Diseases of the orbit


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Diseases of the orbit

  1. 1. Diseases of Orbit
  2. 2. Anatomical considerations• Walls• Apex• Openings• Spaces• Relations• Blood vessels12/11/12 2
  3. 3. Orbital Cavity• Dimensions- conical in shape• Depth- 40 mm• Height- 35 mm• Width- 40mm12/11/12 3
  4. 4. Anatomy of Orbit Frontal Optic Foramen Lesser and Greater wing of Sphenoid Lacrimal Sup Orbital Fissure Ethamoid Palatine Zygomatic Maxillary Sketch of orbit by Dr Sanjay Shrivastava
  5. 5. Anatomy of Apex of Orbit LPS Sup Orbital Fissure Sup Oblique Mus Optic Nerve Med Rectus Muscle Annulus of Zinn Lat Rectus Mus Inf Rectus Muscle Sketch of Apex of Orbit by Dr Sanjay Shrivastava
  6. 6. Walls• Roof- is formed by the orbital plate of frontal bone and lesser wing of sphenoid• Floor- is formed by the maxillary bone- orbital plate and maxillary process of zygomatic bone and orbital process of palatine bone• Medial wall- is formed by the lacrimal and ethamoidal bone, frontal process of maxillary bone and body of sphenoid• Lateral wall- is formed by the greater wing of sphenoid and zygomatic bone12/11/12 6
  7. 7. Apex• Annulus of zinn giving rise to origin to extra ocular muscles• Optic canal• Part of superior orbital fissure12/11/12 7
  8. 8. Openings• Optic canal- optic nerve with meninges and ophthalmic artery• Superior orbital fissure- Outside tendinous ring – structures passing outside are: Lacrimal nerve –V1 Frontal nerve -V2 Trochlear nerve Superior and inferior veins12/11/12 8
  9. 9. Opening• Inside tendinous ring- structures passing inside the ring are - Oculomotor (3rd cranial nerve) upper division Nasociliary nerve Abducent nerve (6th cranial nerve) Oculomotor lower division (3rd cranial nerve) Inferior orbital fissure-inferior ophthalmic vein12/11/12 9
  10. 10. Opening• Foramen rotandum - maxillary nerve• Superior orbital notch-supraorbital nerve and vessels• Infra orbital foramen-infraorbital nerve and artery12/11/12 10
  11. 11. Spaces• Subperiostial space• Peripheral orbital space• Central space• Tenons space12/11/12 11
  12. 12. Relations• Frontal sinus• Sphenoidal sinus• Maxillary sinus• Ethamoidal air cells12/11/12 12
  13. 13. Common lesions• Proptosis• Exophthalmos- endrocrinal• Enophthalmos• Pseudoproptosis-slight prominence of eyes like myopia, paralysis of extra ocular muscles, obese people, mullers stimulation by cocain12/11/12 13
  14. 14. Proptosis and Exophthalmos• Abnormal protrusion of eye ball is called proptosis or exophthalmos.• The term exophthalmos is reserved for prominence of the eye secondary to thyroid disease12/11/12 14
  15. 15. Proptosis• Abnormal protrusion of globe• It may be Unilateral or Bilateral• Unilateral – caused by orbital cellulitis, idiopathic orbital inflammatory disease, thrombosis of orbital vein, arterio-venous aneurysms, tumors of structures of orbit , orbital haemorrahge , emphysema.• Bilateral – endocrine exophthalmos , cavernous sinus thrombosis , symmetrical orbital tumors, oxycephaly - diminished orbital volume12/11/12 15
  16. 16. Proptosis
  17. 17. Proptosis
  18. 18. Proptosis in children• Dermoid and epidermoid cyst• Capillary haemangioma• Optic nerve glioma• Rhabdomyosarcoma• Leukaemias• Metastatic neuroblastoma• Plexiform neurofibromatosis• Lymphomas12/11/12 18
  19. 19. Mass lesion in Left orbitDue Retinoblastoma Stage III
  20. 20. Proptosis in adults• Metastases – (of malignancy) from breast, lung, GIT• Cavernous haemangiomas• Mucocele• Lymphoid tumors• Meningiomas12/11/12 20
  21. 21. Types of Proptosis • Axial proptosis - eye is pushed directly forwards – lesions situated in optic nerve and central space • Non axial- situated elsewhere in orbit pushes eye in opposite direction12/11/12 21
  22. 22. Causes of proptosis in different indifferent locationsExtra conal lesions Intra conal lesions Muscular disordersDermoid cyst Cavernous haemangioma Thyroid ophthalmopathyRhabdomyosarcoma Optic nerve glioma Pseudo tumorExtension of nasal Meningioma Cysticercosis/sinus diseases A-V malformations Lymphoproliferative disorder Rhabdomyosarcoma12/11/12 22
  23. 23. Clinical presentation• Static- as seen usually in congenital causes• Increasing – fast- as in cases of Rhabdomyosarcoma, neuroblastoma, haemopoetic• Gradual- as in cases of meningiomas• Pulsatile- as in cases of carotid cavernous fistula• Intermittent- as in cases of orbital varicosity12/11/12 23
  24. 24. Clinical signs• Impaired mobility• Diplopia• Papilloedema• Optic atrophy• Hertel exophthalmometry – measures more than 18 mm• Difference in two eyes of more than 2 mm is considered positive12/11/12 24
  25. 25. Investigations• Careful history recording• Systemic examination• ENT examination• Biochemical and haematological investigations• Imaging of bony structures- plain x ray• Imaging of soft tissues –CT scan, MRI• Vascular study- orbital venography, carotid angiography, MR angiography, digital subtraction angiography12/11/12 25
  26. 26. Orbital cellulitis• Definition: Purulent inflammation of the cellular tissue of the orbit• Causes of Orbital Cellulitis: Spread of infection from neighbouring structures like nasal sinuses, eyelids, eyeball (like in case of panophthalmitis) facial erysiplas etc Also due to deep penetrating injuries (specially in cases of retained Foreign body) and metastatic infection in cases of pyaemia12/11/12 26
  27. 27. Types of Orbital Cellulitis• Two types- pre septal cellulitis and orbital cellulitis• Pre septal –structures anterior to orbital septum, characterized by erythema, chemosis, conjunctival discharge without restriction of ocular movements and visual impairment12/11/12 27
  28. 28. Types of Orbital Cellulitis • Orbital – behind orbital septum, characterized severe pain, fever, diminution of vision (due to retrobulbar neuritis or compression of optic nerve and /or its blood supply), massive swelling of lids, chemosis, proptosis, restriction of ocular movements, diplopia, an abscess may form pointing somewhere in the skin of the lid near the orbital margin or fornix12/11/12 28
  29. 29. Complications • Panophthalmitis • Extension into brain through meninges , cavernous sinus thrombosis may develop • In diabetic patients fungal superinfection may develop12/11/12 29
  30. 30. Management• Culture and sensitivity of pus, if present and of blood• Treatment –Broad spectrum Intravenous antibiotics , and anti inflammatory• If abscess has formed – Incision and Drainage under cover of antibiotics12/11/12 30
  31. 31. Cavernous sinus thrombosis• Due to extension of thrombosis from various feeding vessels• Superior and inferior ophthalmic vein enter in front• Superior and inferior Petrosal sinus leave from behind• Cavernous sinus communicates with facial veins, lateral sinus, jugular vein, Mastoid emmisary vein- lateral sinus- superior petrosal sinus 12/11/12side ssss 31
  32. 32. Cavernous sinus thrombosis• Cavernous sinus on one side communicates with other side through transverse sinus• Because of connection with mastoid through mastoid emmisary vein, mastoid tenderness is diagnostic feature of cavernous sinus thrombosis
  33. 33. Source of infection• Orbital veins - as in cases of eryiepelas, septic lesion of face, orbital cellulitis , infective condition of face, mouth, nose, sinuses• Furuncle of upper lip – dangerous area of face• Metastatic infection or septic condition12/11/12 33
  34. 34. Symptoms and Signs• Patient may present with symptoms and signs of Orbital cellulitis, there is sever supra-orbital pain• Systemic features – headache, fever ,altered sensorium, vomiting and cerebral symptoms• Transference of symptoms and signs to other eye (bilateral orbital cellulitis with which it may be confused is very rare clinical condition). Mastoid edema and tenderness is present.12/11/12 34
  35. 35. Symptoms and Signs• In case of infection spreading to other eye, the first sign is involvement of lateral rectus of other eye• Papilloedema
  36. 36. Treatment• Emergency• Broad spectrum Intra Venous antibiotics• Anti coagulants• Neurophysicians to be consulted12/11/12 36
  37. 37. Exophthalmos• Endocrine exophthalmos : Graves Ophthalmopathy (dysthyroid eye disease) is the commonest cause of uniocular or bilateral proptosis in age groups between 25 and 50 years12/11/12 37
  38. 38. Graves Disease• Consists of Exophthalmos, and all signs of thyrotoxicosis (i.e. tachycardia, muscular tremors and raised BMR)• In early stage the presentation may be unilateral, becomes bilateral. Palpabral aperture is wide open due to lid retraction (Dalrymple sign). Upper lid fail to follow downward movement of eye (von Graefe sign)12/11/12 38
  39. 39. Summary of signs in Graves disease• Lid retraction• Lid lag (upper and lower• Infrequent blinking and incomplete closure of lids (Stellwag sign)• Lid edema• Exophthalmos• Conjunctival congestion over the insertion of recti muscles and chemosis• Convergence insufficiency (Mobius sign) and Diplopia• Raised intraocular tension may be present• Superior limbic keratopathy12/11/12 39
  40. 40. Werner classification of signs (NOSPECS)• Grade 0 – No signs or symptom• Grade 1 – Only sign (lid retraction)• Grade 2 – Soft tissue involvement (Chemosis)• Grade 3 – Proptosis (which may be minimum <23, moderate , marked >28)• Grade 4 – Extraocular muscle involvement• Grade 5 – Corneal involvement12/11/12 40
  41. 41. Exophthalmic Ophthalmoplegia• Is proptosis with external ophthalmoplegia• Usually seen in middle aged people , it is of insidious onset, typically assymetrical limiting upward movement and abduction due to swollen, pale edematous, infiltrated ocular muscles . There is irreducible exophthalmos with risk of exposure keratitis , globe dislocation mechanical compression of optic nerve and ophthalmic vessels12/11/12 41
  42. 42. Exophthalmic Ophthalmoplegia• Disease is self limiting with intermissions and relapses, usually not affected by any treatment . Spontaneous resolution may take place which rarely is complete12/11/12 42
  43. 43. Treatment of ExophthalmicOphthalmoplegia• Short term oral steroid therapy (with dose of 40- 60 mg) with radiotherapy (1000 rad ) are effective in controlling soft tissue inflammation• Exposed cornea should be protected by doing tarsorrhaphy in less severe cases , by orbital decompression in more severe cases. Lateral tarsorrhaphy may also be needed.• Residual muscle palsy is dealt with muscle adjustment surgery.12/11/12 43
  44. 44. Types• Type – I : Characterized by symmetrical mild proptosis with lid retraction usually associated with thyrotoxicosis• Type – II : Characterized by extreme exophthalmos, compressive neuropathy and extraocular muscle involvement. This form may be associated with any state of thyroid function, but usually with hypothyroidism, seen after thyroidectomy.12/11/12 44
  45. 45. Cause of exophthalmos• Due to edema, lymphocytic infiltration anf fibrosis of orbital contents and extra-ocular muscles• Lid retraction is due to contraction of Muller muscle12/11/12 45