ORBIT & EYE
DEPARTMENT OF OMFS,
“I am a camera with its shutter
open, quite passive, recording,
The human eye
blinks an average of
12 times a min /
4,200,000 times a
All babies are colour
blind when they are
born and do not
produce tears until
the baby is
approximately six to
eight weeks old.
read 25% slower
from a computer
ANATOMY OF ORBIT
ANATOMY OF EYE
ANATOMY OF EYELID
The eye develops from several types of tissues.
i. Retina & RPE – Neural Ectoderm
ii. Lens – Surface Ectoderm
iii. Sclera &
Anterior Chamber – Migrating Cells.
Mutations in the SHH
gene or inhibition of
results in cyclopia. The
phenotype results in a
single eye in the center
of the face.
oThe primary optic vesicles
arise as an evagination of
neural tube epithelium.
oThe optic vesicle is
connected to the
procencephalon by the
optic stalk, which will
become the optic nerve.
oIn humans, eye
completed until several
months after birth.
•The lens placode is induced by contact between the
optic vesicle and the overlying ectoderm.
•The optic vesicle infolds, forming a bilayered optic
cup. The inner wall of the optic cup becomes the
neural retina, while the outer wall becomes the
•The lens placode then invaginates and pinches off to
form a hollow lens and is subsequently filled with
differentiating primary fiber cells that elongate from the
•The surface ectoderm from which the lens vesicle
forms gives rise to the cornea.
•The iris and ciliary body develop at the periphery of
•Unlike the other muscles of the body, part of the iris is
derived from the ectodermal layer.
•Migrating mesenchymal tissues form the sclera,
trabecular meshwork, and anterior chamber.
At birth, the eye is relatively large in relation to the rest
of the body.
The eye reaches full size by the age of 8 years.
The lens continues to enlarge throughout the life.
The iris has a bluish color due to little or no pigment
on the anterior surface.
During early infant life, the cornea & sclera can be
stretched by raised IOP → enlargement of the eye.
Orbit / eye socket is
roughly irregular four
sided pyramid located on
either side of root of nose.
Base - at the orbital
Apex - at optical canal
Axis directed posteriorly
Medial walls - nearly
Medial and lateral walls
makes an angle of 45
CONTRIBUTED BY 7 BONES
ENTRANCE OF THE ORBIT
Frontal, Zygomatic, Maxillary Bones
Orbital plate of frontal bone
Posteriorly small portion contributed by lesser wing
Anteriomedially frontal sinus is present in the
Supra orbital foramen is present at junction of
medial and middle half.
Orbital plate of maxilla
Anteriolaterally- zygomatic bone
Posteriomedially- orbital process of palatine bone
On the lateral side, anteriorly continues with the
lateral wall but separated posteriorly by inferior
It roofs maxillary sinus
Its thin and is most commonly fractured.
Orbital plate of ethmoid bone (lamina papyracia)
Anteriorly – lacrimal bone
At the apex – body of sphenoid
Lacrimal bone contains fossa for nasolacrimal sac
L ATERAL WALL
Frontal process of zygomatic bone anteriorly and
the orbital surface of greater wing of sphenoid
Thickest wall of the orbit
Orbital tubercle – lateral palpebral ligament
Continuous with roof anteriorly and separated
posteriorly by superior orbital fissure
Located between two roots that connect lesser
wing of sphenoid with body of sphenoid
Connects orbit and middle cranial fossa
Transmits optic nerve, menengial sheaths,
SUPERIOR ORBITAL FISSURE
Gap between greater and lesser wings of sphenoid
Connects orbit and cranial cavity
Transmits occulomotor, trochlear, opthalmic,
abduscens nerves and opthalmic veins
INFERIOR ORBITAL FISSURE
Above – greater wing of sphenoid
Below – maxilla
Laterally – zygomatic bone
Connects orbit with pterigopalatine and
Transmits infraorbital, zygomatic branches of
maxillary nerve and vessels, orbital rami of
At the junction of frontal and ethmoid bones,
anteriorly and posteriorly
Connects with ethmoid sinuses, anterior cranial
fossa, nasal cavity.
Openings for Zygomatico temporal and
zygomatico facial nerves
In the lateral wall on zygomatic surface
Eye ball occupying 1/5th of the orbit
Extra ocular muscles
Optic, Occulomotor, Trochlear, Abduscens,
Opthalmic and Maxillary nerves
Ciliary parasympathetic ganglion
Orbital fat and connective tissue
Mucous membrane with
non keratinized squamous
epithelium and globlet
Extends from limbus to
cover interior eyelids.
Thin, richly vascularized
Can be divided into three
• The cornea occupies the center of the
anterior pole of the globe.
• It measures
12 mm horizontally & about 11 vertically.
• The cornea is transparent and highly innervated.
• It is avascular, gets O2 & nutrients from aqueous
humor and outside surface.
• Kept moist by tears.
• Responsible for most of the eye’s ability to refract
and focus light
• The sclera covers the posterior four fifths of the surface
of the globe, with an anterior opening for the cornea
and a posterior opening for the optic nerve
• Composed of dense fibrous connective tissue, almost
• Maintains shape of the eyeball
• Anteriorly – Corneoscleral junction – limbus
• Posteriorly – fused with dural sheath of optic nerve
• Externally covered by bulbar conjunctiva
• Internally attached to choroid by suprachoroid lamina
• Provides protection to delicate structures,
• Serves as an attachment for the extraocular muscles
The choroid, the posterior portion of the uveal
tract, nourishes the outer portion of the retina. It
averages 0.25 mm in thickness and consists of
three layers of vessels:
The choriocapillaris, the innermost layer
A middle layer of small vessels
An outer layer of large vessels
• Colored structure surrounding the pupil.
• Controls amount of light entering the eye
• Controls the size of the pupil through the sphincter
pupillae (shrinks pupil) and a diffuse dilator pupillae
• Spongy stroma with melanocytes: faces anterior
• Pigmented epithelium faces posterior chamber. This
epithelium becomes the ciliary body laterally.
• When it is full open, it is about f/2 and f/3. This
Triangular in cross section.
The apex of the ciliary body is directed posteriorly
toward the ora serrata.
Base gives rise to the iris.
The ciliary body has three principal functions:
◦ aqueous humor formation: low-protein plasma-
like substance made continuously by the
epithelium of ciliary body. Nourishes cornea, lens,
iris, corneal endothelium, & stroma. Secreted into
posterior chamber, flows around iris through pupil
to “the angle”
◦ It also plays a role in the trabecular and
uveoscleral outflow of aqueous humor
The lens is a biconvex structure located directly behind
the posterior chamber and pupil
Diameter of about 9-10 mm & width of about 6 mm.
lens fibers: extremely long cells with no nuclei, stretch
anterior to posterior. Cytoplasm filled with crystallin,
arranged in a regular lattice
Lens capsule: thick basement membrane surrounding
lens. Attachment site for the zonules.
The lens has certain unusual features. It lacks
innervation and is avascular. Transparent because of
anucleate nature and fibers containing crystalline
Photoreceptors: contain photopigment in discs
located within outermost segment. When light
interacts with the photo pigment, conformational
change and neural signal
Blood supply: central retinal artery enters through
optic disk and ramifies in the inner surface of retina
Capillary network of the choroid, the
choroicapillaris supplies photoreceptors through
Bruch’s membrane and the RPE
2 types of photoreceptors:
◦ Rods: sensitive in dim light, not wavelength
◦ Cones: sensitive in bright light, differential
sensitivity to wavelength. Three kinds of cones
are - red, green, and blue. These cones work
together to help us see millions of colors.
Iris and lens separate eye into three chambers
Vitreous chamber : largest chamber, posterior to
lens, filled with gel like vitreous humour
Anterior chamber : between cornea and iris
Posterior chamber : between iris and lens
Both are filled with aqueous humour, which provides
nourishment to avascular lens and cornea
The vitreous cavity occupies four fifths of the
volume of the globe
Important to the metabolism of the intraocular
tissues because it provides a route for
metabolites used by the lens, ciliary body and
serves as a medium to maintain the path of light
between the lens and the retina
free from diffusing and absorbing elements
Its volume is close to 4.0 ml
Although it has a gel-like structure, the vitreous
is 99% water
Its viscosity is approximately twice that of water,
mainly because of the presence of the
mucopolysaccharide, hyaluronic acid.
The lens changes shape to focus light on the back of the
eye regardless of the distance of the object
Cornea curvature is fixed, so focus comes from changes
in the lens curvature through the ciliary muscles
Lens with no tension: would be curved/round
normal state of lens: flattened by the tension of the
To curve lens: ciliary muscles contract and ciliary body
moves closer to the lens. Zonules go slack.
To flatten the lens: ciliary muscles relax, ciliary body
moves away from the lens. Stretches the zonules.
This person can see close objects clearly, but has
trouble seeing distant objects.
Usually occurs because the distance between the
lens and the retina is too large or because the
cornea-lens combination converges light too
Light from distant objects is brought into focus in
front of the retina.
• This person had no problem seeing objects in the
distance, but has trouble seeing nearby objects.
• The eye cannot refract light well enough to form an
image on the retina.
• Usually occurs because the distance between the
lens and the retina is too small or because the
cornea-lens combination is too weak. Light from
nearby objects focuses behind the retina.
Even within the cone and rod system, your retina
adjusts its sensitivity in response to the overall light
When you walk into a dark room, you can’t see
anything, but after a few minutes, you adapt and can
start to see things and vice- versa.
Dark adaptation is a slow process, but allows us to
see in a huge range of light levels
DARKADAPTION CLINICAL CORRELATIONS
Elevated intraocular pressure from overproduction
of aqueous humor or blockage in drainage. High
pressure in the anterior chamber transduced
through vitreous body, pressure on retina. Can
damage neural retina by impeding blood flow in
◦ Open angle glaucoma: increased production
◦ Closed angle glaucoma: iris closes the angle,
Clouding of the crystalline lens of the eye.In a
normal eye, the crystalline lens is almost
transparent, however injury, age or disease can
cause the lens to eventually lose its clarity.
Blindness in one-half of the visual field
Amblyopia: (lazy eye)
Decreased vision in one eye that leads to the use
of the other eye as the dominant eye. A problem
most commonly associated with children.
Progressive loss of vision which begins in mid-life.
Near vision becomes blurry, making reading
glasses necessary. Over time, the blurriness
extends to intermediate vision, making computer
glasses useful. Bifocals are worn to improve near
vision and distance vision if necessary.
• Diplopia (double vision)
The perception of two images of a single object.
Strabismus: (Misaligned eyes / crossed eye)
Condition is the lack of coordination between the eyes,
one eye turns out, down, or up while the other looks
Rapid and uncontrollable eye movements. an
involuntary, constant, rhythmic movement of the
eyeball that can be congenital or caused by a
neurological injury or drug use
A condition in which the pupils are unequal in size. this
condition can be congenital or caused by a head injury,
aneurysm or pathology of the central nervous system
• Chalazion :
A slowly developing lump that forms due to
blockage and swelling of an oil gland in the eyelid.
• papilledema (chocked disk)
swelling and inflammation of the optic nerve at the
point of entrance into the eye through the optic
disk. this swelling is caused by increased
intracranial pressure and can be due to a tumor
pressing on the optic nerve
• Scotoma (blind spot)
An abnormal area of absent or depressed vision
surrounded by an area of normal vision
• Bitot spots : Raised, silvery white, foamy, triangular
An eye condition where the eye cannot focus light
uniformly in all directions resulting from an irregular
curvature. Astigmatism results in mild to
moderately blurred vision and/or eyestrain.
Floaters and Spots:
A generalized term used to describe small specks
moving subtly but noticeably in your field of vision.
A floater or a spot is likely a tiny clump of gel or
cells in the vitreous. Aging, eye injury and
breakdown of the vitreous are the main causes of
floaters and spots.
• Subconjunctival hemorrhage
Bleeding between the conjunctiva and the sclera.
A raised growth on the eye that is most often directly
related to over-exposure to the sun. Dry, dusty
conditions may also contribute to development of these
growths. Protecting your eyes from UV radiation is a
critical preventive measure.
Inflammation of the eyelids. It can have a variety of
causes, such as an allergic reaction, bacterial infection,
or excess oil produced by eyelid glands.
An inflammation of the lacrimal gland that can be
caused by a bacterial, viral or fungal infection. signs
and symptoms include the sudden severe pain, redness
and pressure in the orbit of the eye
An inherited corneal disease. The cornea gradually
becomes thinner and less able to maintain its shape
against the pressure of the fluids inside the eye.
Increased pressure on the globe
Traction of extrinisic eye muscles
Ocular regional anesthesia techniques
( and severe increased sphincter tone for
Stimulation causes to activation of an Afferent Arc
via CN V, trigeminal.
Efferent Arc via CN X, vagus.
Verify adequate ventilation & oxygenation
Atropine IVP .01-.02mg/kg (pretx does not always
May also need local anesthetic infiltration
Via retrobulbular block or peribulbar block.
Severe Cases: May need to perform CPR.
Reflex usually subsides with repeated
More common in strabismus surgery
with pediatric pts.
Can occur in all age groups.
Be vigilant, be prepared.
ANATOMY OF EYELID
An eyelid is a thin fold of skin that covers and
protects an eye.
THE LID MARGIN
When eye is open, the upper lid covers about
1/6th of the cornea & the lower lid just touches
It is About 2mm broad and is divided into two
parts by punctum.
The medial, lacrimal portion is rounded and
devoid of lashes or glands.
The lateral, ciliary portion consist of rounded
anterior border, a sharp posterior border and an
The medial canthus is about 2mm higher than
the lateral canthus
LAYERS OF EYE LIDEYELID
Anterior (cutaneous) to posterior (conjunctiva)
Striated muscle (orbicularis).
Submuscular areolar tissue.
Fibrous layer with tarsal plates.
Mucous membrane or Conjunctiva.
It is elastic having fine texture and is the thinnest of the body.
2.THE SUBCUTANEOUS AREOLAR TISSUE:
It is very loose and contain no fat. It is thus readily distended
by oedema or blood.
3.THE LAYER OF STRIATED MUSCLE:-
It consist of orbicularis muscle which comprises three
It closes the eyelids & is supplied by zygomatic branch of
the facial nerve.
4. SUBMUSCULAR AREOLAR TISSUE:
The layer of loose connective tissue.
The nerve and vessels lie in this layer.
Therefore, to anaesthetize lid, injection is given in this plane.
5.FIBROUS LAYER:-consists of central tarsal plate and
peripheral septum orbitale.
a.) Tarsal plate:
There are two plates of dense connective tissue, which give
shape and firmness to the lids.
Both join with each other at medial and lateral canthi and
attached to the orbital margins through medial and lateral
b.) Septum orbitale
It is thin membrane of connective tissue perforated by
nerves , vessels and LPS muscle, which enter the lids
from the orbit.
6. LAYER OF NON-STRIATED MUSCLE FIBRES:
It consist of the palpebral muscle of muller which lies deep
to the septum orbitale in both the lids.
In the upper lid it arises from the fibres of LPS muscle and in
the lower lid from prolongation of the inferior rectus
muscle; and is inserted on the peripheral margins of the
It is supplied by sympathetic fibres.
NERVES OF LIDS
Facial - supplies orbicularis muscle,
Oculomotor - supplies LPS muscle
Sympathetic fibres - supply the muller’s muscle.
From branches of the trigeminal nerve.
Four in number, approximately strap shaped
Attached to common tendinous ring
Each rectus passes forwards and attached to
tendinous expansion into the sclera
Superior rectus Upwards and medially
Inferior rectus Downards and medially
Medial rectus Medial movement ( adduction )
Lateral rectus Lateral movement ( abduction )
Arises from body of sphenoid, passes through
trochlear fossa of frontal bone, attached to sclera
between superior and lateral recti muscles
Moves the eye laterally and intrudes the eyeball
Lies near anterior margin of floor of orbit
Inserted into the lateral part of the sclera behind
the equator of eyeball
Moves eye laterally and causes extorsion
• Thin triangular muscle
• Arises from inferior aspect of lesser wing of
• Ends in wide aponeurosis, some fibers attaches to
anterior end of tarsal plate and others to the skin
• Laterally passes between orbital and palpebral
parts of lacrimal gland and attached to the orbital
• Medially continues as loose connective tissue on
medial palpebral ligament
• Innervated by occulomotor nerve
• Elevates upper eyelid
• Linked to superior rectus by check ligament, thus
upper eyelid elevates when eye directed upwards
Intrinsic Eye MusclesEYEMUSCLES
Internal carotid artery
Central retinal A
Short post ciliary A
Long post ciliary A
Anterior ciliary A
Superior muscular A
Inferior muscular A
Posterior ethmoidal A
Anterior ethmoidal A
Central retinal V
Superior vortex V
Superior episcleral plexus
Inferior vortex V
Inferior episcleral plexus
Cranial Nerve III
• It supplies all the extraocular muscles except the
superior oblique and the lateral rectus
• It also carries cholinergic innervation to the
pupillary sphincter and the ciliary muscle
• The CN III nucleus consists of several distinct,
large motor cell
subnuclei, each of which subserves the extraocular
muscle it innervates
• The Edinger-Westphal nucleus provides the
parasympathetic preganglionic efferent innervation
to the ciliary muscle and pupillary sphincter
Cranial Nerve III
CN III usually divides into superior and inferior
The superior division of CN III innervates the
superior rectus and levator palpebrae muscles.
The larger inferior division splits into three branches
to supply the medial and inferior rectus muscles and
the inferior oblique.
The parasympathetic fibers enter the inferior
division, and course through the branch that supplies
the inferior oblique muscle and join the ciliary
They synapse with the postganglionic fibers, which
emerge as many short ciliary nerves.
Cranial Nerve IV (Trochlear)
Cranial nerve IV has the longest intracranial course
The CN IV the only cranial nerve that is completely
decussated and the only motor nerve to exit dorsally
from the nervous system.
CN IV enters the orbit through the superior orbital
fissure outside the annulus of Zinn and runs
superiorly to innervate the superior oblique muscle
Cranial Nerve V (Trigeminal)
The largest cranial nerve
Possesses both sensory and motor divisions The
sensory portion subserves the greater part of the
scalp, forehead, face, eyelids, eye, lacrimal gland,
extraocular muscles, ear, dura mater, and tongue
The motor portion innervates the muscles of
mastication through branches of the mandibular
Divisions of Cranial Nerve V
Cranial Nerve VI (Abducens)
The nucleus of cranial nerve VI is situated in the
floor of the fourth ventricle, beneath the facial
colliculus, in the caudal pons
CN VI runs below and lateral to the carotid artery
and may transiently carry sympathetic fibers from
the carotid plexus
It passes through the superior orbital fissure within
the annulus of Zinn and innervates the lateral
rectus muscle on its ocular surface
Para sympathetic ganglion which is a
small, flat, reddish grey swelling 1-2 mm
diameter, located near the apex of orbit
medial to superior orbital fissure.
Three types of nerve fibers run through
1. parasympathetic fibers
Only parasympathetic fibers form
synapses in the ganglion and other two
types of nerve fibers simply pass
Ciliary nerve innervates two muscles
constricts the pupil, a movement known as Miosis.
Releasing tension on the , making the lens more convex, also
known as accommodation
Contains two compartments:
Central compartment (retrobulbar &
Peripheral compartment (peribulbar &
The importance of the orbital fat, is that it
contains the motor & sensory nerves for the
Therefore regional anesthesia can be injected
into the fat and provide the patient with an
- orbital part
- palpebral part
Separated by levator palpebrae superioris and are
Basic First-Aid Techniques
◦ Specks in the eye
Do not rub the eye
Flush the eye with a large amount of water
See a doctor if the speck does not wash out, or if pain or
◦ Cuts, punctures, or objects stuck in the eye
Do not wash out the eye
Do not try to remove an object stuck in the eye
See a doctor at once
◦ Chemical burns
Flush the eye immediately with water or any
drinkable liquid and continue flushing for at least
15 minutes. For caustic or basic solutions, continue
on the way to the doctor.
Flush the eye even if it has a contact lens. Flushing
over the lens may dislodge it.
◦ Blows to the eye
Apply a cold compress without pressure.
Tape a plastic bag containing crushed ice to the
forehead and let it rest gently on the injured eye.
See a doctor at once in cases of continued pain,
reduced vision, blood in the eye, or discoloration,
MAKE EYE SAFETY
•BLOOD SPLASH INJURY
•Disposable surgical masks with full-face visors have been
shown to offer the highest level of protection from blood splash
•The use of masks and visors should be standard practice for all
theatre staff, including assistants, scrub nurses and observers.
•If such an incident occur, a procedure similar to that used for
needle-stick injury may be followed.
•The eye should first be rinsed thoroughly to remove as much of
the fluid as possible.
•Serology should be ordered promptly to obtain a baseline for
•Hiv screen and acute hepatitis screen are indicated.
•Post-exposure prophylaxis (pep) should be initiated as soon as
practicable unless the patient is known to be HIV, HBV and HCV
Ophthalmic assessment is mandatory for every
patient who has sustained mid facial trauma severe
enough to cause a fracture.
- Time, place, nature of injury
- whether glasses were worn at the time of
- antecedent visual status
- whether any squit or other abnormalities
before the injury
• Measure of resolving power of the eye
• Recorded as a fraction
distance of the patient from the chart
line he / she sees at that distance
PRINCIPLE : Two distinct points appear as separate
only when they subtend an angle of 1 minute at
nodal plane of the eye.
Each test letter is designed as it subtends an angle of
5 minutes at nodal plane of eye.
• SNELLEN’S CHART
• Patient at 6 mts from snellen’s
• Test letters are constructed so
that edges subtend a visual
angle of 1min of arc.
• For normal eye with 6/6 vision,
each complete test letter
subtends 5 min of arc at the
• If patient cant read at 6/6 and
doesn’t have glasses before,
patient is asked to see through
pin hole. If acuity increases
When visual acuity is less and patient cant read ,
then measured by counting fingers.(CF)
If acuity is still less, then hand movements are
For patients with polytrauma acuity for near vision
can be measured as snellens letters subtends
same angle at 0.33 mts.
Assessed in patients with sustained severe head
CENTRAL VISUAL FUNCTION
Patient is asked to look at red object and x-ray
illuminator with each eye separately and compare
the color and brightness perceived respectively.
Color desaturation – traumatic optic neuropathy
Decreased brightness – optic nerve damage
Patient is told to look at the examiners nose with
each eye separately and asked whether any part of
face is missing or blurred. This detects paracentral
scotoma (choroidal tear)
BINOCULAR VISUAL FIELD TESTING
Examiner sits opposite to patient at 1mt looking
into his eyes.
Hands were placed in outer quadrants and asked
to identify the finger movements.
Patients suspected of left homonymous
hemianopia when left field of vision is defecit.
CENTRAL VISUAL FIELD TO CONFRONTATION
Traumatic damage to visual pathways is more
likely to cause impairment of central 30 degrees of
A small red pin is introduced from periphery to
center along the coronal plane and oblique
meridians to check quadrantic field loss.
PERIPHERAL VISUAL FIELD
Examiner introduces large white pin from behind
the patient and moved in an arc of 0.33 mts radius
and peripheral visual field is assessed.
SUBJECTIVE VISUAL FIELD
Examiner sits opposite the patient, one eye of
patient and examiner should be closed and fixes
the other eye.
Red pin is moved in all quadrants adjecent to
examiners eye and noted for color desaturation if
In traumatic chiasmatic damage, all the other
findings except this are normal.
DIRECT AND CONSENSUAL PUPILLARY
Penlight source is illuminated from below in each
eye twice, first for the direct and next for
SWINGING FLASH LIGHT TEST
Pupils were illuminated in same manner but light
shined in each eye for 2 seconds and then swung
rapidly to illuminate the other eye.
Afferent pupillary defect, unilateral third nerve palsy
PHOTO STRESS TEST
Visual acuity is recorded and one eye illuminated
with bright light for 30 sec.
Visual acuity is again noted observing the recovery
Normal recovery time is 10 – 30 sec.
If more than this, retinal damage is suspected.
DISPLACEMENT OF GLOBEOPHTHALMICASSESSMENT
Hematoma and swelling of orbital tissue
(commonly resolves spontaneously)
Subperiosteal hematoma, notably orbital roof
Inward displacement of orbital bone fragments
Common late sequela, Initially masked by
intraorbital tissue swelling and hematoma
Expansion of the orbit
Prolapse of soft tissue through a blow out fracture
Necrosis of soft tissue and fibrosis
Sucken upper lid may be present.
DISPLACEMENT OF GLOBEOPHTHALMICASSESSMENT
Commonly seen with orbital fractures.
In acute phase upward displacement due to
hematoma and later phases downward
displacement is commonly seen.
Laterally displaced – medial canthal ligament
Similar to squint
In both these cases corneal light reflexes are
symmetrical and double vision is not seen.
Caused by vascular rupture beneath the bulbar
conjunctiva or by osmotic increase of vascular
1)find out the cause
Poor Vascular perfusion of
the optic nerve and retina
Afferent pupil defect
◦ Lateral Canthotomy
◦ Lateral canthal tendon
◦ IV acetazolamide
◦ IV mannitol 0.5 g/kg
decompression of the
H/O loss of vision 24 to 48 hrs after injury
Mostly occurs after severe skull fracture, chest
compression, long bones fractures.
Multiple discrete, superficial infarcts of retina
accompanied by development of multiple cotton
wool spots adjacent to optic nerve head.
No specific treatment.
In most of cases gradual recovery of vision in few
The degree of cover of cornea is determined.
Cornea is examined for any ulceration.
Botulinum toxin into levator palpebrae superioris,
results in complete ptosis for 4 to 6 weeks.
Optic nerve heads are to be examined in patients
suspected with raised intra cranial pressure.
EYE LID INJURIES
Eyelid swelling & hematoma
Commonly seen following orbital injuries
Spontaneous resolution in few weeks
Widening of medial canthus
Due to disruption of nasoethmoid complex
Trans nasal wiring
EYE LID INJURIES
EYE LID LACERATIONS
Should be repaired within 72 hrs.
Surgical repair should be done in layers accurately
First Margin should be restored with non
absorbable suture passing through the gray line.
Tarsal plate is repaired with absorbable suture,
only passing through partial thickness.
Any damage to levator should be carefully
identified and repaired to prevent ptosis.
Outward turning of
Inversion of the lid
Drooping or inferior displacement of
the upper lid
◦ Congenital vs acquired
◦ Myogenic, aponeurotic, neurogenic,
mechanical, or traumatic
◦ Iimitators: dermatochalaisis and brow
Intermittent contractions of
the entire side of face
Present during sleep
Compression of 7th nerve
at the level of the brain
7TH NERVE PALSY
Location of lesion:
◦ Supranuclear, brain
Cause of paralysis:
NASO LACRIMAL INJURIES
• Damage to naso lacrimal drainage system results in
• Any lacerations of middle third of lower eyelid should
suspect injury to inferior canaliculus.(3/4th of tear
• Epiphora following nasal fractures is due to protective
influence of medial canthal ligament.
• Post operative epiphora
- due to malposition of lower eyelid
- due to malposition of bone fragments while
reducing fracture fragments
• Canalicular lacerations are to be examined and
Orbital fractures can be divided into
- sturdy orbital rim
- comparitively thin lateral walls, roof & floor
- these can be blow–in or blow–out
Isolated orbital fractures accounts for 5% of mid facial
Most common is the blow – out fracture.
It can occur in the floor, medial and lateral walls.
Commonly floor of the orbit is involved
BLOW – OUT FRACTURE
Bone conduction theory
Small fractures limited
Larger fracture involving
entire floor and medial
Should suspect more
Mechanism of injury
Double vision, blurry vision
Nausea and vomiting (especially in
Forced duction test
CT Scan (sagittal)
Indications for Repair
Diplopia that persists beyond 7 to 10 days
Obvious signs of entrapment (positive forced
Relative enophthalmos greater than 2mm
Fracture that involves greater than 50% of the
orbital floor (most of these will lead to significant
enophthalmos when the edema resolves)
Entrapment that causes an oculocardiac reflex with
resultant bradycardia and cardiovascular instability
Progressive V2 numbness
reflex with entrapment
◦ Bradycardia, heart block,
nausea, vomiting, syncope
Early enophthalos or
hypoglobus causing facial
“White-eyed” floor fracture
When the criteria have been
met, surgery performed as
soon as possible
Dulley and fells mentioned
72% of enopthalmas in
patients operated 6 months
after injury and 20% when
operated with in 14 days.
Repair Within Two Weeks
Symptomatic diplopia with positive forced duction
Large floor fracture causing latent enophthalmos
Progressive infraorbital hypesthesia
◦ Not in primary or downgaze
Good ocular motility
No significant enophthalmos
No significant hypoglobus
Trapdoor fractures with entrapment differ in
children and adults
◦ Children repaired within 5 days of injury do
better that those repaired within 6-14 days or
those repaired > 14 days
◦ There is no difference in early timing of adults
(1-5 days or 6-14 days)
◦ Adults repaired less than 14 days from injury
have less long term sequela than those repaired
greater than 14 days from injury
Reconstruction of orbital floor
Most favoured and high tissue compatibility
Inner aspect of anterior iliac crest
Posterior iliac crest
Lateral mandibular cortex
Lateral antral wall
Lypophilised dura, allogenic bone and cartilage
Polyethylene Methyl methacrylate
Poly vinyl sponge Marlex mesh
0.62 mm threaded steinmann pin
Titanium flosor plate
MEDIAL WALL FRACTURES
Second most commonly disrupted orbital wall.
It causes entrapement or damage of medial rectus
muscle and orbital wall.
Diagnosed consistently by limitation in abduction of
the globe and globe retraction.
Forced duction test is mandatory
Axial CT scan is done to evaluate size and extent
MEDIAL WALL FRACTURES
If amout of orbital tissue loss is minimal, not
necesssary to seal the fracture site
When the defect is larger, reconstructed with
alloplastic or allogenic materials and secured
Killian and lynch incision – curvelinear, made along
the lateral wall of nose , 12 mm medial to medial
BLOW IN FRACTURES
Presents with proptosis because of decreased
Restricted ocular motility
Minimally displaced – no need of treatment
Immediate decompression with reconstruction
◦ No visible scar
◦ Less incidence of ectropion
and scleral show
◦ Poorer exposure without
lateral canthotomy and
◦ Better access to the medial
◦ Risk of entropion
◦ Easier approach
◦ Scar camouflage
◦ Skin necrosis
◦ Highest incidence of
◦ Highest incidence of
scleral show (a) Subciliary incision
(b) Periosteum elevated and
entrapped orbital contents freed
(c) Defect repaired with
(d) Periosteum sutured
◦ Easiest approach
◦ Direct access to floor
◦ Good exposure
◦ Postoperative edema the worst
◦ Visible scar
Stay below orbital
inferior rectus muscle
Slightly overcorrect if
Avoid V2 injury
Endoscopic Balloon catheter
Insert Foley and inflate
Leave in place for 7-10 days
Best for large trapdoor fractures without
Broad spectrum antibiotics
Anatomical proximity, common blood supply and
All sinuses share common bony wall with orbit –
prone to infections from sinuses
Thin walls of orbit
Periorbita is loosely attached to bone except at the
rim and apex
Relatively closed compartment
STAGE I Preseptal cellulitis. Infection is confined to the lids and
periocular soft tissue anterior to orbital septum. orbit may be
inflamed secondarily but not directly infected
STAGE II Orbital cellulitis with proptosis, limitations in movements, and
possible optic nerve compromise.
STAGE III Orbital cellulitis with a subperiosteal abscess
STAGE IV Orbital cellulitis with a true orbital abscess within the orbital
STAGE V Retro orbital spread of the infection into the cavernous sinus or
◦ Vision, motility, pupils, disc are
◦ globe itself is not proptotic
◦ 90% secondary to sinus disease
◦ high risk of morbidity and mortality
i. Paranasal sinusitis
ii. Upper respiratory tract infection
iii. Direct inoculation
• SIGNS AND SYMPTOMS
• H/O swelling of eyelids
• Spread of infection confined to the lid
• Chemosis may be present
• Proptosis, limitation in eye movements, optic
nerve dysfunction are not present
• CT SCAN to rule out any orbital involvement has
to be done.
ORBITAL CELLULITIS & ABSCESSORBITALINFECTIONS
• Infection of retroseptal soft tissue of the orbit
• Serious condition that should be quickly diagnosed
• Mostly occurs in children and spreads from
• Typically begins with painful swelling of the eyelids
and chemosis is seen mostly
• Distuingished from preseptal cellulitis by presence
of proptosis, limitation of ocular movements,
pupillary dysfunction and optic nerve damage
• Should be diagnosed radiographically