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