Orbital Diseases

Col Zulfikar Hasan

Prof & HOD (Ophthalmology)
 Scope and Limitations
1. To cover the basic idea about how we need
to approach to PROPTOSIS patients.
2. To give you clue for further reading and
Clinical exam methods.
3. Clinical exam not possible to demonstrate.
4. Investigations Management aspects
(specially Surgical procedures) NOT covered
in details

Col Zulfikar. AFMC. Lecture. 2

 Orbit- Anatomy
1. Develop from mesoderm
2. Volume : 30 ml
3. Contents:
a. Eyeball with Extraocular Muscles
b. Cr Nerves (II, III, IV, V, VI), Plexus, Ganglion
c. Blood vessels , Lymphatic vessels
d. Orbital Fat, Lacrimal Gland and Sac
4. Orbital foramina
a. Sup Orbital fissure
b. Inf Orbital fissure
c. Optic Foramina

Col Zulfikar. AFMC. Lecture. 3

 Orbital Anatomy
1. Roof : 2 bones
2. Lat wall: 2 bones
3. Floor: 3 bones
4. Med Wall : 4 bones
5. Sup Orbital fissure : Between Greater and
Lesser wing of Sphenoid bone
6. Inf Orbital Fissure : Between Greater wing of
Sphenoid and Maxilla
Col Zulfikar. AFMC. Lecture. 4
 Orbit – Anatomy
Orbital Walls Orbital Contents

Col Zulfikar. AFMC. Lecture. 5

Orbit Anatomy

Col Zulfikar. AFMC. Lecture. 6

Orbit Anatomy

Col Zulfikar. AFMC. Lecture. 7

Orbital Fissures

Col Zulfikar. AFMC. Lecture. 8

 Proptosis

1. Proptosis: Forward
protrusion (>20 mm
from Lat Orbital margin)
of Orbital contents .
2. Exophthalmos : Forward
protrusion of Eyeball
only eg: Thyroid
Ophthalmopathy

Col Zulfikar. AFMC. Lecture. 9

 Causes of Proptosis
Unilateral Bilateral
1. Systemic disease : Thyroid 1. Systemic : TED
Eye Disease (TED) 2. Cavernous sinus
2. Inflammation: Orbital thrombosis
Cellulitis, Pseudotumour 3. Orbital cellulitis
3. Neoplastic: Haemangioma,
Dermoid, Glioma,
Meningioma,
Rhabdomyosarcoma

Pulsatile Proptosis: Carotido Cavernous Fistula (Post traumatic)

Col Zulfikar. AFMC. Lecture. 10

 Evaluation of Proptosis
Clinical exam Investigations
1. VA , Pupillary reaction 1. Haematological tests
2. Measurement of Proptosis : 2. Plain X Ray Orbit
Hertel’s Exophthalmometer 3. CT Scan , MRI
3. Palpation of Orbital rim 4. FNAC
4. Ocular Movements
5. Fundus Exam
6. Thyroid Gland
7. Myxoedema, hand tremor

Col Zulfikar. AFMC. Lecture. 11

 Principles of treatment
1. Medical :
a. Thyroid Eye Disease (TED/Hyperthyroidism) :
Carbimazole, Propanolol
b. Cellulitis: Syatemic Antibiotics
c. Pseudotumour: Systemic Steroid
2. Radio/Chemo/Surgery: For Malignant lesions
3. Surgical : (To prevent Exposure Keratitis )
a. Tarsorrhaphy (Stitching of both Eyelids )
b. Orbitotomy
Col Zulfikar. AFMC. Lecture. 12
 Thyroid Eye Disease (TED)
1. Synonym : Thyroid Associated Ophthalmopathy
(TAO) or Graves Ophthalmopathy
2. Hyperthyroidism (Increased secretion of
Hormones) : Graves disease (Commonest type)
3. Organ specific Autoimmune disease
4. Deposition of GAG> water imbibation> Proptosis
5. Middle aged adult (F>M), Unilateral/Bilateral
Axial proptosis
6. D/D: Haemangioma, IOID, O N Meningioma (F)
Axial Proptosis (Uni/Bilateral) any gender, Consider TED

Col Zulfikar. AFMC. Lecture. 13

 Work up for TED
1. Ocular (VA usually normal)
a. Axial Proptosis (Uni/Bilateral,
Symmetrical/Asymmetrical) frequently Permanent
b. Lid retraction (50 % cases)
c. Ophthalmoplegia/ Restrictive Myopathy (30%
cases)
d. Optic Neuropathy (6 % Cases)
2. Systemic: Goitre, Weight loss, Tremor ……

Col Zulfikar. AFMC. Lecture. 14

 Work up for TED
3. Investigations :
a. Blood : TSH (Low) , FT4, FT3 (Raised level)
b. CT Scan (EOM Enlargement sparing tendons )
4. Management :
a.Treatment of Proptosis :
Mild Proptosis : Lubricant (Artificial Tear)
Moderate to severe: Systemic Steroid / Radiotherapy /
Surgery
b. Rx of Hyperthyroidism (By Physician)
Carbimazole (5 mg) To reduce Hormone
Propanolol (10mg) To reduce Symptom
Col Zulfikar. AFMC. Lecture. 15
 Exophthalmos
Goitre TED

Col Zulfikar. AFMC. Lecture. 16

 Work up for TED
Clinical Exam CT Scan

Col Zulfikar. AFMC. Lecture. 17

 Orbital Inflammation
Orbital Pseudotumour
1. Idiopathic Orbital
Inflammatory disease
( IOID)
2. Inflammation of Orbital
contents
3. Adult , Unilateral
4. Normal vision
5. May have motility defect
6. Rx Systemic Steroid
Orbital cellulitis
1. Spread from PNS (Mainly
Ethmoid sinus )
2. Acute condition (fever)
3. Painful Red Eye with
reduced Vision, and
Ophthalmoplegia
4. Common in Children (D/D :
Rhabdomyosarcoma)
5. Investigations:
6. Rx: Hospitalization , IV
Antibiotics , Surgery

Col Zulfikar. AFMC. Lecture. 18

 IOID
1. IOID : Non-neoplastic, 1. Mild Proptosis
Non-infective Orbital 2. CT Scan: Ill defined
space occupying lesion Opacities
(SOL) with Inflammatory 3. EOM + Tendon
features involvement
2. Clinical entities :
a. Orbital Myoscitis
b. Acute Dacryo adenitis
c. Tolosa – Hunt
syndrome (Orbital apex
syndrome/ Sup Orbital
fissure Syndrome)

Col Zulfikar. AFMC. Lecture. 19

 Non- Neoplastic Vascular lesions
Cavernous Sinus thrombosis
1. Acute painful
Ophthalmoplegia (From
Sinisitis/Otitis)
2. Uni/Bilateral Proptosis
3. Systemic features of
infection
4. High mortality rate
5. Rx: Systemic Antibiotics
Col Zulfikar. AFMC. Lecture.
Carotid-Cavernous Fistula
1. A-V fistula (ICA-Cav Sinus)
> rise of venous pressure
2. Types: Direct/ Indirect
3. Usually post-traumatic
(Head Injury)
4. Uni/Bilateral Pulsatile
Proptosis (with Bruit)
Ophtghalmoplegia, Ptosis
5. Rx: Sx ( If NO spontaneous
regression) to save vision
20
 Benign Orbital Tumour
1. Cavernous Haemangioma:
a. Adult , F>M, Axial, Encapsulated, VA may be Normal
2. Deep Dermoid: (Choristoma)
a. Painless swelling, Non Axial, VA normal
b. RX: Excision in toto
3. O N Glioma: (Pilocytic Astrocytoma) (with NF-1)
a. Children , Non Axial, VA reduced
4. O N sheath Meningioma: (From meningothelial cells of
Arachnoid Villi)
a. Middle aged female, Axial, VA reduced
Rx: Surgical Removal for all types

Col Zulfikar. AFMC. Lecture. 21

Haemangioma & Dermoid
Haemangioma Dermoid (superficial & Deep)

Col Zulfikar. AFMC. Lecture. 22

 Glioma & Meningioma
O N Sheath Meningioma O N Glioma

Col Zulfikar. AFMC. Lecture. 23

 Malignant Orbital Tumour
1. Rhabdomyosarcoma
a. Children, Rapidly growing
b. D/D: Orbital Cellulitis
2. Lacrimal Gland Tumour (Pleomorphic Adenoma)
a. Middle age , Infero nasal dystopia
b. NO Biopsy before excision
3. Metastatic Tumour (of Adult)
a. Non axial proptosis
b. Primary site: Breast (70 %), Bronchus, Prostate, Skin,
GIT, Kidney
4. Lymphoma : Bilateral , Elderly, Non-Hodgkin (B Cell type)
Rx: Radiotherapy, Chemotherapy, Surgery
Col Zulfikar. AFMC. Lecture. 24
Inflammation & malignancy
Orbital Cellulitis Rhabdomyosarcoma

Col Zulfikar. AFMC. Lecture. 25

 Take home message
1. Orbital Anatomy: walls, Fissures and Contents
2. Proptosis : Froward displacement of Eyeball
3. Commonest : TED/TAO (Uni/Binocular axial)
4. D/D:
a. IOID (Inflammation + Mild Proptosis )
b. Haemangioma (Axial)
c. Deep dermoid (Non- axial)
5. Investigations : Blood (TSH, FT4), CT Scan
6. Conservative /Steroid/ Radiotherapy/ Surgery

Col Zulfikar. AFMC. Lecture. 26