THE ORBIT LEARNING OBJECTIVES

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1 THE ORBIT DR FAIZ-UR-RAB ASSISTANT PROFESSOR DUHS LEARNING OBJECTIVES Brief Anatomy of orbit. Clinical features of orbital diseases Dysthyroid ophthalmopathy Preseptal cellulitis Septal cellulitis Exophthalmos/ Enophthalmos Orbital Margins are: Superior margin; frontal bone Inferior margin; maxilla and zygomatic Medial margin; frontal, lacrimal and maxilla Lateral margin; zygomatic and frontal

2 CLINICAL FEATURES OF ORBIT DISEASES: Despite the number of different tissues present in the orbit, the expression of disease due to different pathologies is often similar. Clinical features are: Exophthalmos (proptosis) Enophthalmos Pain Eyelid and conjunctival changes Diplopia Visual acuity disturbances Causes : Intra-conal lesions: The lesion lies within the cone formed by extra-ocular muscles, thus the eye globe is displaced directly forwards, e.g. most commonly dysthyroid eye disease, others like Optic nerve sheath meningioma Extra-conal lesions: the lesion is outside the cone, so the eye is displaced to one side, e.g. mostly tumors, tumor of the lacrimal gland displaces the globe nasally. Examples : The most common cause is Graves disease, it usually causes bilateral proptosis. Infectious (Orbital cellulitis)

3 Orbital Inflammatory disease Vasculitis (wegener s granulomatosis) Neoplastic (unilateral): Lacrimal, Lymphoma, Metastatic. DYSTHYROID OPHTHALMOPATHY It is an organ specific auto-immune disorder in which a humoral agent (Ig G antibody) is believed to be responsible for following changes: Hypertrophy of EOM Cellular Infiltration of interstitial tissues Proliferation of orbital fat WERNER S CLASSIFICATION- NO SPECS No symptoms or signs Only signs Dalrymple sign Von Graefe sign Kocher s sign Soft tissues swelling» Lid Edema» Chemosis» Conjunctival congestion» Superior limbic keratoconjunctivitis» Proptosis

4 » Unilateral / Bilateral» Acute / chronic Extra-ocular muscle involvement Inferior & Medial Rectus Corneal ulceration Sight loss Corneal ulceration Optic neuropathy Increased intraocular pressure MANAGEMENT Non- Specific: Reassurance Head elevation at night Taping of eyelids Topical therapy» Lubricants for ocular irritation Systemic Therapy» Diuretics» Steroids Radiotherapy Surgery Orbital Decompression Squint surgery

5 Eyelid Surgery Tarsorrhaphy Levator Recession Blepharoplasty PRESEPTAL CELLULITIS It is infection of subcutaneous tissues anterior to the orbital septum. It must be differentiated by less common orbital cellulitis. Rarely can progress to orbital cellulitis. Skin trauma Spread of local infection From remote infection CAUSES Signs: Unilateral, tenderness of eyelid Redness of eyelid Periorbital oedema On CT- Opacification anterior to orbital septum seen. TREATMENT Topical antibiotics Systemic antibiotics Orbital Cellulitis It is a life threatening infection of soft tissues behind the orbital septum. Causes of Orbital Cellulitis.

6 EXTENSION FROM PERIORBITAL STRUCTURES Paranasal sinuses Face and eyelids Lacrimal sac (dacryocystitis) Teeth (dental infection) Exogenous causes Trauma (rule out foreign bodies) Surgery (after any orbital or periorbital surgery) Endogenous causes Bacteremia with septic embolization Intraorbital causes Endophthalmitis Dacryoadenitis PRESENTATION: Severe malaise, fever, pain & visual impairment. SIGNS: Unilateral tender warm & red periorbital oedema Proptosis Painful ophthalmoplegia Optic nerve dysfunction On CT- Opacification posterior to orbital septum COMPLICATIONS OCULAR Exposure Keratopathy

7 Raised IOP CRAO/CRVO Endophthalmitis Optic Neuropathy SYSTEMIC Meningitis Brain abscess Cavernous sinus thrombosis SUB-PERIOSTEAL ABSCESS Hospital Admission TREATMENT: Antibiotics Monitoring of Optic Nerve Function Surgical Intervention APPROACH TO EXOPHTHALMOS: HISTORY: Duration, rate of onset. Associated ocular symptoms (pain, decreased visual acuity or field, diplopia, transient visual loss). Complaints of foreign body sensation or dry gritty eyes

8 History of trauma Family history ONSET: Slow onset usually indicates benign tumours. Acute onset indicates inflammatory disorder, malignant tumours, caroticocavernous sinus fistula. Intermittent onset indicates orbital varices, induced by increasing the cephalic (head) venous pressure. Examination: Full ophthalmic & systemic examination Exophthalmometer Treatment : Depends on the underlying cause, but if left untreated it could lead to: Failure of the eyelids to close, causing corneal ulcerations and damage. Compression on the optic nerve or ophthalmic artery leading to blindness.

9 If it is left untreated it could lead to: COMPLICATIONS Failure of the eyelid to close leading to corneal damage, ulceration, & Possibly perforation. Compression on the optic nerve or ophthalmic artery leading to blindness Restriction of eye movements & squint CAUSES OF ENOPHTHALMOS: Primary enophthalmos indicates a congenital etiology( Postnatal, inadequate, orbital cavity development) Acquired ( secondary): - * Blow out trauma - * Postsurgical muscle shortening - Horner s Syndrome.. Will cause aberrant enophthalmos ; due to ptosis!!! INVESTIGATION OF ORBITAL DISEASE CT MRI Systemic tests depending on the DDx. D/D of Orbital Diseases

10 Trauma Disorders of extra-ocular muscles (Dysthyroid eye disease and ocular myositis, rhabdomyosacroma) Infective disorders (orbital cellulitis and Preseptal cellulitis) Inflammatory diseases (Sarcoidosis, orbital pseudo-tumors caused by lymphofibroblastic disorders) Vascular abnormalities (Carotico-Cavernous sinus fistula, orbital varix, capillary hemangioma) Orbital tumors (lacrimal gland tumors, meningioma of the optic nerve, optic nerve glioma, rhabdomyosarcoma) Dermoid cysts THANK YOU