28 Diss of te edt
Introduction
Applied anatomy
‘The orbit isa pear-shaped cavity whose stalkis the optic
canal (Figure 2.1), The intraorbital portion of the optic
nerve is much longer (25mm) than the distance between
the back of the globe and the optic canal (18mm). This
allows for significant forward displacement of the globe
{proptosis) without causing excessive stretching of the
‘optic nerve
‘The roof consists of two bones: the lesser wing of the
sphenoid and frontal. It is located adjacent to the anterior
cranial fossa and frontal sinus. A defect in the roof of the
orbit may cause a pulsatile proptosis as a result of
transmission of cerebrospinal pulsations to the obit
The lateral wall also consists of two bones: the greater
‘wing of the sphenoid and zygomatic. The anterior half of
the globe is vulnerable to lateral trauma because the
Iateral wall protects only the posterior half of the globe.
The floor consists of three bones: zygomatic, maxillary
and palatine. The posteromedial portion of the maxillary
bone is relatively weak and may be involved in a ‘blow
‘ut fracture. The floor of the orbit also forms the roof of
the maxillary sinus so that maxillary carcinoma invading,
the orbit may displace the globe upwards,
‘The medial wall consists of four bones: maxillary,
lacrimal, ethmoid and sphenoid. The lamina papyracea,
which covers the medial wall, is very thin and is
perforated by numerous foramina for nerves and blood
vessels. For this reason orbital cellulitis is frequently
secondary to ethmoidal sinusitis
Clinical evaluation of orbital disease
wisroRY
The two most helpful symptoms are (1) pain and 2)
mode of onset of proptosis. For example, benign
tumours are usually slow growing and painless, whereas
pain is a feature of inflammatory orbital lesions,
haemorrhage and malignant tumours. Significant points
in the past history are thyroid dysfunction, systemic
malignancies, orbital trauma and sinus disease.
DIRECTION OF PROPTOSIS
Direction of proptosis may give clues as to the possible
pathology (Figure 2.2). For example, spaceoceupying
lesions within the muscle cone, such as cavernous
hhaemangioma and optic nerve tumours, cause an axial
pproptosis, whereas masses in the anterior orbit cause
‘eccentric proptosis with displacement of the globe away
from the Site of the lesion,
SEVERITY OF PROPTOSIS|
This can be measured either with a Hertel exophthalm-
cometer Figure 23) ora plastic rule resting on bone at the
lateral canthus (Figure 24). Measurements should be
taken in both erect and supine positions. The normal
distance between the apex of the comea and the lateral
orbital rim is usually less than 20mm. A reading of
21mm or more is abnormal and a difference of 2mm
between the two eyes is suspicious. The extent of vertical
‘or horizontal displacement of the globe is measured by
Optic foramen Supraorbital noteh
Lesser and,
wings of
Superior ad inferior.
cnbitel Beauree
Zygomatc:
Anterior lacrimal crest
Infrzorbital foramen
Infrzorbital groove | Zygomatic~Mavillary suture
Maxillary
igure 2.1 Aocoy ofthe orbit