Orbit John H, Sullivan, MD PHYSIOLOGY OF SYMPTOMS ‘Owing to the rigid bony scructute of che orbic, with only an anterior opening for expansion (Chapter 1), any increase in che orbital contents taking place co the side of o¢ behind the eyeball will displace chat organ forward (proptosis). Procrusion of the eyeball is the hallmark of orbital disease. Expansive lesions may be benign or malignant and may arise from bone, muscle, nerve, blood vessels, or connective tissue. A mass may be inflammatory, neoplastic, cystic, or vascular. Procru- sion is not in itself injurious unless the lids are unable to cover the cornea. The underlying cause, however, is usually serious and sometimes life-threatening. Pseudo- proptosis is apparent propos in the absence of orbital disease. Such confusion may arise wich high myopia, buphthalmos, and lid retraction History and examination provide many clues to the cause of proptosis, The position of the eye is deter- mined by the location of the mass. Expansion within the muscle cone displaces the eye straight ahead (axial proptosis), whereas a mass arising outside the muscle cone will also cause sideways or vertical displacement of the globe direcily away from che mass (nonaxial prop- tosis). Bilateral involvement generally indicates sys- emic disease, such as Graves’ disease, The cerm “ex- ophthalmos” is often used when describing proptosis associated wich Graves’ disease. Pulsating proptosis re- Alcets the pulse of an orbital vascular malformation or transmission of cerebral pulsations in the absence of the superior orbital roof, as in type 1 neurofibromatosis, Positional proptosis—which changes wich Valsalva’s maneuver—is 2 sign of orbital varices or meningocele. Intermittent proptosis may be the cesulc of a sinus mucocele. The Hertel exophchalmomerer (see Chapter 2) is the standard method of quantifying the magnitude of proprosis, Serial measurements are most accurace if performed by the same individual with the same inseru- ment. ‘With the change in position of the eyeball, especially if it takes place rapidly, there may be enough mechani- cal interference with the movement of the eye 10 cause dissociation of ocular movements and diplopia (double vision), Pain may occur as a resule of sapid expansion, inflammation, or infiltration of sensory nerves. Vision isnot usually affected early unless the lesion arises from the optic nerve. Pupillary signs and color vision vesting may identify subtle optic nerve compression or involve- ment before acuity is reduced significantly. Involve- mene of the superior orbital fissure by trauma or cumor produces a characteristic combination of diplopia re- sulting from disturbance of function of the oculomotor, wochlear, and abducens nerves and corneal and facial anesthesia (ophthalmic division of trigeminal nerve), known as the orbital fissure syndrome. Expanding le- sions ar che orbital apex result in the orbital apex syn- drome, characterized by proprosis and optic nerve compression, variably accompanied by the diplopia and cornea) and facial anesthesia seen in the orbical fissure syndrome. DIAGNOSTIC STUDIES 1. Imaging CT &MRI Imaging by computed tomography (CT scan) (Figures 13-1 and (3-2) was a major advance in osbital diagnosis. Continued improvement in resolution qual- icy—as well as three-dimensional reconstructions— have made CT the single most imporcant diagnostic study in the investigation of orbital disease. Contrast enhancement with CT during study of vascular lesions sometimes provides additional information. Magnetic resonance imaging (MRI) is capable of displaying sub- ale changes within soft tissue that cannot be imaged with CT, bur it is less useful for bony changes. A sur- face coil applied directly to the orbie enhances image resolucion, MRI is contraindicated in the presence of a ferrous intraorbital or intracranial foreign body. Ultrasonography “The use of ultrasonography in the diagnosis of orbital disease has largely been supplanced by CT and MRI. Although i is a noninvasive and inexpensive form of imaging, its usefulness in boch A and B mode is limited (© the anterior portion of che orbic. Ic is of greatest value in the hands of the clinician-ultrasonographer ca- pable of intexprering “real rime” images Venography Venography is occasionally useful in defining the extent of orbical venous disease. Although the diagnosis can be 250ORBIT / 251 Nasolacrimal a — Base of the globe Inferior oblique — muscle ~ Inferior rectus muscle _= Medial rectus muscle Inferior ophthalmic —— vein Inferior rectus Lateral rectus muscle muscle Lens ——__ _= Lacrimal gland Optic nerve Optic nerve — ~ Ophthalmic artery —Trochlea ‘Superior— ~ Levator and ‘ophthalmic superior vein rectus muscles Figure 13-1. Normal CT scan showing the anatomy of the orbit. Axial CT sections, thickness 1.5 mm. Az Lowest section. H: Highest section. Note clear delineation of individual muscles, optic nerve, and major veins within the orbital fat.252 / CHAPTER 13 Corea and—I anterior chamber ‘Superior oblique tendon Lateral palpebral ligament Inferior rectus muscle Apsidal vain: Lateral rectus muscle Superior ‘ophthalmic vein Laterat~ rectus muscie Interior ophthalmic vein Figure 13-2. Coronal computer reconstructions from axial CT sections. A: ‘Anterior chamber palpabral tendon ‘Superior oblique muscie oblique muscle Lovator and superior rectus muscles ‘Superior ophthalmic vein — Optic nerve Medial rectus muscle Inferior rectus muscie Inforior rectus muscle lost anterior section, H: Most poste- rior section. Note detailed demonstration of ocular and orbital structures. made by MRI, contrast injection into the orbical veins via a scalp vein can sometimes reveal the presence of varices char have escaped detection by CT. Angiography Selective carotid angiography with bone subtraction is sometimes necessary 10 make the diagnosis of certain orbital vascular disorders, In spontaneous, low-flow dural carotid artery-cavernous sinus fistula, angiogra- phy is required for delineation of the extent of involve- mene and for treatment by embolization. Radiography Plain x-rays are sufficient for diagnosis of many oxbival disorders such as fractures. However, the thin walls of the orbit are difficult co visualize even wich tomography and CT or MRI imaging is used ro determine the exter: of injury. Dacryocystography and radionuclide scanni can tomerimes be helpful in localizing the sive lacrimal obstructions, bur these procedures are seldor used. The results are difficule to interpret, and treatmen: is sekdom altered by the findings. Positive concrast radi ography and pneumo-orbitography are no longer used. Orbical chermography isa research procedure