Diseases of Orbit

Dr. I Gede Suparta SpM

Bag. Mata FK UNRAM/SMF Ilmu Penyakit
Mata RSU Prop. NTB Mataram

Anatomical considerations

Walls
Apex
Openings
Spaces
Relations
Blood vessels

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Orbital Cavity

Dimensions- conical in shape

Depth- 40 mm
Height- 35 mm
Width- 40mm

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Anatomy of Orbit
Frontal

Optic Foramen

Lesser and Greater

wing of Sphenoid

Lacrimal
Sup Orbital Fissure

Ethamoid
Palatine

Zygomatic

Maxillary

Sketch of orbit by Dr Sanjay Shrivastava

Anatomy of Apex of Orbit

LPS

Sup Orbital Fissure

Sup Oblique Mus

Optic Nerve
Med Rectus Muscle

Annulus of Zinn

Lat Rectus Mus

Inf Rectus Muscle

Sketch of Apex of Orbit by Dr Sanjay Shrivastava

Walls
Roof- is formed by the orbital plate of frontal
bone and lesser wing of sphenoid
Floor- is formed by the maxillary boneorbital plate and maxillary process of
zygomatic bone and orbital process of
palatine bone
Medial wall- is formed by the lacrimal and
ethamoidal bone, frontal process of
maxillary bone and body of sphenoid
Lateral wall- is formed by the greater wing
of sphenoid and zygomatic bone
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Apex
Annulus of zinn giving rise to origin
to extra ocular muscles
Optic canal
Part of superior orbital fissure

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Openings
Optic canal- optic nerve with meninges
and ophthalmic artery
Superior orbital fissureOutside tendinous ring structures
passing outside are:
Lacrimal nerve V1
Frontal nerve -V2
Trochlear nerve
Superior and inferior veins
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Opening
Inside tendinous ring- structures passing
inside the ring are Oculomotor (3rd cranial nerve) upper division
Nasociliary nerve
Abducent nerve (6th cranial nerve)
Oculomotor lower division (3rd cranial nerve)
Inferior orbital fissure-inferior
ophthalmic vein
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Opening
Foramen rotandum - maxillary nerve
Superior orbital notch-supraorbital
nerve and vessels
Infra orbital foramen-infraorbital
nerve and artery

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Spaces

Subperiostial space
Peripheral orbital space
Central space
Tenons space

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Relations

Frontal sinus
Sphenoidal sinus
Maxillary sinus
Ethamoidal air cells

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Common lesions

Proptosis
Exophthalmos- endrocrinal
Enophthalmos
Pseudoproptosis-slight prominence of
eyes like myopia, paralysis of extra
ocular muscles, obese people,
mullers stimulation by cocain

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Proptosis and Exophthalmos

Abnormal protrusion of eye ball is
called proptosis or exophthalmos.
The term exophthalmos is reserved
for prominence of the eye secondary
to thyroid disease

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Proptosis
Abnormal protrusion of globe
It may be Unilateral or Bilateral
Unilateral caused by orbital cellulitis,
idiopathic orbital inflammatory disease,
thrombosis of orbital vein, arterio-venous
aneurysms, tumors of structures of orbit ,
orbital haemorrahge , emphysema.
Bilateral endocrine exophthalmos ,
cavernous sinus thrombosis , symmetrical
orbital tumors, oxycephaly - diminished
orbital volume
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Proptosis

Proptosis

Proptosis in children

Dermoid and epidermoid cyst

Capillary haemangioma
Optic nerve glioma
Rhabdomyosarcoma
Leukaemias
Metastatic neuroblastoma
Plexiform neurofibromatosis
Lymphomas

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Mass lesion in Left orbit

Due Retinoblastoma Stage III

Proptosis in adults
Metastases (of malignancy) from
breast, lung, GIT
Cavernous haemangiomas
Mucocele
Lymphoid tumors
Meningiomas

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Types of Proptosis
Axial proptosis - eye is pushed
directly forwards lesions situated
in optic nerve and central space
Non axial- situated elsewhere in
orbit pushes eye in opposite
direction

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Causes of proptosis in different

in different locations
Extra conal lesions

Intra conal lesions

Muscular disorders

Dermoid cyst

Cavernous haemangioma

Thyroid
ophthalmopathy

Rhabdomyosarcoma

Optic nerve glioma

Pseudo tumor

Extension of nasal
/sinus diseases

Meningioma

Cysticercosis

A-V malformations

Lymphoproliferative
disorder
Rhabdomyosarcoma

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Clinical presentation
Static- as seen usually in congenital causes
Increasing fast- as in cases of
Rhabdomyosarcoma, neuroblastoma,
haemopoetic
Gradual- as in cases of meningiomas
Pulsatile- as in cases of carotid cavernous
fistula
Intermittent- as in cases of orbital varicosity
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Clinical signs

Impaired mobility
Diplopia
Papilloedema
Optic atrophy
Hertel exophthalmometry measures
more than 18 mm
Difference in two eyes of more than 2
mm is considered positive
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Investigations

Careful history recording

Systemic examination
ENT examination
Biochemical and haematological
investigations
Imaging of bony structures- plain x ray
Imaging of soft tissues CT scan, MRI
Vascular study- orbital venography, carotid
angiography, MR angiography, digital
subtraction angiography
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Orbital cellulitis
Definition: Purulent inflammation of the cellular
tissue of the orbit
Causes of Orbital Cellulitis:
Spread of infection from neighbouring structures
like nasal sinuses, eyelids, eyeball (like in case
of panophthalmitis) facial erysiplas etc
Also due to deep penetrating injuries (specially
in cases of retained Foreign body) and
metastatic infection in cases of pyaemia
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Types of Orbital Cellulitis

Two types- pre septal cellulitis and
orbital cellulitis
Pre septal structures anterior to
orbital septum, characterized by
erythema, chemosis, conjunctival
discharge without restriction of
ocular movements and visual
impairment
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Types of Orbital Cellulitis

Orbital

behind
orbital
septum,
characterized severe pain, fever, diminution
of vision (due to retrobulbar neuritis or
compression of optic nerve and /or its blood
supply), massive swelling of lids, chemosis,
proptosis, restriction of ocular movements,
diplopia, an abscess may form pointing
somewhere in the skin of the lid near the
orbital margin or fornix

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Complications
Panophthalmitis
Extension into brain through meninges ,
cavernous sinus thrombosis may develop
In diabetic patients fungal superinfection
may develop

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Management
Culture and sensitivity of pus, if
present and of blood
Treatment Broad spectrum
Intravenous antibiotics , and anti
inflammatory
If abscess has formed Incision and
Drainage under cover of antibiotics
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Cavernous sinus
thrombosis
Due to extension of thrombosis from various
feeding vessels
Superior and inferior ophthalmic vein enter in
front
Superior and inferior Petrosal sinus leave from
behind
Cavernous sinus communicates with facial veins,
lateral sinus, jugular vein, Mastoid emmisary
vein-lateral sinus- superior petrosal sinus

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Cavernous sinus thrombosis

Cavernous sinus on one side
communicates with other side through
transverse sinus
Because of connection with mastoid
through mastoid emmisary vein, mastoid
tenderness is diagnostic feature of
cavernous sinus thrombosis

Source of infection
Orbital veins - as in cases of
eryiepelas, septic lesion of face,
orbital cellulitis , infective condition
of face, mouth, nose, sinuses
Furuncle of upper lip dangerous
area of face
Metastatic infection or septic
condition
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Symptoms and Signs

Patient may present with symptoms and signs of
Orbital cellulitis, there is sever supra-orbital pain
Systemic features headache, fever ,altered
sensorium, vomiting and cerebral symptoms
Transference of symptoms and signs to other
eye (bilateral orbital cellulitis with which it may
be confused is very rare clinical condition).
Mastoid edema and tenderness is present.
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Symptoms and Signs

In case of infection spreading to other eye,
the first sign is involvement of lateral
rectus of other eye
Papilloedema

Treatment
Emergency
Broad spectrum Intra Venous
antibiotics
Anti coagulants
Neurophysicians to be consulted

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Exophthalmos
Endocrine exophthalmos : Graves
Ophthalmopathy (dysthyroid eye
disease) is the commonest cause of
uniocular or bilateral proptosis in age
groups between 25 and 50 years

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Graves Disease
Consists of Exophthalmos, and all signs of
thyrotoxicosis (i.e. tachycardia, muscular
tremors and raised BMR)
In early stage the presentation may be
unilateral, becomes bilateral. Palpabral
aperture is wide open due to lid retraction
(Dalrymple sign). Upper lid fail to follow
downward movement of eye (von Graefe
sign)
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Summary of signs in Graves

disease
Lid retraction
Lid lag (upper and lower
Infrequent blinking and incomplete closure of lids
(Stellwag sign)
Lid edema
Exophthalmos
Conjunctival congestion over the insertion of recti
muscles and chemosis
Convergence insufficiency (Mobius sign) and
Diplopia
Raised intraocular tension may be present
Superior limbic keratopathy
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Werner classification of signs (NO

SPECS)
Grade 0 No signs or symptom
Grade 1 Only sign (lid retraction)
Grade 2 Soft tissue involvement
(Chemosis)
Grade 3 Proptosis (which may be
minimum <23, moderate , marked >28)
Grade 4 Extraocular muscle involvement
Grade 5 Corneal involvement
Grade 6 Sight loss
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Exophthalmic
Ophthalmoplegia
Is proptosis with external ophthalmoplegia
Usually seen in middle aged people , it is
of insidious onset, typically assymetrical
limiting upward movement and abduction
due to swollen, pale edematous, infiltrated
ocular muscles . There is irreducible
exophthalmos with risk of exposure
keratitis , globe dislocation mechanical
compression of optic nerve and ophthalmic
vessels
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Exophthalmic
Ophthalmoplegia
Disease is self limiting with
intermissions and relapses, usually
not affected by any treatment .
Spontaneous resolution may take
place which rarely is complete

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Treatment of Exophthalmic
Ophthalmoplegia
Short term oral steroid therapy (with dose of
40-60 mg) with radiotherapy (1000 rad ) are
effective in controlling soft tissue
inflammation
Exposed cornea should be protected by
doing tarsorrhaphy in less severe cases , by
orbital decompression in more severe cases.
Lateral tarsorrhaphy may also be needed.
Residual muscle palsy is dealt with muscle
adjustment surgery.
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Types
Type I : Characterized by symmetrical
mild proptosis with lid retraction usually
associated with thyrotoxicosis
Type II : Characterized by extreme
exophthalmos, compressive neuropathy
and extraocular muscle involvement.
This form may be associated with any
state of thyroid function, but usually
with hypothyroidism, seen after
thyroidectomy.
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Cause of exophthalmos
Due to edema, lymphocytic
infiltration anf fibrosis of orbital
contents and extra-ocular muscles
Lid retraction is due to contraction of
Muller muscle

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