OPHTHALMOLOGY:

The Orbit

Department of Ophthalmology
Transcriber: Patrick Angelo R. Bautista July 2019
LANDMARKS

INTRODUCTION Landmarks
• The Eye is the organ for sight.
• It is situated in the bony orbit.
• It is protected by orbital soft tissue including the eyelids.

CLINICAL ANATOMY OF THE ORBIT

Orbit

• A pear–shaped cavity, tapering posteriorly

• With a stalk – optic canal
• Intraorbital portion of the optic nerve – 25 mm
• Globe to the optic canal – 18 mm • Lateral orbital tubercle - • Optic foramen
Lateral canthal tendon • Superior orbital fissure
Orbital Bones ORBITAL BONES • Medial canthal tendon (ant • Inferior orbital fissure
and post crus) • Ant and post ethmoidal
• Anterior lacrimal crest foramina
• Posterior lacrimal crest • Zygomatico maxillary and
• Nasolacrimal canal Zygomatico facial foramina
• Lacrimal Sac fossa • Supraorbital foramen
• Lacrimal gland fossa • Infraorbital groove, canal,
foramen
• Orbit is lined with periorbita (periosteum)
• Orbit is lined with periorbita (periosteum)

• Anteriorly limited by orbital septum
• Anteriorly limited by orbital septum
• Orbital contents supported by fine network of septae Apertures/ Notches
• Orbital contents supported by fine network of septae
• Orbital growth mature at 7 years of age

• Orbital growth matures at 7 years of age Supraorbital Notch or Foramen

• Supraorbital neurovascular bundle
Orbital Walls • The supraorbital branch of the frontal nerve (supraorbital nerve)

exits at the supraorbital notch with the supraorbital artery

Zygomatic Foramina
• Zygomaticotemporal (to temporal fossa)
• Zygomaticofacial (to cheek)

Infraorbital Foramen
• Infraorbital groove → canal → foramen
• Infraorbital Neurovascular Bundle (V2)
• Zygomatic Branch of Maxillary Division of CN V
• Infraorbital Nerve & Vein
• Inferior Orbital Vein
Notes from old Trans:
• Lateral walls - perpendicular; length = 40 to 45 mm long Nasolacrimal Canal
• Medial walls - parallel, 25 mm apart; length = 45 to 50 mm long • In the extreme anteromedial wall of the maxillary sinus

• Separated from both the sinus and the nasal cavity by a thin lamina
• Medial walls are parallel to each other 2.5 cm apart
of bone
• Lateral walls at right angles to each other
• Lacrimal sac fossa to inferior meatus
• Lateral rims are recessed 2 – 3 cm
Ethmoidal Foramina
Superior Wall/ Roof Lateral Wall
• Anterior Ethmoidal Foramen – branch of Nasociliary Nerve
• Frontal • Frontal
• Posterior Ethmoidal Foramen
• Lesser wing of the Sphenoid • Zygomatic

• Greater wing of the Sphenoid
Superior Orbital Fissure
Inferior Wall Medial Wall
• Maxillary • Maxillary • Outside of Annulus of Zinn
• Zygomatic • Lacrimal o CN IV, Lacrimal, Frontal, SOV
• Palatine • Ethmoid • Annulus of Zinn
• Lesser wing of the Sphenoid o Oculomotor Foramen, CN III (sup/inf), CN VI, Nasociliary

Adult Orbital Dimensions

Horizontal Entrance Width 40 mm

Vertical Entrance Width 35 mm
3
Volume 30 cm
Orbital Depth 45 – 55 mm
from rim to the optic strut
3
Globe 7.5 cm
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Inferior Orbital Fissure LANDMARKS OF THE EXTERNAL EYE
Landmarks of the External Eye

Superior
Optic Canal eyelid crease
• Optic Nerve, Ophthalmic Artery, Sympathetic Nerves Plica
• Optic Foramen semilunaris

o Orbital End of Canal

o Adult Size by 3 years of age; <6.5 mm Medial canthal Lateral
canthal angle
• Optic Strut angle

o Separates from SOF Caruncle

Optic Nerve
• Neural fibers from the optic nerve arise from primitive neuroblasts
that become the ganglion cells in the retina & grow toward the brain • The upper eyelid margin lies at the superior corneal limbus in
•The upper eyelid margin lies at the superior corneal limbus in
children and 1.5 to 2 mm below it in the adult.
• The retina differentiates from the wall of the forebrain → the optic children and 1.5 – 2 mm below it in the adult.
•The lower eyelid margin lies at the inferior corneal limbus
nerve is NOT a true peripheral nerve but an evaginated fiber tract • The lower eyelid margin lies at the inferior corneal limbus
from the diencephalon
• are customarily classified as a special somatic sensory cranial nerve Eyebrows

• In the adult, about 50 mm in length from optic disc to optic chiasm Eyebrow Position
• Each nerve contains approximately 0.7 to 1.4 million axons, with a • Rests on superior orbital rim
mean axon diameter of 0.85 um • Medial - nasal ala

• Apex - temporal corneal limbus on 1° gaze and lateral commissure
INTRAOCULAR INTRACANALICULAR • Lateral - nasal ala and the lateral commissure
• Within the posterior sclera: • 5 – 6 mm in length

lamina cribrosa
• 1 mm in length
INTRAORBITAL INTRACRANIAL
• Immediately behind the sclera • From the intracranial opening
• Become myelinated by of the optic canal to the optic
oligodendrocytes & chiasm Females: thinner, gently arched Males: fuller and flatter
surrounded by pia, arachnoid • 10 mm long (3 – 16 mm)
and dura matter → Eyebrow Cilia
enlargement to 3 – 4 mm in • large vascularized follicles
diameter as it exits the globe • first to elaborate terminal hairs
25 - 30 mm length: • varied distribution, direction of growth
redundancy for ocular motility

Surgical Spaces of the Orbit

Eyebrow Muscles
Surgical Spaces of the Orbit

Frontalis and Corrugator Muscles
• Intraconal space • brow elevation
•o Intraconal space • Tenon’s space
central surgical space, contains the optic nerve and orbital fat • forehead horizontal furrows
• •Extraconal space
Extraconal space • Extraorbital space
o peripheral surgical space, contains the lacrimal gland, superior Eyelid
• Subperiosteal space
oblique muscle & trochlea, nerves and vessels in the extraconal

orbital fat Eyelid “Vital Signs” - Margin Reflex Distance

• Subperiosteal space MRD1
o potential space between orbital bones and periorbita • Distance from the central light reflex to the upper lid margin
• Tenon’s space • Normal value: 4 – 5 mm
o between the eye and fibrous Tenon’s capsule
• Extraorbital space or periocular tissue MRD2
o Includes all structures surrounding the orbit: bone, brain, • Distance of the lower lid from the corneal light reflex
sinuses, nasal, skin, and conjunctiva • Normal value: 5 mm

Palpebral Fissure (MRD1 + MRD2)
• Normal value: 9 – 10 mm

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ANATOMY
Anatomy of the Eyelid OF THE EYELID

LAMELLAE
ANTERIOR
• Skin

• Orbicularis Oculi

• Lid Retractors

• Orbital Septum

POSTERIOR
LAMELLAE
• Tarsus

• Horizontal length: 25 – 28 mm
• Central vertical height:
• Conjunctiva
o Upper: 8 – 12 mm
o Lower: 3.5 – 4 mm
Eyelid Skin
• Contains Meibomian glands
• thinnest of the body; no subcutaneous fat layer
• subjected to constant movement with each blink
• very minimal dermal tissue Conjunctiva (Eyelid Posterior Lamella)
• non-keratinizing squamous epithelium
Orbicularis Oculi ORBICULARIS OCULI • contains goblet cells, and accessory
Frontalis
glands of Krause and Wolfring
Frontalis
Corrugator
muscle
Orbital
Preseptal Levator Muscle (Upper Eyelid Retractor)
Pretarsal
Procerus • The levator muscle originates in the
apex of the orbit from the periorbita of
the lesser wing of the sphenoid.
D Santiago, MD, MBA for • The superior division of the oculomotor
FEU-NRMF
nerve innervates the levator muscle.
• The aponeurosis lies behind the orbital
septum and fat, loosely connected to
the orbicularis muscle anteriorly except
for the slips of tissue that form the
Eyelid Margin eyelid crease. UPPER EYELID RETRACTOR
• Mucocutaneous Junction • Disinsertion, dehiscence, or rarefaction of the aponeurosis may
MULLER’S MUSCLE
• Meibomian gland Orifices result to ptosis.
o Upper – 25 glands
D Santiago, MD, MBA for
FEU-NRMF
o Lower – 20 glands • Muller’s muscle originates
Muller’s Muscle
posterior to the levator
• Lash Line (Upper Eyelid Retractor)
o 2 – 3 irregular rows aponeurosis
• Muller’s muscle originates
o upper eyelid lashes: 100 – 150; 8 – 12 mm • 10-12 mm in height.
posterior to the levator
o lower eyelid lashes: 50 – 75; 6 – 8 mm aponeurosis
• provides approx. 2 mm of
o glands of Zeiss and Moll • 10 – 12 mm in height.
elevation of the upper
• provides approx. 2 mm of
eyelid
elevation of the upper eyelid
• • inserts on the superior
inserts on the superior tarsal
border tarsal border

Orbital Septum
Gray Line • the anterior most septal sheet of the orbital fascial complex
• surface anatomic landmark used in the repair of lacerations
involving the lid margin
• Corresponds histologically to the most superficial portion of the
orbicularis muscle – “muscle of Riolan”

Tarsal Plates
• It is medially and laterally connected to the bony orbital margins by
ligamentous fibrous tissue
• Dense fibrous tissue approx. 1 – 1.5 mm thick
• Give structural integrity to the eyelids

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Soft Tissues Ciliary Ganglia
• the anterior most septal sheet of the orbital fascial complex • Ganglion is small, irregular
o Periorbita o Extraocular Muscles • measuring 2 mm horizontally by 1 mm vertically
o Orbital Fat o Annulus of Zinn • Postganglionic fibers pass from the ciliary ganglion into 4 to 6 short
o Optic Nerve o Vascular System
posterior ciliary nerves
o Other Nerves o Lacrimal Gland
• 95 – 97% innervate the ciliary muscle, 3 – 5% destined for the

pupillary sphincter muscle of the iris
Periorbita
• Lies about 10 mm anterior to the SOF and 7 mm anterior to the
• Fuses to dura of optic nerve, orbital septum, periosteum annulus of Zinn
• Tightly adherent: arcus, sutures, fissures, foramina, canals • In retrobulbar anesthesia, anesthetic agent must be placed in the
• Arcus Marginalis – fusion of periorbita, orbital septum, periosteum vicinity of the ciliary ganglion and the motor nerves to the EOMs to

achieve both sensory and motor blockade
Orbital Fat

• Surrounds globe, muscles, nerve Oculomotor Nerve (CN III)
• Divided by fibrous septae (one cause of post-trauma motility
• Carries somatic motor fibers to MR, SR, IR muscles; IO muscle, and
restriction even without muscle entrapment)
levator palpebrae superioris muscle

• Carries parasympathetic fibers to intrinsic muscles of the eye &
Preaponeurotic Fat Pockets
sensory neurons from proprioceptive receptors in EOMs it innervates
• Within the main nerve trunk, pupilomotor fibers maintain a
• Immediately behind the septum superomedial position → lesions located in the cavernous sinus
are the preaponeurotic fat result in partial 3rd nerve palsies with sparing of pupillary function
pockets • Complete dysfunction of the CN III results in a downward outward
• Upper eyelid 2 fat pockets: deviation of the globe with ipsilateral upper lid ptosis
medial and central
• Lower eyelid 3 fat pockets: Trochlear Nerve (CN IV)
central, lateral and medial. • Innervate the contralateral SO muscle
• Has a long intracranial course.
Lacrimal Gland • Part of its orbital extent lies adjacent to the bony wall; thus, it is
• Within lacrimal fossa in superolateral orbit predisposed to injury from blunt head trauma
• Orbital & Palpebral lobes – divided by lateral horn of Levator
Aponeurosis Abducens Nerve (CN VI)
• Ducts from both lobes pass through the palpebral lobe • It is the last of the motor nerves to appear in embryogenesis: first
seen in 8-week stage of development
Nerves o Failure to develop may result in aberrant innervation of the LR
• II: Optic Nerve – optic foramen muscle by the CN III (Duane’s syndrome)
• III: Oculomotor Nerve – SOF intraconal • Unlike the CN III and CN IV, it does not lie within the lateral wall of
• IV: Trochlear Nerve – SOF extraconal the cavernous sinus but runs within the body of the sinus → 1
st

• V: Trigeminal Nerve – SOF nerve affected by an intracavernous carotid aneurysm

o Nasociliary – SOF intraconal
o Lacrimal, frontal – SOF extraconal Other Nerves
o Infraorbital nerve V2 – IOF • Parasympathetic
• VI: Abducens Nerve – SOF intraconal o Accommodation, pupil constriction, lacrimal stimulation;
complicated course
Sensory Nerves
• Sympathetic
The sensory component of the trigeminal nerve carries fibers for pain,
o Pupil dilation, vasoconstriction, Muller’s muscle, hidrosis;
touch, temperature and proprioception from the eye, face and scalp
follows arterial supply
V1 V2
• Facial Nerve (CN VII)
• Frontal • Zygomatic
o Not an orbital nerve
• Lacrimal
o Supply motor fibers to eyelid protractors temporal and
• Nasociliary
zygomatic branches
• Infraorbital
o Parasympathetic fibers to the lacrimal gland

o Hemifacial spasm results from a vascular cross- compression of
Motor Nerves
the facial nerve root
CN III CN IV CN VI

Inferior: IR, MR, IO
SO LR Extraocular Muscles
Superior: SR, Levator
O O O
EOM 1 2 3 CN
Trigeminal Nerve (CN V) MR Adduct III
• Consists of a small motor and a larger sensory component
LR Abduct VI
• Three main divisions: ophthalmic, maxillary and mandibular SR Elevate Adduct Intort III
• Ophthalmic division – major sensory input from the eyelids & orbit IR Depress Adduct Extort III
• Maxillary division – contributes small component from the lower lid SO Depress Abduct Intort IV
• Mandibular IO Elevate Abduct Extort III
• The motor fibers supply the masseter, temporalis, internal
pterygoid muscles; tensor tympani; tensor veli palatini; omohyoid;
and the anterior belly of the digastric muscle

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LACRIMAL SYSTEM
2 Components of the Lacrimal Apparatus:
1. SECRETORY SYSTEM
o structures that contribute to the formation of the
o middle (aqueous) layer
2. EXCRETORY SYSTEM
o structures that form the conduit by which the tears pass
from the conjunctival fornices into the nasal cavity

Hyperlacrimation VS. Epiphora
From Anatomy of the Eye Topic
• True epiphora – watering due to obstruction in the lacrimal outflow

• Hyperlacrimation – excessive watering due to irritation of the
In general:
corneal surface, as in cases of dry eye, corneal abrasion or corneal
• All oblique muscles are abductors
foreign body
• All vertical recti muscles are adductors

• All superior muscles are intorters
Lacrimal Gland
• All inferior muscles are extorters
• Within lacrimal fossa in superolateral orbit
Arterial Supply to the Orbit • Orbital & Palpebral lobes – divided by lateral horn of levator
aponeurosis

• In the adult, the vascular supply to the orbit derives primarily from
• Orbital lobe
the internal carotid artery
o 65% -75% of the gland
• The ophthalmic artery carries the major blood supply to the orbit in
o 20mm long x 5mm thick x 12mm wide
96% of individuals. In about 3%, the middle meningeal artery shares
• Palpebral lobe
equally through an enlarged accessory ophthalmic (“recurrent
o 25%-35% of the gland
meningeal”) branch. In 1% of individuals, the middle meningeal

artery is the only source of arterial blood to the orbit
The Lacrimal System
• The order of branching along the arterial tree varies considerably
• Ophthalmic Artery supplying branches to: • The path for tears to travel from the eye into the nose begins at the
o Muscular arteries, central retinal arteries, ciliary arteries punctum & continues into horizontal canaliculus towards the nose
o Anastomosing with branches of External Carotid Artery • Most of the tear flow is actively pumped from the tear lake by the
orbicularis muscle
Venous System of the Orbit • Evaporation accounts for approximately 10% of tear elimination in

• The orbital venous system is composed of two major vessels: the the young, and up to 20% or more in older adults
superior and inferior ophthalmic veins • The lacrimal puncta conduct the tear fluid from the tear meniscus
• Unlike the arterial system in the orbit, the veins maintain an and lacrimal lake into the ampulla and canaliculi
intimate relationship with the orbital fascial systems → more • This is effected by a lacrimal pump mechanism that actively pumps
vulnerable to compression by enlarging adjacent muscles or masses tear into the sac with each blink.
• The orbital veins do NOT contain valves, and blood flow within them
depends largely on local pressure gradients. OCULAR EXAMINATION
• The major drainage is backward to the cavernous sinus, secondary • Visual acuity
flow is into the pterygoid plexus and in some may drain forward to • Pupillary examination
the fascial system • Slit lamp examination
• The orbital veins do not follow a course parallel to the arteries, as do • Intra-ocular pressure
the veins in other parts of the body. • Fundoscopy
• Exceptions: lacrimal and ethmoidal veins • Extraocular muscle movements
• Venous Drainage
o Superior Ophthalmic Vein to Cavernous Sinus Visual Acuity
o Inferior Ophthalmic Vein to Pterygoid Plexus

• Goal: Obtain the best objective estimate of visual function

• The measurement of even a very poor initial acuity serves as a
Lymphatic System
pretreatment baseline of visual function that may become
• The primary function of lymphatic vessels is to return to the vascular
important should litigation ensue
compartment large protein molecules and excess fluid extravasated
• The finding of NLP versus bare light perception may have a profound
into tissues from the blood.
impact on subsequent surgical decisions
• Two Divisions:

o Superficial system – drains the skin and orbicularis oculi muscle
Afferent Pupillary Defect
o Deep system – drains the tarsi and the conjunctiva

• Preauricular Nodes – Drainage from the: • Pupillary reactions measured

o lateral 2/3 of the upper lid in dim light
o lateral 1/3 of the lower lid • Record response to direct
o lateral half of the conjunctiva illumination, a near target
• Submandibular Nodes – Drainage from the: and the presence of an
o medial 1/3 of the upper eyelid afferent pupillary defect
o medial 2/3 of the lower eyelid • An APD indicates
o medial half of the conjunctiva involvement in the afferent
• Anterior & Deep Cervical Nodes pathway, found with optic
nerve lesions

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FUNDOSCOPIC CHANGES
Fundoscopic Changes Secondary to Orbital Disease
Secondary to Orbital Disease SPECIAL INVESTIGATIONS

Plain Radiographs

Orbital tumors : diagnosis and treatment

[ed] Zeynel A. Karcioglu, MD © 2005 Springer

ADVANTAGES DISADVANTAGES
• Metallic FBs eye/orbit • Localization of FB
• Readily available • Radiolucent FB
• Cost effective • Often misses significant ocular
• May diagnose orbital wall / and orbital injury
Exophthalmometry RADIOGRAPHY
skull fracture/s
• Exophthalmometry measures anterior projection of cornea relative

to lateral orbital rim and quantifies amount of proptosis or ◼ Water's view - the single most
enophthalmos valuable radiograph , visualising
• Measurements between the two eyes are usually within 2 mm of maxilla, maxillary sinus, orbital
floor and rim, zygomatic bone,
each other nasal bone, mandible

fractures ·
Race Hertel measurement (mm)
◼ Submentovertex - visualization of
Asian 18 the zygomatic arches and any
Caucasian 20 impingement of these bones upon
African American 22 the coronoid process of the
mandible Waters' radiograph. This reveals
◼ Frontal (Caldwell) and lateral herniation of fat into the left maxillary
sinus, due to an orbital floor fracture.
sometimes helpful for
Water's view
visualization of frontal bone,
zygomaticofrontal suture, frontal
• single most valuable x-ray, visualizing maxilla, maxillary sinus,
sinus, medial orbital rim, ethmoid
orbital floor & rim, zygomatic & nasal bone, mandible fractures

Submentovertex
• visualization of the zygomatic arches and any impingement of these
GLOBE REPOSITION bones upon the coronoid process of the mandible
Frontal (Caldwell) and lateral
• sometimes helpful for visualization of frontal bone,
zygomaticofrontal suture, frontal sinus, medial orbital rim, ethmoid

Ultrasound

ADVANTAGES DISADVANTAGES
• Posterior segment pathology • May miss deep orbital FBs
CLINICAL EVALUATION with media haze (next to orbital wall)
• Direction of proptosis – clues to pathology • Can detect and localize FB in • Contraindicated in suspected
o Lesions within the muscle cone cause an axial proptosis anterior orbit open globes
o Lesions outside the muscle cone cause eccentric proptosis • Can determine lens position • Muscles poorly defined
• Severity of proptosis – measured by Hertel Exophthalmometer • Posterior optic nerve poorly
o Distance – lateral orbital rim and apex of the cornea < 20mm visualized
• Impaired ocular Motility – evaluated Forced Duction Tests • miss scleral ruptures (25%)

o Restrictive myopathy
MRI
o Third nerve palsy

o Tethering of an extraocular muscle NEVER a primary imaging study for trauma

o Splinting of the optic nerve And is contraindicated with metallic foreign body

FORCED DUCTION TESTS ADVANTAGES DISADVANTAGES

POSITIVE NEGATIVE • Excellent soft tissue • Poor visualization of bone
• Difficulty or inability to move • No resistance encountered delineation • Longer scanning time
the globe with the forceps • Blood in eye/ brain diagnosed • Metallic foreign body
indicates a restrictive problem easily
• Vegetable FBs diagnosed
• Impaired Visual Acuity • Optic nerve/ Optic canal
o Choroidal folds at the macula anatomy better visualized
o Optic nerve compression
o Exposure keratopathy
• Diplopia – double vision due to lesions affecting EOM

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MRI (continuation) Indirect or “Blow-Out” Fractures
• 1 – 2 walls (floor, medial wall)
T1 Weighted Sequences T2 Weighted Sequences • rim uninvolved

• Indirect or blowout fractures result
from blunt trauma with a non-
penetrating object such as a fist or a
ball which results in sudden increase
in intraorbital pressure.
• The orbit is acutely decompressed by
“blowing out” the susceptible orbital bones.
provide the best anatomical Not ideal for imaging normal
details of the orbit because they anatomy; Useful in revealing Complex Fractures
display superior contrast pathologic conditions • >1 wall; rim involved
resolution between normal Easily recognized by a bright • Zygomatico-maxillary complex or “tripod” fracture
structures vitreous signal
• Naso-orbital-ethmoidal (NOE) fracture
Yields maximum energy release
• Le Fort I, II & III midfacial fractures
per unit time → higher resonance
signal → BRIGHTER IMAGE
Orbital Floor Fractures
CT Scan • Vertical diplopia
EOM rounding on CT

•
• Infraorbital nerve hypesthesia
• Orbital/subcutaneous emphysema
• Enophthalmos
• Oculocardiac reflex
o aka Aschner phenomenon, Aschner reflex, or Aschner-Dagnini

reflex, is a ↓ in pulse rate associated with traction applied to
ADVANTAGES DISADVANTAGES extraocular muscles and/or compression of the eyeball.
• Exact determination of orbital • Thick slices may miss small FB • Pupil abnormalities
fracture/s • Multiple FBs – artifacts may be
• Helps determine Zygoma/ Le Fort misleading ZMC “Tripod” Fracture
fractures • Dental filling interference • Frontozygomatic suture
• Good soft tissue delineation • Wooden FBs missed • Zygomaticomaxillary suture
• Deep orbit / intracranial / PNS frequently • Zygomatic arch
visualization • Exposure to radiation* • Orbital floor
• Readily detects air in globe/ orbit • Signs and Symptoms: Point tenderness,
• Most radiolucent FBs diagnosed Ecchymosis, Malar flattening, Lateral rim
(except wood) step-off, Lateral canthal dystopia
• Localization of FB – globe, orbit, (downward displacement), V2
intracranial hypoesthesia, Trismus, Malocclusion of jaw
• Contrast – vascular lesions
*Radiation dose is far below the threshold for cataract formation
NOE (Nasal-Orbital-Ethmoid)/ Medial Wall Fracture
Cataract formation is believed not to occur with doses < 1-2 Gy for a single exposure
• Facial flattening

ORBITAL IMAGING SUMMARY • Telecanthus – Increased intercanthal

distance)
CT MRI UTZ • Epistaxis, CSF rhinorrhea, Anosmia
Localization + + • Horizontal diplopia
Topography + + • Enophthalmos
Bone + • Nasolacrimal damage
Tissue Diff’n + + • Optic canal damage
Optic Nerve +

Intraocular +
Orbital Roof Fracture

• Restricted upgaze
ORBITAL FRACTURES • Ptosis

Resistance of Various Parts of the Facial Skeleton to Fracture- • Epistaxis, CSF rhinorrhea
producing Forces: nasal bone (least resistant) • Anosmia
• Depression of superior rim
• V1 hypoesthesia
• hypo-ophthalmos
• Pulsatile exophthalmos
• Traumatic optic neuropathy
• May represent a threat to life by:
o Direct CNS injury
o An intracranial foreign body
o Presence of a dural tear with CSF leakage
• may develop Pneumocepahalus, brain abscess, infectious meningitis


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MISDIRECTED EYELASHES and EYELID MALPOSITIONS Eyelid “Vital Signs” – Levator Function

• The levator function is the amount of movement of the upper eyelid
from downgaze to upgaze
• Normal value: 15 mm
• Levator Function:
o Good: > 12 mm
o Fair: 5 - 11 mm
o Poor: < 4 mm
• The retractive and protractive forces constitute the external forces
in the lid • Normal levator function
o In involutional ptosis
Trichiasis o Treatment: levator aponeurosis advancement option

Primary trichiasis • Reduced levator function

• Managed conservatively o In simple congenital ptosis
o Epilation o Treatment: frontalis sling operation
o Soft contact lenses
o Electrolysis - valuable if only a few lashes are affected Types of Ptosis
• A new lash will regrow in 6 weeks • Simple Congenital Ptosis
• If more than a few lashes are involved, a more complex surgical o Usually bilateral
approach is recommended o Mild to severe
o Reduced levator function
Secondary trichiasis o Weak or absent skin crease
• If the trichiasis is secondary to a primary lid abnormality, surgical • Involutional Ptosis
correction of the lid position resolves the trichiasis o Often bilateral
o Normal levator function
o High skin crease
o Brow elevation with deep forehead wrinkles
• Unusual Ptosis

INFECTIONS

Hordeolum
NORMAL LOWER LID ENTROPION • Acute infection of Meibomian gland
MARGIN Laxity of the lower lid (internal stye or acute chalazion) or Zeis’ or
Retractors pull the lower retractors is the primary
margin of the tarsus inferiorly and cause of involutional Moll’s gland (external or common stye)
posteriorly, stabilizing the eyelid entropion. • may become chalazia (chronic)

Districhiasis
DISTRICHIASIS: Incomplete row of eyelashes arises
from the meibomian gland orifices
• Incomplete row of eyelashes arises from the Meibomian gland
Incomplete row of eyelashes arises from the meibomian
orifices Chalazion
gland orifices • lipogranulomatous inflammation within the
Entropion ENTROPION Meibomian gland
• Eyelid margin turns inward against the globe • acute stage: appears as a generalized painful
- Eyelid• margin
Causes: turns INWARD against the globe swelling, more commonly in the lower lid
CAUSES: o Congenital - Rare; caused by hypertrophy/ excess of skin and • may resolve spontaneously or progress to
– Congenital
underlying orbicularis oculi muscle which is poorly attached to
Rare; caused by
hypertrophy/ excess
◼
the chronic stage
the lower eyelid retractors of skin and
underlying orbicularis
o Spastic oculi muscle which is
Cellulitis

o Involutional poorly attached to the

lower eyelid Preseptal Cellulitis Orbital Cellulitis
o Cicatricial
– Spastic retractors
Vision Normal May decrease
– Involutional Pupillary Reaction Normal AbN, + APD
Proptosis (-) (+)
ECTROPION
ECTROPION Orbital Pain (-) (+)
•• Malposition
Malposition ofofthe
the eyelid
eyelid in in which
which the
the upper
upper or
or Pain on Motion (-) (+)
Motility Normal Decreased
–lower
lower eyelid
eyelid falls,
Cicatricial falls,or
Ectropion
or isis pulled
pulledaway
awayfrom
fromits
its
normal
normal apposition
appositionto tothethe globe
globe Chemosis Rare Common
• Malposition of the eyelid in which the upper or lower eyelid falls, or Corneal Sensation Normal May decrease
is pulled away from its normal apposition to the globe Ophthalmoscopy Normal Venous Congestion
CLASSIFICATION:
CLASSIFICATION:
• Classification: Disc Edema
1.
1.Flaccid o --Flaccid – excess relaxation of eyelid tissues
Flaccid excess
excessrelaxation
relaxation of
of eyelid
eyelid tissues
tissues
o Cicatricial – deficiency of tissue in the anterior lamellae
2.
2.Cicatricial
Cicatricial --deficiency
deficiency of oftissue
tissue in
in the
the anterior
anterior
o Mechanical
lamellae
lamellae
3.
3.Mechanical
Mechanical

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Orbital Inflammation Idiopathic Inflammatory Pseudotumor

Specific (Thyroid – related Eye Disease) vs. Non-Specific (Pseudotumor) Clinical Characteristics
• Abrupt onset
Thyroid Disease • Unilateral - The left orbit is affected twice as often as the right
• Prevalence of thyroid fxn abnormalities in the Philippines: 8.53% • Bilateral orbital involvement, either simultaneous or separated by
o subclinical hyperthyroidism: 5.33% variable intervals, occurs in almost half of the cases
o true hyperthyroidism 0.61% • NO sex predilection
o true hypothyroidism 0.41% • Rapid development
o subclinical hypothyroidism 2.18% • Blurring of vision – 6/12 or better in 75%
• Females: 55% • Optic nerve head edema is noted in one third of cases.
• Mean age: 48 years (95% CI 45.9-50.1 years) • Systemic complaints variable but may include fever, malaise,
anorexia, and nausea.
• Orbital symptoms may follow an upper respiratory tract infection

Presentation
• Proptosis, Eyelid edema, Pain, Chemosis, conjunctival vascular
engorgement

Subtypes Orbital Imaging Studies have allowed

• Anterior the topographical subdivision of IIPT
• Diffuse into:
• Lacrimal • Myositis
• Myositic • Dacroadenitis
• Apical • Episcleritis/ Tenonitis/ Perineuritis
• Localized mass

MYOSITIS THYROID OPHTHALMOPATHY

Thyroid Related Eye Disease
• VON GRAEFE’s - upper eyelid lag on downgaze
• GRIFFITH’s - lower lid lag on downgaze
• STELLWAG’s - incomplete and infrequent blinking
• KOCHER’s - spasmodic retraction of upper lid during fixation
• ROSENBACH’s - tremor of gently closed lids
• THYROID - RELATED EYE DISEASE
GIFFOR’s - difficult eversion of upper lid
• THYROID - RELATED EYE DISEASE
GROVE’s - resistance to downward pull of upper eyelid

Insertion of the muscle is widened in myositis, whereas it is spared in thyroid (arrows)

• Insertion of the muscle is widened in myositis, whereas it is spared
V indicates vitreous cavity. (Bottom): A-scan shows that thickened muscle (M) is low reflective in
in thyroid (arrows)
myositis but is higher and more irregular in thyroid disease
• V indicates vitreous cavity. (Bottom):

o A-scan shows that thickened muscle (M) is low reflective in
myositis but is higher and more irregular in thyroid disease

ORBITAL SURGERY

Evisceration
• Removal of the intraocular contents; sclera & EOM intact
• Indication: Treatment of endophthalmitis
EXTRAOCULAR MUSCLE • Advantages:
o Technically simpler procedure
o Less disruption of orbital anatomy
o Good motility of the prosthesis
o Lower rate of implant migration/
extrusion and reoperation

Enucleation
• Removal of entire globe
MUSCLE BELLY
• Indications:
ENLARGEMENT TENDON-
SPARING o Primary intraocular malignancies
o Intraocular pathology is unknown
or ocular tumor is suspected –
allows complete histologic exam of
the eye and optic nerve
Normal Thyroid-related Eye Disease • Advantage:

o Reduces risk of sympathetic ophthalmia in the fellow eye

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Exenteration DIAGNOSIS AND MANAGEMENT OF PATIENT WITH TEARING
• a radical procedure in which part or all of the orbital soft tissues

are removed Findings Suggesting Obstruction of the Lacrimal System

• It is used primarily for life-threatening disease processes NOT • Epiphora
treatable by more conservative methods • Unilateral symptoms
• Primary malignant tumors of the conjunctiva & eyelids that involve • History of dacryocyctitis
deeper orbital tissues • Onset after the following:
• Non-malignant diseases o Conjunctivitis
o Orbital mucormycosis – diffuse or w/ extensive necrosis o Facial fracture
o Patients who have severe proptosis & orbital pain from diffuse o Nasal surgery
lymphangiomas or other benign tumors
• Adenoid cystic carcinoma of the lacrimal gland, resection of Treatment of Congenital Nasolacrimal Duct Obstruction (NLDO)
adjacent bone may be necessary for complete tumor excision • Obstruction of the valve of Hasner is the cause
• Use massage and topical antibiotic
Orbitotomy • Most spontaneously resolve by the end of the first year of life
Transorbital Approaches
• Anterior orbitotomy without osteotomy or with osteotomy of the Dacryocystorhinostomy (DCR)
superior orbital rim • Fistulizes the lacrimal sac to the nasal cavity
• Lateral orbitotomy • Indications for DCR
• Medial orbitotomy o Acquired NLDO with patent canaliculi
• Combination of the lateral and medial orbitotomies o Persistent CNLDO after probing & intubation
o Chronic dacryocystitis
Anterior Orbitotomy o Lacrimal sac foreign body
• Access to lesions in the subperiorbital or anterior peripheral surgical • Absolute contraindication to DCR
space o Lacrimal sac malignancy
• Majority can be palpated near the orbital rim § procedure of choice is dacryocystectomy
• Inflammatory tumors • Highest success rate (75-100%); “Gold Standard”
• Lymphomas • Disadvantages:
• Cystic masses o Presence of external scar
o Complications: post-operative nasal bleeding, injury to the
Lateral Orbitotomy medical canthal tendon
• First proposed by Kronlein in 1889 for a large orbital & temporal
fossa dermoid cyst Reference: PPT by FEU-NRMF Department of Ophthalmology
• Standardized in 1976 by Maroon & Kennerdell No proof reading done. Use at your own risk.
• Useful for retrobulbar lesions & can be extended for more posterior
lesions Involves temporary removal of the lateral wall of the orbit to
gain access

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