DISEASES OF THE ORBIT

DISCUSSION
Orbit
Content
Superior orbital fissure : structures
Inferior O F
Proptosis
Preseptal cellulitis
Orbital cellulitis
Cavernous sinus thrombosis
Thyroid Ophthalmopathy
ORBIT
Quadrangular truncated
pyramids situated between
the anterior cranial fossa
and the maxillary sinuses
below.
40 mm in height, width and
depth
Formed by 7 seven bones :
Frontal, Maxilla, Zygomatic,
Sphenoid, Palatine,
Ethmoid and Lacrimal.
Has 4 walls – medial,
lateral, superior and
inferior.
WALLS OF ORBIT
Medial – 2 orbits are parallel , formed by four bones
maxillary , lacrimal , ethmoid , sphenoid.
Inferior – (floor) triangular , commonly involved in
blow—out Fractures.
Lateral – triangular, covers posterior half of
eye ball.
Roof – formed by orbital plate of frontal bone.
Apex – posterior end where 4 walls converge , 2
orifices, the optic canal which transmits optic nerve
and ophthalmic artery and Superior orbital fissure
which transmits arteries, veins and nerves.
FASCIA BULBI
(TENON’S CAPSULE)
Envelops the globe from the margin of
cornea to the optic nerve.
It has thickened lower part to form a sling
where the globe rests ; ‘Suspensory
ligament of Lockwood’ .
CONTENTS OF ORBIT
Volume : 30 cc.

1/5th is occupied by eyeball.

Part of optic nerve, Extraocular muscles ,

lacrimal gland, lacrimal sac, ophthalmic artery
and its branches, 3rd, 4th and 6th cranial nerves
and ophthalmic & maxillary divisions of
cranial nerves , sympathetic nerve and fascia.
SUPERIOR ORBITAL
FISSURE
It is a foramen in skull lying between lesser
and greater wing of sphenoid.
STRUCTURES PASSING
THROUGH SOF
Superior and inferior division of Oculomotor nerve.
(3)
Trochlear nerve(4)
Lacrimal, frontal and nasociliary nerve of
Ophthalmic branch of Trigeminal nerve (V1)(5)
Abducent nerve (6)
Superior and inferior division of Ophthalmic vein
Sympathetic fibers from cavernous plexus.
INFERIOR ORBITAL
FISSURE
Zygomatic
branch of
trigeminal
nerve and
ascending
branch of
pterygopalatine
ganglion
PROPTOSIS
Forward displacement of eyeball beyond the line
joining superior and inferior orbital margins.

Classification :
1. Unilateral
2. Bilateral
3. Acute
4. Intermittent
5. Pulsating
UNILATERAL
PROPTOSIS
Congenital : dermoid, teratoma
Trauma : Orbital hemorrhage, FB, aneurysm,
emphysema
Inflammatory : cellulitis, thrombophlebitis, CST,
Pan ophthalmitis.
Circulatory : varix and aneurysms
Cysts : hydatid cyst, cysticercoses
Tumors : primary, secondary or metastatic
Mucoceles of PNS : Common – frontal , ethmoidal
and maxillary.
 BILATERAL PROPTOSIS
• Developmental anomalies : Craniofacial
dysostosis
• Osteopathies : Rickets, acromegaly
• Inflammatory condition : Mikulicz’s disease,
CST
• Endocrinal exophthalmos : Thyroid ds
• Tumors : Lymphoma, lymphosarcoma
• Systemic disease : Histiocytosis, amyloidosis
• Most common cause of bilateral proptosis in
children is neuroblastoma and leukemia
[chloroma].
ACUTE PROPTOSIS
EXTREME RAPIDITY

• Orbital emphysema
• Orbital hemorrhage
• Rupture of ethmoidal mucocele
INTERMITTENT
PROPTOSIS
This type of proptosis appears and
disappears on its own,

• Orbital varix
• Periodic orbital oedema
• Recurrent orbital hemorrhage
• Vascular tumors
 PULSATILE PROPTOSIS
Caroticocavernous fistula
Saccular aneurysm of Ophthalmic artery
Deficient Orbital floor in congenital
meningocele.
INVESTIGATION
History Systemic
Local examination examination
• Inspection
Laboratory
• Palpation investigation
• Auscultation
Imaging
• Transillumination
• Visual acuity Invasive procedure –
• Pupil reaction Orbital venography,
• Fundoscopy carotid angiography,
• Ocular motility radioisotope
• Exophthalmometry
arteriography.
• Perimetry Histopathological
Hertels exophthalmometer
PRESEPTAL
CELLULITIS
Infection of subcutaneous tissues anterior
to the orbital septum.

Causes : Staphylococcus aureus or

Streptococcus pyogenes, occassionally
Haemophilus influenza.
MODES OF INFECTION
Exogenous
Endogenous
Neighbouring
structures
CLINICAL FEATURES
Inflammatory oedema of lids and periorbital skin sparing the
orbit.

Painful periorbital swelling

Erythema & hyperaemia of lids
Fever & leucocytosis
Proptosis – absent
Normal ocular movements
Conjunctiva- not congested
VA – Normal
TREATMENT
Systemic antibiotics
› Mild to Moderate : Oral co-amoxiclav 500/125 mg tds or
fiucloxacillin 500 mg QID for about 10 days.

› Severe : IV Ceftriaxone 1-2 g/day in divided dose for 4-5

days.

› Systemic analgesics

› Warm compression
› Surgical exploration
ORBITAL CELLULITIS
Acute infection of orbital tissues of the orbit
behind the orbital septum.
May or may not develop to subperiosteal abscess
or orbital abscess.
 Pathology : similar to suppurative inflammation
of body in general.
• Infection establishes early d/t absence of
lymphatics
• Rapid spread with extensive necrosis
• Raised IOP d/t tight compartment.
CLINICAL FEATURES
• SYMPTOMS
Swelling & severe pain .
Associated general symptoms
Vision loss &/or diplopia
• SIGNS
Swelling of lids
Chemosis of conjunctiva
Axial proptosis
Restricted ocular movements
Papillitis or Papilloedema
COMPLICATIONS
Ocular : Exposure keratopathy, optic neuritis and CRAO.

Orbital : Subperiosteal abscess &/or orbital abscess.

Temporal/parotid abscess

Intracranial complication : CST, Meningitis & Brain Abscess.

Septicaemia & pyaemia.

INVESTIGATIONS
Bacterial cultures
Complete haemogram
X-ray : PNS
Orbital USG
CT scan & MRI
TREATMENT
Intensive antibiotic therapy

Analgesic & anti-inflammatory

Topical antibiotics

Nasal decongestant

Revaluation

Surgical intervention : canthotomy/cantholysis

CAVERNOUS SINUS
THROMBOSIS
Septic thrombosis of cavernous sinus is a
disastrous sequela, resulting from spread
of sepsis travelling along the tributaries
from the infected sinuses, teeth, ears, nose,
and skin of the face.
COMMUNICATIONS
Anteriorly : superior and inferior
ophthalmic vein drain in the sinus.
Receive blood from face, nose,
pns & orbits.
Posteriorly : Superior and inferior
petrosal sinuses leave it to join
lateral sinus. Labyrinthine vein
opening into inferior petrosal
sinuses
Superiorly : veins of cerebrum and
may be infected from meningitis
and cerebral abscesses.
Inferiorly : pterygoid venous
plexus
Medially : transverse sinus which
connects two cavernous sinuses.
CLINICAL FEATURES
Usually starts unilateral condition , which soon
becomes bilateral in more than 50% of cases d/t
intercavernous communication

General features : severe, high grade fever chills

and rigor , vomiting & headache.
OCULAR FEATURES
Severe pain in the eye and forehead on the affected side
Conjunctiva is swollen and congested.
Proptosis develops rapidly
Ipsilateral ophthalmoplegia – Diplopia caused d/t palsy of 3 rd,
4th and 6th cranial nerves.
Ipsilateral ptosis, dilated pupil, and absence of direct and
consensual pupillary light reflex – 3rd nerve palsy.
Corneal anaesthesia
Oedema in the mastoid region.
Fundus : may be normal, retinal vein may be congested.
INVESTIGATIONS
Ct scan head
and orbit
MR venography
Blood culture
COMPLICATIONS
Hyperpyrexia and signs of meningitis or
pulmonary infarction may precede death.
TREATMENT

Antibiotics
Analgesics and anti-
inflammatory drugs
THYROID EYE
DISEASE
Also labelled as :
• Endocrine exophthalmos
• Malignant exophthalmos
• Dysthyroid ophthalmopathy
• Graves disease
• Thyroid associated ophthalmopathy
ETIOPATHOGENESIS
Hyperthyroidism (90%)
Hypothyroid (4%)
Euthyroidism (6%)
RISK FACTORS
Females (4-6 times) common than male.
Smoking
Middle age
Autoimmune thyroid disease
HLA-DR3 & HLA-B8
PATHOGENESIS
Autoimmune disease with orbital fibroblasts as the
primary target of inflammatory attack and EOM
being secondarily involved.
Target antigen is shared between the thyroid
follicular cells and orbital fibroblasts.
Activated T—cell act on fibroblast-adipocyte
lineage within the orbit and stimulate
adipogenesis, fibroblast proliferation and
glycosaminoglycan synthesis.
CLINICAL FEATURES
1. Lid signs
• Dalrymple’s sign : retraction of the
upper lids produces staring and
frightened appearance.
• Von Graefe’s sign : when globe is
moved downward, the upper lid
lags behind.
• Enroth’s sign : Fullness of eyelid.
• Gifford’s sign: difficulty in eversion
of eyelid
• Stellwag’s sign : Infrequent
blinking
C/F (CONTINUED)
• Conjunctival signs : deep injection & chemosis.
• Pupillary signs : less important
• Ocular motility defects : Mobious sign – convergence
weakness to partial or complete immobility of one or all
extrinsic ocular muscles.
• Unilateral elevator palsy :d/t inferior rectus failure
• Failure of abduction due to Medial rectus involvement
• Exophthalmos
• Exposure keratitis
• Optic neuropathy
 CLASSIFICATION

AMERICAN THYROID ASSOCIATION

“NO SPECS”
Class 0:N: No signs and symptoms
Class 1:O: Only signs no symptoms(signs are limited to lid
retraction,with or without lid lag and mild proptosis)
Class 2:S: Soft tissue involvement with signs and symptoms
including lacrimation,photophobia,lid or conjunctival
swelling
Class 3:P: Proptosis is well established
Class 4:E: Extraocular muscle involvement
Class 5:C: Corneal involvement
Class 6:S: Sight loss due to optic nerve involvement
CLINICAL COURSE
• Self-limiting disease
• Lasts from 1-5 years
• Phases:
1. Congestive or active phase
2. Fibrotic or inactive phase
DIAGNOSIS
1. TFT
2. Thyroid Antibody Assay
3. USG
4. CT Scan
5. MRI
MANAGEMENT
1. Periodic clinical workup
2. Non-surgical measures
3. Surgical management
 PERIODIC CLINICAL WORK UP
Pain 1.Retrobulbar pain
2.Pain on ocular movement
Redness 3.Redness of lids
4.rednesss of conjunctiva
Swelling 5.swelling of lids
6. swelling of conjunctiva
7. swelling of caruncle
8.proptosis(in proptosis over 1-3 months)
Loss of function 9.Decrease in eye movement by
10.Decrease vision by 1 snellen line over 1-3 months
NON-SURGICAL MANAGEMENT
1. Smoking cessation
2. Head elevation at night and cold compress in morning
3. Lubricating artificial tear drops
4. Eyelid taping
5. Guanethidine 5% eyedrops
6. Prisms
7. Systemic steroids
8. Radio therapy
9. Combined therapy
SURGICAL MANAGEMENT
1. Orbital decompression
2. Extra-ocular muscle surgery
3. Eyelid surgery
THANK YOU