Orbit clinical round for undergraduate 4th year medical student

1. By/Mohamed Ahmed El –Shafie
Assistant Lecturer in ophthalmology department
KafrELShiekh University

2. ANATOMY OF ORBIT

3.  bony cavities : globes, EOM, nerves, fat and blood
vessels
 pyramidal or conical in shape
 consists of an apex, a base and 4 sides: roof, floor,
medial wall and lateral wall
 7 bones: frontal, zygomatic, maxillary, sphenoid,
ethmoid, lacrimal, & palatine

4. Bones of Orbit
Frontal Ethmoid Sphenoid
Lacrimal Palatine
Maxillary Zygomatic

5. Boundaries of Orbit
 Roof
 Floor
 Side walls
 Orbital apex

6.  Roof of the Orbit
 frontal bone and lesser wing of the sphenoid
 located adjacent to anterior cranial fossa and frontal sinus
 Lateral wall of the Orbit
 zygomatic bone and greater wing of the sphenoid
Inferiorly – inf orbital fissure
Medially – sup orbital fissure

7.  Medial Wall
 ethmoid, lacrimal,
maxillary and sphenoid
bones
 forms the lateral wall of
the sphenoid sinus
 Floor of the Orbit
 maxillary, palatine,&
zygomatic bones

8. • Orbital Apertures
1. Optic Canal
– Optic Nerve, Ophthalmic
Artery, Sympathetic
Nerves
2. Superior Orbital Fissure
– CN III,IV,VI, V1,
Sympathetic Nerves
3. Inferior Orbital Fissure
– CN V2,

9.  Orbital apex syndrome/ Tolosa - hunt syndrome :
Damage to structures at apex 2 nd, 3 rd, 4 th ,6 th
nerves
Symptoms : visual loss, ophthalmoplegia
periorbital & facial pain

10. Contents of orbit
 Eye ball
 Orbital fat
 Connective tissue system: Periorbita
Orbital septum
Tenon’s capsule
 Blood vessels
 Nerves
 Extraocular muscles

11.  Orbital septum:
Interconnecting / circumferential radial
webs of fascial system
support and transmit forces in trauma
Compressive optic neuropathy following
trauma

12.  6 P’s
 Pain
 Proptosis
 Progression
 Palpation
 Pulsation
 Periorbital
Changes

15.  Proptosis
 Axial Displacement - retrobulbar lesions like
cavernous hemangioma, glioma, meningioma,
AV mal, lesions with in the muscle cone

16.  Non Axial Displacement - outside the muscle cone
 Superior Displacement - maxillary tumor invading the
floor of the orbit
 Inferomedial displacement - dermoid cyst and lacrimal
gland tumor
 Bilateral proptosis Grave’s disease and lymphoma,
pseudotumor
 Progression
 Days to weeks: inflammatory diseases. Infectious
diseases, metastatic tumors
 Months to years: dermoids, benign mixed tumors,
lymphomas

17.  Palpation
 superonasal - Mucoceles, neurofibromas dermoids
 superotemporal - lacrimal gland tumor pseudo
tumor
 Pulsations
 with bruit - CCS Fistula
 without bruit - meningoencephalocoeles

18. CT Scan
 Good for most orbital
conditions, esp fractures
 Good view of bone & Ca
 Degraded image of orbital apex
due to bony artifact
 Less soft tissue detail
 Good for metallic foreign body
 Less expensive
 Shorter Scanning time
MRI
 Better for orbitocranial lesions
 No view of bone & Ca
 Good view of Orbital Apex
 More soft tissue detail
 Contraindicated for Metallic
Foreign Body
 More expensive
 Longer Scanning time

20. Graves’ Ophthalmopathy
 Autoimmune disorder that is related to excess
secretion of thyroid hormone
 10-25% occurs in the absence of any thyroid
dysfunction
 Female/male ratio 8:1
 4th to 5th decades of life
 most common cause of adult unilateral and bilateral
exophthalmos

21. Pathogenesis:
1. Hypertrophy of Extraocular Muscles
2. Cellular Infiltration
3. Proliferation of orbital fat, connective tissue

22. Main Clinical Manifestation
1. Eyelid retraction
2. Soft Tissue involvement
3. Proptosis
4. Optic Neuropathy
5. Restrictive Myopathy

23.  Eyelid Retraction
 Soft Tissue Involvement
1. Conjunctival Injection
2. Chemosis
3. Eyelid Fullness

24.  Proptosis
Restrictive Myopathy
IR>MR>SR>LR

25. CT Scan
 EOM
Hypertrophy
with tendon
sparing

26. Orbital Infections
 Preseptal Cellulitis
 Infection confined to the eyelids and periorbital
tissues anterior to the orbital septum
 Globe is uninvolved,
 Pupillary rxn, VA, & EOM’s are NORMAL
 no chemosis, no pain

27.  Orbital Cellulitis
 active infection posterior to the septum
 90% occurs as a 2ndary extension of bacterial
sinusitis
 fever, proptosis, chemosis, EOM restrictions,
pain on eye movement
 decrease VA, pupillary abnormalities

28. Orbital Tumors
 Vascular
 capillary hemangioma
 cavernous hemangioma
 lymphangioma
 Lacrimal Gland
 Benign Mixed Tumor
 Malignant Tumor
 Rhabdomyosarcoma
 Cystic Lesions
 dermoid cyst
 mucocele
 Neural
 optic nerve glioma
 Metastatic
 Tumor invasion from
adjacent structures

29. Capillary Hemangioma
 Most common tumor of the orbit in childhood
 increase in tumor size during crying and straining
 absent bruit and pulsation
 involute spontaneously

30. Cavernous Hemangioma
 Most common benign orbital lesion in adults
 middle-aged women commonly affected
 enhanced well-encapsulated mass on CT scan
 Tx: Surgical Excision

31. Rhabdomyosarcoma
 Most common primary orbital malignancy of childhood
 age-onset is 7-8 y/o
 rapid onset of proptosis
 Tx: Exenteration, Radiation Therapy combined with systemic
chemotherapy

32. Pleomorphic Adenoma
 Most common epithelial tumor of the lacrimal gland
 4th -5th decades of life, mostly men
 progresssive, painless, downward & inward displacement

33. Epidermoid / Dermoid Cyst
 Dermoid is a benign cystic teratoma
 well-encapsulated lined by stratified squamous & contain
dermal appendages
 Epidermoid - does not contain dermal appendages

35. Fractures of the Orbit
 Orbital floor Fracture
 Most frequently involve wall
 Usually along the infraorbital canal

36.  Clinical Features
 Periocular Changes: ecchymosis, edema, subcutaneous
emphysema
 Enophthalmos
 Infraorbital nerve anesthesia
 Diplopia