5. kavita orbit

8/11/2019 5. Kavita Orbit

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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

Sketch of orbit by Dr Sanjay Shrivastava

Frontal

Ethamoid

Zygomatic

Lesser and Greater

wing of Sphenoid

Maxillary

Lacrimal

Palatine

Optic Foramen

Sup Orbital Fissure



Anatomy of Apex of Orbit

Sketch of Apex of Orbit by Dr Sanjay Shrivastava

Sup Orbital Fissure

Annulus of Zinn

Med Rectus Muscle

Inf Rectus Muscle

Lat Rectus Mus

LPS

Sup Oblique Mus

Optic Nerve



Walls

• Roof- is formed by the orbital plate of frontal boneand lesser wing of sphenoid

• Floor- is formed by the maxillary bone- orbital plate

and maxillary process of zygomatic bone and orbitalprocess of palatine bone

• Medial wall- is formed by the lacrimal andethamoidal 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 fissure-

Outside tendinous ring –

structures passing outsideare:

Lacrimal nerve –V1

Frontal nerve -V2Trochlear 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 orbitalvein, arterio-venous aneurysms, tumors of structuresof orbit , orbital haemorrahge , emphysema.

• Bilateral – endocrine exophthalmos , cavernous sinus

thrombosis , symmetrical orbital tumors, oxycephaly- diminished orbital volume

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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 orbitDue 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

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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 Lymphoproliferativedisorder

Rhabdomyosarcoma



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, carotidangiography, MR angiography, digital subtractionangiography

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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 structureslike nasal sinuses, eyelids, eyeball (like in case

of panophthalmitis) facial erysiplas etc

Also due to deep penetrating injuries (speciallyin 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 bloodsupply), massive swelling of lids, chemosis,

proptosis, restriction of ocular movements,

diplopia, an abscess may form pointing

somewhere in the skin of the lid near theorbital margin or fornix

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Complications

• Panophthalmitis

• Extension into brain through meninges , cavernoussinus thrombosis may develop

• In diabetic patients fungal superinfection maydevelop

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Management

• Culture and sensitivity of pus, if present and ofblood

• Treatment –

Broad spectrum Intravenousantibiotics , 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 feedingvessels

• 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 diagnosticfeature 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 lateralrectus 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 50years

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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 followdownward 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 , globedislocation 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 doingtarsorrhaphy 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 mildproptosis with lid retraction usually associatedwith thyrotoxicosis

• Type –

II : Characterized by extremeexophthalmos, compressive neuropathy andextraocular muscle involvement. This formmay 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

5. kavita orbit

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