflects the pulse of an orbital vascular
malformation
- transmission of the cerebral pulsations
in the absence of orbital roof

• Positional Proptosis
changes with valsalva’s maneuver
seen in orbital varices or menigocoele

• Intermittent Proptosis
sinus mucocoele
ANTONIO SAY, MD
 Progression
• Onset occur over days to weeks
– Idiopathic orbital inflammatory disease
– Cellulitis
– Hemorrhage
– Thrombophlebitis
– Rhabdomyosarcoma
– Thyroid ophthalmopathy
– Neuroblastoma
– Metastatic tumors or granulocytic sarcoma
ANTONIO SAY, MD
 Progression
• Onset occurring over months to years
– Dermoids
– Benign mixed tumors
– Neurogenic tumor
– Cavernous hemangiomas
– Lymphoma
– Fibrous histiocytoma
– osteomas

ANTONIO SAY, MD
 Palpation
• Masses palpable in the superonasal
quadrant
– Mucocoeles, mucopyoceles, encephaloceles,
neurofibromas, dermoids or lymphoma
• Masses palpable in the superotemporal
quadrant
– Dermoid, prolapsed lacrimal gland, lacrimal
gland tumor, lymphoma or inflammatory
• Lesions behind the equator – not palpable

ANTONIO SAY, MD
 Pulsation
• Pulsation without bruit
– Neurofibromatosis, meningoencephaloceles
• Pulsation with or without bruits
– Carotid cavernous fistula, dural arteriovenous
fistula or orbital arteriovenous fistula

ANTONIO SAY, MD
ANTONIO SAY, MD
ANTONIO SAY, MD
 Orbital infection
• Cellulitis
• Necrotizing fasciitis (bacterial inf fascia strep)
• Phycomycosis (most virulent fungal disease)
• Aspergillosis (fungal inf)
• Orbital tuberculosis (periostitis cold abscess)
• Parasitic diseases (trichinosis & echinococcosis)

ANTONIO SAY, MD
 Cellulitis
• Pre septal cellulitis
• Orbital cellulitis

ANTONIO SAY, MD
 Pre septal cellutiis
• Inflammation and infection- eyelids and periorbital structures
ant to orbital septum
• Eyelid edema, erythema
• Globe not involved
• Pupillary reaction, visual acuity & ocular motility not affected
• Absent of pain on eye movement & chemosis
• Due to penetrating trauma or cutaneous source
• Children –sinusitis
• < 5 yrs old – bacteremia, septicemia, meningitis (h.
influenzae)
• Teens & adult – superficial source eg traumatic inoculation,
infected chalazion or epidermal inclusion cyst (staph aureus
most common)

ANTONIO SAY, MD
 Orbital cellulitis
• Infection posterior to the orbital septum
• 90% secondary extension of acute or chronic
bacterial sinusitis
• Fever, leukocytosis, proptosis, chemosis,
restriction of ocular motility & pain on movement
of the globe
• Decreased vision & pupillary abnormalities
suggest orbital apex involvement
• Delay may result to orbital apex syndrome or
cavernous sinus thrombosis
ANTONIO SAY, MD
• Intravenous antibiotics

• Culture and sensitivity of the blood,

nasal and conjunctival secretions
(H. influenza, Staph, anaerobes)

• Nasal decongestants, vasoconstrictors,

ENT consult

• Early surgical drainage of abscess

ANTONIO SAY, MD
 Necrotizing Fasciitis
Uncommon severe bacterial infection
Potentially fatal occurrence
Anesthesia or disproportionate pain
Patient may rapidly deteriorate if not treated
early

ANTONIO SAY, MD
 Phycomycosis
Also called mucormycosis
Extension from sinuses
Proptosed eye, orbital apex syndrome
Common in systemically ill/ debilitated
patients

ANTONIO SAY, MD
 Aspergillosis
From fulminant sinus infection with orbital
spread
Infection can be destructive to the bones
Fungus ball formation
Treated by excision and fungicidal drugs
administration

ANTONIO SAY, MD
 Parasitic Disease
Includes trichinosis and echinococcosis
Infestation may cause lid and extraocular
muscle inflammation
Cysticercosis from tapeworm may present
as mass lesion in the orbit

ANTONIO SAY, MD
 Orbital inflammation
• Graves ophthalmopathy
• Idiopathic orbital inflammation(orbital
pseudotumor)
• Sarcoidosis
• Vasculitis – giant cell arteritis, polyarteritis
nodosa

ANTONIO SAY, MD
 Congenital Anomalies

• Anophthalmos
• Microphthalmos
• Cranifacial Clefting
• Tumors

ANTONIO SAY, MD
 Orbital neoplasm
• Congenital orbital tumor
• Vascular tumor
• Neural tumor
• Mesenchymal tumor
• Lymphoproliferative disorders
• Lacrimal gland tumor
• Secondary orbital tumors
• Metastatic tumors
ANTONIO SAY, MD
ANTONIO SAY, MD