ORBITAL

DISEASES
Tinatin Jikurashvili PhD
Ophthalmologist Laser surgeon
Associated professor
Orbital Diseases

■ Congenital
■ Inflammatory – thyroid ophthalmopathy
■ Infectious – orbital celullitis
■ Neoplastic- primary, secondary
■ Vascular anomalies – Carotid –cavernous fistula
■ Traumatic – blow-out fracture
 Symptoms
■ Proptosis ( the hallmarks of orbital disease)
The normal range is 12–21 mm. A difference greater than 2 mm between the eyes is
significant
■ Enophthalmos – blow out fractures
■ Binocular Diplopia
■ Visual impairment
■ RAPD
■ Color vision impairment
■ Limitation of ocular movement
■ Pain
Proptosis
axial proptosis ( swelling within the muscle cone)
non- axial proptosis ( swelling outside the muscle
cone)
Pulsating proptosis – with vascular malformations
Intermittent proptosis- with sinus mucocele

Speed of onset
A slow onset suggests a benign tumor

A rapid onset - inflammatory disorders, malignant

tumors and carotico- cavernous fistula.
 Symptoms
■ Proptosis ( the hallmarks of orbital disease)

■ Enophthalmos – blow out fractures

■ Binocular Diplopia
■ Visual impairment
■ RAPD
■ Color vision impairment
■ Limitation of ocular movement
■ Pain
Enophthalmos
 Symptoms
■ Proptosis ( the hallmarks of orbital disease)
■ Enophthalmos – blow out fractures

■ Binocular Diplopia
■ Visual impairment
■ RAPD
■ Color vision impairment
■ Limitation of ocular movement
■ Pain
Binocular diplopia

■ Direct muscular involvement

Myositis
Dysthyroid ophthalmopathy

■ Involvement of the nerve supply of extraocular muscles

Diagnostic Studies

Hertel Exophthalmometer

- CT Scan
- MRI
- Ultrasound
- Venography
- Angiography
Graves ophthalmopathy
or Graves’ orbitopathy
Or dysthyroid ophthalmopathy or orbitopathy
Or thyroid eye disease

■ Graves’ diseases affects approximately 2 to 3% of the population or almost 10 million

people.
■ 25% - 50 % of patients with Graves ‘disease suffers from Graves’ ophthalmopathy
■ It occurs 10 times more common in women than in men. However, severe cases occur
more often in men than in women
■ In addition, most patients are aged 30-50 years, with severe cases appearing to be more
frequent in those older than 50 years.
■ Is part of an autoimmune process that can affect the orbital and periorbital tissue and
the thyroid gland.
Clinical findings

■ Eyelid retraction and lag on downgaze

■ Restriction of eye movement
( typical involved inferior and medial recti)
■ Proptosis ( unilateral or bilateral)
■ Dry eye syndrome, limbic keratoconjunctivitis
■ Diplopia ( first on upper gaze)
■ IOP elevation ( especially on upgaze)
■ APD and color vision impairment ( if optic nerve
compression)
Investigation:

■ Thyroid function tests;

■ Anti - thyroid antibodies.
Treatment

■ Endocrinologist ( Control of thyroid disease)

■ Steroids
■ Orbital decompression surgery
■ Topical lubricants
 Superior orbital fissure syndrome

■ Proptosis
■ Ophthalmoplegia
■ Diplopia
■ Facial anesthesia ( caused by compression of
trigeminal nerve)
■ Pupil dilatation
Orbital apex syndrome Cavernous sinus syndrome

■ Proptosis
■ Ophthalmoplegoa
■ Ophthalmoplegia
■ Proptosis
■ Diplopia
■ Ocular and conjunctival congestion
■ Facial anesthesia ( caused by
compression of trigeminal nerve) ■ Trigeminal sensory loss
■ Pupil dilatation ■ Horner syndrome
■ Optic nerve involvement
Orbital Pseudotumor
Non neoplastic ( mainly inflammatory) processes inside the orbit that causes proptosis
■ Vasculitis
■ Myositis
■ Dacryoadenitis
■ Superior orbital fissure syndrome
■ Optic perineuritis
Orbital pseudotumor

Symptoms- acute onset

unilateral proptosis
pain ( frequently present)
Treatment- systemic NSAIDs
systemic steroids
immunosupressants
Carotid Cavernous fistula
Direct – Type A

Indirect – Type B-
D

Presenting Symptoms:
-Bruit (can sometimes be auscultated
over the globe)
-Blurred Vision
-Headache
-Diplopia
-Ocular or orbital pain
-Proptosis
-Chemosis and conjunctival injection
-Cranial Nerve Palsies (notably III,
IV, V1, V2, VI)
Carotid Cavernous sinus fistula
Direct
■ Marked orbital congestion
■ Chemosis
■ Pulsating proptosis
■ Raised IOP
■ Retinal hemorrhages
■ Ophthalmoplegia
■ Loud bruit
Carotid Cavernous sinus fistula
Indirect
■ Often Misdiagnosed
■ Orbital congestion
■ Arterilization of episcleral veins
■ Elevated IOP
■ Mild proptosis
■ Faint bruit
Diagnosis and Treatment

■ Orbital Doppler
■ CT and MRI angiography

Treatment
- High flow fistulas by transvenous or intraarterial balloon or coil embolization
- Low flow fistulas- resolve spontaneously or transvenous or intra arterial emolisation
 Orbital Cellulitis
■ Preseptal
■ orbit

The orbital septum (palpebral fascia) is a membranous

sheet that acts as the anterior boundary of the orbit. It
extends from the orbital rims to the eyelids. It forms the
fibrous portion of the eyelids.
 Orbital cellulitis Preseptal cellulitis
■ Bacterial infection superficial to orbital septum
■ Bacterial infection of deep to the orbital septum.
■ Caused by the spread of infection from eyelids
■ Common cause of proptosis in children
( hordeolum),
■ Cause blindness even death if untreated promptly-
surgical or traumatic wound
■ Caused by the extension of infection form paranasal sinusis
insect or animal bite
Causative agents
- In children Streptococcus pneumoniae
Haemophilus influenza
Staphylococcus aureus ( less common)

- In adults anaerobic organisms

- Staphyloccocus aureus ( MRSA)
- B- hemolytic streptococci
 Symptoms
■ Fever
■ Pain
■ Proptosis
■ Blurring vision
■ Chemosis
■ Limitation of Extraocular muscle activity
 Diagnosis and Treatment
CT or MRI

Treatment
- broad spectrum antibiotics- cephalosporins
- Surgical Drainage
Dermoid cysts
- congenital lesions are caused by the continued growth of ectodermal tissue beneath the surface,
- It may present in the medial or lateral aspect of the superior orbit.
- Excision is usually performed for cosmetic reasons
 Cavernous hemagioma

- Cavernous hemangioma are benign, slow growing tumor

- Become symptomatic in middle life
- Most common in women
- The most favorable location- muscle cone and produces axial proptosis,
huperopia and choroidal folds
- They do not regress spontaneously
- Surgical excision is succesfull
 Lacrimal gland tumor
- Lacrimal gland tumors are rare;
- 50% of tumors are epithelial and
one half of these are malignant
-- another 50% are lymphoproliferative tumors
- The most common epithelial tumor is pleomorphic adenoma:
Painless slowly growing proptoses or swelling iin the superolateral
eyelid
Smooth , firm , non - tender mass in the lacrimal gland fossa
inferonasal dystopia

Excision without biopsy

Malignant tumors should be suspected when there is pain and destructive bony changes on CT
Orbital exenteration with osteotomy is required.
 Optic nerve glioma
■ Become apparent before age 10
■ 25-50% are associated with neurofibromatosis 1
■ Low grade astrocytomas
■ Those anterior to chiasm are tend to be less
aggressive and may regress spontaneously
■ Those posterior to chiasm are more aggressive :
optic nerve atrophy are most common sign
■ Treatment options are controversial :
observation, surgical exsicion, radiotheraphy,
chemotheraphy
rabdomyosarcoma

■ The most common malignant tumor of orbit in

childhood
■ Presentation before age 10 and rapid growth
■ Tumor destroys orbital bone and spreads in
brain
■ Treatment: external megavoltage radiation in
combination with chemotherapy