Orbit

Bhavna, M Optom, FASCO.

Faculty, Sankara College of Optometry, Bangalore.

Orbit in the skull

Clinical signs of orbital diseases
Soft tissue involvement
Proptosis
Enophthalmos
Dystopia
Ophthalmoplegia: restrictive vs. neurological
Dynamic properties
Fundus changes
Clinical signs of orbital diseases
Signs of soft tissue involvement include
Lid and peri-orbital oedema
chemosis
Lid oedema and chemosis
Lid oedema and chemosis
Clinical signs of orbital diseases
Proptosis
Abnormal protrusion of globe
Caused by retrobulbar lesions or shallow orbit
Asymmetrical is best seen from above and behind
Direction
Axial vs. eccentric
Severity
With a ruler or exophthalmometer

Is it really proptosis? Pseudoproptosis

Asymmetric globe
Myopia
Congenital Glaucoma (buphthalmos)
Microphthalmia
Asymmetric lid height
Ptosis
Lid retraction
Facial palsy
Contralaleral enophthalmos
Orbital asymmetry

Exophthalmometry
Measuring Proptosis Hertel’s Exophthalmometer
Clinical signs of orbital diseases
Proptosis severity
Mild 21-23 mm
Moderate 24-27 mm
Severe >28 mm
Clinical signs of orbital diseases
Enophthalmos
Sunken globe within the orbit
Causes
Atrophy of orbital contents
Orbital floor fracture
Sclerosing orbital lesions
Enophthalmos
Clinical signs of orbital diseases
Dystopia
Displacement of the globe in the coronal plane
May co-exist with proptosis or enophthalmos
Horizontal displacement is measured from midline to the nasal limbus
Clinical signs of orbital diseases
Dystopia
Vertical is read from a vertical scale perpendicular to a horizontal ruler placed over the bridge of the
nose
Eye should be fixating when measurement taken, as squint may be present
Dystopia vs. axial proptosis
Clinical signs of orbital diseases
Ophthalmoplegia
Defective ocular motility
Causes
Orbital mass
Restrictive myopathy eg. In thyroid
Ocular motor nerve involvement eg. CCF
Tethering in blowout fracture
Splinting of optic nerve in optic nerve sheath meningioma
Ophthalmoplegia
Myopathy in thyroid
Clinical signs of orbital diseases
Dynamic properties
Increased venous pressure
Valsava manouvre

Pulsation caused by
Arterio-venous communication (when it is accompanied by a bruit)

Bruit
Due to CCF
Orbital roof
Meningo-encephalocoele
Normal optic disc vs OA
Fundus changes
Choroidal folds
Special investigations in orbital disease
CT scan for bony structures (fracture) and size of tumour etc.
CT guided biopsy in suspected orbital metastasis and orbital invasion by contiguous structures.
(complications ocular penetration and bleeding)
MRI for apex lesions and intracranial extension
Orbital diseases
TED
Can occur in Euthyroidism, hyperthyroidism and hypothyroidism
Risk factors
Thyrotoxicosis or Graves disease

Smoking

Gender: women 5 times more likely

Radioactive iodine used for treating Graves disease worsens TED

Two stages of clinical disease
Thyroid Eye Disease
Clinical manifestations of TED
Soft tissue involvement
Lid retraction
Proptosis
Optic neuropathy
Restrictive myopathy

Clinical manifestations of TED: Soft tissue involvement

Clinical manifestations of TED: Lid retraction
Clinical manifestations of TED: Proptosis
Clinical manifestations of TED: Proptosis
Coronal and axial CT scan
Clinical manifestations of TED: Optic neuropathy
Clinical manifestations of TED: Optic neuropathy
Clinical manifestations of TED: restrictive myopathy
Orbital infections
Preseptal cellulitis
Not strictly orbital disease
Infection of subcutaneous tissues anterior to orbital septum
Has to be differentiated from the more serious ‘orbital’ cellulitis
Preseptal cellulitis
Preseptal cellulitis
Signs
Periorbital oedema
Hyperaemia
Tenderness
Investigations
CT scan shows opacification anterior to the orbital septum
Treatment
Co-amoxiclav
Severe infection (Inj Benzylpenicillin and oral flucloxacillin)
Preseptal cellulitis
Orbital cellulitis
Presentation
Rapid onset of severe malaise, fever, pain and visual impairment
Signs
Unilateral periorbital oedema
Chemosis and hyperaemia
Proptosis, obscured by lid swelling
Painful ophthalmoplegia
Optic nerve dysfunction
CT
Preseptal and orbital opacification
Orbital cellulitis
Orbital Cellulitis
Orbital cellulitis CT
Orbital cellulitis complications
Ocular
Exposure keratopathy
^IOP
CRAO, CRVO
Optic neuropathy
Endophthalmitis
Intracranial
Meningitis
Cavernous sinus thrombosis
Brain abscess
Subperiosteal abscess
Usually along medial wall
Potential for intracranial extension
Orbital abscess
Post-traumatic or postoperative
Orbital vs. preseptal cellulitis
In preseptal cellulitis
Vision not reduced
Proptosis not present
Chemosis absent
Pupillary reactions normal
Ocular motility unimpaired
CT confirms the diagnosis, when in doubt
Lymphangioma
Non-functional benign vascular malformations
Not neoplastic
Can be confused with haemangioma
Presentation in early childhood
Signs
Anterior- bluish discolouration in upper nasal quadrant
Posterior – proptosis (can cause secondary optic nerve compression due to sudden haem)
Blood can get encysted ‘chocolate cyst’
Treatment difficult as friable; cysts can be drained if optic nerve is compressed
Lymphangioma
Lymphangioma
Cysts
Superficial dermoid cyst
Presentation
In infancy with painless nodule
Usually superotemporal
Signs
Firm
Round
Smooth
Non-tender mass
Posterior margins palpable
Tx
Excision in totality, as leaking of keratin can cause reactions
Superficial dermoid cyst
Deep dermoid cyst
Presentation
In adolescence or adult life
Signs
Proptosis
Dystopia
CT
Well circumscribed lesion
Tx
Excision in ‘toto’
Leak may cause fibrosis, recurrence and persistent low grade inflammation
Deep dermoid cyst
Tumours
Capillary haemangioma
Cavernous haemangioma
Pleomorphic lacrimal gland adenoma
Lacrimal gland carcinoma
Optic nerve glioma
Optic nerve sheath meningioma
Metastatic tumours
Capillary haemangioma
Most common tumour of orbit in childhood

Girls > boys

Capillary haemangioma
Capillary haemangioma
Capillary haemangioma tx
Indications
Amblyopia
Optic nerve compression
Exposure keratopathy
Cosmesis
Laser in superficial lesions
In < 2mm thickness
Steroid injection in superficial or preseptal lesions
Systemic steroids in orbital lesions
Local resection with cutting cautery
Cavernous haemangioma
Most common benign orbital tumour in adults

Females > males

Cavernous haemangioma
Presentation
4th to 5th decade
Signs
Axial proptosis
Optic disc oedema
Choroidal folds
CT
Well circumscribed oval lesion
Tx
Surgical excision
Well encapsulated, so easier to excise when compared to capillary haemangioma
Cavernous haemangioma

Pleomorphic lacrimal gland adenoma

Lacrimal gland carcinoma – eversion of lid

Lacrimal gland carcinoma
Optic nerve glioma
Optic nerve glioma
Optic nerve sheath meningioma
Metastatic tumours
Infrequent cause of proptosis (more site for metastasis is choroid)

Source: breast, bronchus, prostate, skin melanoma, GIT and kidney

Metastatic tumours
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