EL Dr/ Mahmoud Medhat 011 67 660 33 The orbit is a quadrilateral pyramidal oo : Sphenoid cavity having a roof, floor, medial & (lesser wing) lateral walls. Its volume is 30 em’, , Ethmoid from which only 1/4 is occupied by the globe, while the remaining Palatine volume is occupied by “the lacrimal agrimal gland, “optic nerve, “extraocular muscles, “orbital vessels & nerves and “fat (The largest part). Bony orbit (7 bones) Posteriorly at the optic foramen Anterior & being closed by soft tissue Frontal bone (Orbital plate) & lesser wing of sphenoid bone Floor Maxillary (Main part), Zygomatic & palatine bones Medial wall_| Maxillary (Frontal process), Lacrimal, Ethmoid & body of sphenoid Lateral wall _| Greater wing of sphenoid bone & zygomatic bone (Orbital process) Orbital apertures Communicates with the brain through the “optic foramen & “superior orbital fissure. Communicates with the pterygoid fossa through the inferior orbital fissure. O, ‘Abnormal protrusion of the eyeball. Normally: A line between the middle of the upper & lower orbital margins just touches or misses the corneal apex, through the closed evelids. Etiology 1. Congenital: a. Orbital dermoid cyst. b. Meningocele. 2. Traumatic: a. Retrobulbar haematoma. b. Surgical emphysema. ¢, Carotid-cavernous fistula. -130-EL Dr/ Mahmoud Medhat 011 67 660 33 3. Inflammatory: a. Acute: © Orbital cellulites, periosteitis. Panophthalmitis. © Cavernous sinus thrombosis. b. Chronic: ¢ Non-specific: Orbital pseudotumour. © Specific: Orbital TB. 4. Tumours: a. Benign: Haemangioma (Commonest benign orbital mmour) & neurofibroma. b. Malignant: © Orbital tissues: Sarcomas. © Orbital organs: Malignant lacrimal ie ll © Intraocular tumours spreading into the orbit e.g. retinoblastoma. gland tumours. ¢ Tumours of the nose & sinuses. © Intracranial tumours: Sphenoidal ridge carcinoma. © Metastatic: e.g. prostatic & breast carcinoma. 5. Endocrine: Dysthyroid eye disease is the commonest cause of proptosis. 6. Miscellaneous: a. Orbital varix. b. Hydatid cyst. c. Blood cyst. d. Aneurysm. e. Bone disease e.g. Paget's disease. Management of a case of proptosis L History ¢ Onset, course & duaration. Associated ocular symptoms e.g. pain & diplopia. © Trauma, systemic diseases or infection.EL Dr/ Mahmoud Medhat 011 67 660 33 IL. Examination 1. Exclude pseudoproptosis which may be due to: © High myopia, especially if unilateral. © Craniofacial anomalies & Shallow orbit. © Buphthalmos. © Contralateral exophthalmos. 2. Ocular examination for signs of inflammation, edema, optic nerve aflection.ete, 3. Determine direction of proptosis (Anterior, up, down... ). 4. Measurement of proptosis: ¢ Simple ruler. ¢ Hertel's exophthalmometer. Normally the distance between the lateral orbital margin & the comeal apex is between 10-20 mm. A difference > 2 mm between the two 5. Type of proptosis: Bilateral or unilateral. Intermittent or recurrent. Pulsating. IIL Investigations Laboratory 1. Blood count: Detecting leukemia. 2. Tuberculin for TB & W.R. for syphilis. 3. Erythrocyte sedimentation rate. 4. Casoni test for hydatid disease. 5. Thyroid function test: T3, T4 & TSH. Radiological 1. X-ray: Detecting enlarged optic foramen, calcification or erosion. 2. CT. 3. MRI. 4. US (Orbital). 5. Carotid angiography. Biopsy: In orbital tunours: 1. Fine needle aspiration biopsy. 2. Excision biopsy.EL Dr/ Mahmoud Medhat 011 67 660 33 I. Traumatic proptosis 1. Retrobulbar haemorrhage: «© Trauma. © Orbital fracture. © Retrobulbar injection. 2. Surgical emphysema: « Trauma to the ethmoid sinuses > air passes into the orbit & SC tissue of the eyelids. ¢ Tt with blowing of the nose & gives feeling of soft crepitations in the lid. 3. Arte nous fistula: Severe head trauma © internal carotid artery rupture while passing in the cavernous sinus © severe Tf of venous pressure. © Clinical picture: o Redness, chemosis. © Dilated retinal veins, papilloedema. o Ophthalmoplegia. © Proptosis (Pulsatile with audible bruit). IL. Inflammatory proptosis . Orbital cellulites ‘Acute suppurative inflammation of the orbit soft tissues. Etiology Causative organism: Staph, Strept, Pneumococci & rarely fungi. Route of infection: Nasal sinuses. * Blood borne. Symptoms © General symptoms: Pain, fever, headache & malaise. e Late: UL vision (Due to optic atrophy). -133-EL Dr/ Mahmoud Medhat 011 67 660 33 Signs ¢ Marked edema & redness of the lid & conjunctiva. © Proptosis. ¢ Limited ocular motility. Complications © Orbital abscess: May point in the lower fornix or into the skin near the orbital margin. © Comeal ulceration, due to exposure & hyposthesia. Differential diagnosis Treatment 1. Hot fomentation. 2. Systemic antibiotics. 3. Local antibiotics (Peribulbar & Retrobulbar). 4. Orbital abscess: Incision & evacuation of pus. 2. Cavernous sinus thrombosis (CST): Etiology: Spread of infection from: 1. The face: The angular V. communicates with the ophthalmic V. 2. The orbit (Orbital cellulites) & globe. 3. Mouth, pharynx & nasal sinuses: Through the pterygoid plexus. 4, Middle ear & mastoid: Through the petrosal ve sinus. 5, Blood-bome. Symptoms © General: Marked fever, malaise, rigors & cerebral | symptoms. i © Local: © Pain, © Limited ocular movement. © Late: JL vision (Due to optic neuritis). © Marked edema & redness of the lid & conjunctiva. ‘© Proptosis: Unilateral then bilateral (Spread to the other sinus). * Limited ocular motility. . Fundus: Engorged veins, papilloedema or papillitis. Mastoid region: Tenderness & edema. N.B. The earliest sign of spread to the other sinus is paralysis of the lateral rectus & mastoid edema. Treatment © Prophylactic: Treatment of the source of infection. © Massive antibiotics. Anticoagulants.EL Dr/ Mahmoud Medhat 011 67 660 33 N.B, Differential diagnosis of inflammatory proptosis: See uveal tract. N.B. Orbital _periostitis: Inflammation of the orbital periostium, due to injuries or extension of infection from the neighbouring structures. 1. Periostitis at the orbital marg © Pain & swelling at the orbital margin. © Swelling & redness of the eyelids & conjunctiva. # Abscess may form at the site of inflammation. 2. Deep periostitis: © General: Marked constitutional symptoms. © Deep seated pain in the orbit. * Swelling & redness of the eyelids & conjunctiva. © Proptosis (May deviate to one side). Complications 1. Orbital cellulites. 2. Superior orbital fissure syndrome. 3. Sinus formation. 4. Spread of infection to the brain (Maningitis, CST). Treatment 1. Systemic antibiotics. 2. Incision of an abscess. 3. Exploratory orbitotomy may be necessary in deep periostitis. Ill. Dysthyroid ophthalmopathy (Thyroid eye disease) Clinical features & complicatio 1. Eyelid signs. 4. Extraocular muscle affection. 2. Infiltrative ophthalmopathy. 5. Optic neuropathy. 3. Exophthalmos. 1. Eyelid signs: «© Upper lid retraction > Staring look. © Upper lid lag: The upper lid does not follow the globe on looking downward. © Infrequent blinking. 2. Infiltrative ophthalmopathy: ¢ Proliferation of orbital fat & CT with retension of fluid, accumulation of mucopolysaccharides & cellular infiltration by lymphocytes & plasma cells.EL Dr/ Mahmoud Medhat 011 67 660 33 Extraocular muscle enlargement, due to tt mucopolysaccharides & edema © degeneration of the muscle fibers, fibrosis, weakness & restricted ocular movements. Clinical signs 1. Conjunetiva: Hyperemia, injection & chemosis. 2. Lid edema. 3. Exophthalmos: The most common cause of both unilateral & bilateral exophthalmos. 4. Extraocular muscle affection: Weakness & restricted ocular movement. 5. Optic neuropathy: Symptoms 1. Slowly progressive impairment of central vision. 2. Defective red-green colour appreciation. Signs 1. Ophthalmoscopy: © Optic atrophy in advanced cases. o Papilloedema. o Chorioretinal folds. 2. Visual field defects: Central or paracentral scotoma +/- nerve fiber bundle defect (DD from POAG). 3. Afferent pupillary defect, due to optic nerve involvement. Management 1. Protection against exposure: Local lubricants, dark glasses. 2. Early cases with painful exophthalmos: Systemic steroids. 3. Radiotherapy if steroids are contraindicated or ineffective. 4. Surgery: © Orbital decompression: In severe proptosis. o Extraocular muscle surgery: If there is diplopia in the primary or reading position.EL Dr/ Mahmoud Medhat 011 67 660 33 Enophthalmos Retraction of the globe. Etiology 1. Senility: Absorption of the orbital fat. . Post-traumatic. won . Post-operative. 4. Post-inflammatory. . Homer's syndrome. Operations on the orbit 1. Orbitotomy: Indications: Tumour excision a itd & decompression in severe *ow thyroid ophthalmopathy. n . Evisceration: Evacuation of the contents of the eyeball. Indications: Endophthalmitis & “panophthalmitis. Excision of the 3. Enucleation: eyeball (Followed by insertion of an artificial eye). Indications: a. Intraocular tumours e.g. retinoblastoma & malignant melanoma. b. Severely traumatized eye (To avoid sympatheticDr/ Mahmoud Medhat 011 67 660 33. } ophthalmitis). c. Blind painful eye eg. absolute glaucoma. Contraindications: Infection e.g. panophthalmitis. 4. Exentration: — All orbital contents, orbital periosteum, lids & conjunctiva are removed. Indications: a. Malignant orbital tumours. b. Intraocular malignant tumours spreading into the ‘ orbit. c. Malignancy of lids or conjunetiva. Contraindications: If there is distant metastasis or “the orbital periosteum is invaded by the —