The document provides an overview of orbital anatomy and diseases. It describes the bones that make up the walls of the orbit, as well as the contents of the orbit such as the eyeball, muscles, nerves and blood vessels. Common orbital diseases are discussed including thyroid eye disease, infections, tumors and cysts, and trauma. Clinical evaluation involves assessing features like proptosis, extraocular motility, and imaging studies. Specific conditions like dermoid cysts, hemangiomas and fractures are also outlined.

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

2. ANATOMY
OF
ORBIT

3. Frontal Ethmoid Sphenoid
Lacrimal Palatine
Maxillary Zygomatic
 pyramidal or conical in shape
 consists of an apex, a base and
4 sides: roof, floor, medial wall and lateral wall

4. WALLS OF THE ORBIT
 Medial
 Lateral
 Floor
 Roof

5.  Roof of the Orbit
 frontal bone
 lesser wing of the sphenoid
 Lateral wall of the Orbit
 zygomatic bone
 greater wing of the sphenoid
Inferiorly – inf orbital fissure
Medially – sup orbital fissure

6.  Medial Wall
ethmoid,
lacrimal,
maxillary and
sphenoid bones
 Floor of the Orbit
 maxillary,
 zygomatic bones
 palatine

7. SUPERIOR ORBITAL FISSURE

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

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

10. CLINICAL EVALUATION
Patient Sheet 6 P’s
History
Complain Pain
Visual acuity
Anterior segment
 Soft tissue
 Proptosis :
1. Severity: Hertl’s exophthalmometer, pen
and ruler.
2. Direction
3. Exclude pseudoproptosis.
 Extra Ocular Motility
 Forced duction test
 Differential IOP
Proptosis
Progression
Palpation
Pulsation
Periorbital
changes
Posterior segment : fundus examination
Special investigation: CT, MRI, Needle aspiration

11. SPECIAL CONSIDERATION IN
ANTERIOR SEGMENT
EXAMINATION
• Soft tissue signs:
• Oedema :lid
• Retraction of upper lid
• Ptosis
• Chemosis (conjunctival and caruncle oedema)
• Proptosis
• Enophthalmos
• Dystopia
• Extra ocular motility: (ophthalmoplegia)

12. SOFT TISSUE
PERIORBITAL LID
SWELLING
LID
RETRACTIONCHEMOSIS

13. PROPTOSIS
• Examining A case of proptosis entails:
• Degree or severity
• Direction
• Exclude psuedoproptosis
Protrusion of globe
• Apparent forward displacement of eye ball seen
with :
1. Enophthalmous of the opposite eye
2. Very large ipsilateral globe e.g. : High myopia
3. Facial asymmetry
4. Retraction of upper eyelid on the ipsilateral side
(same side)
• Should be differentiated from
psuedoproptosis

14. MEASUREMENT OF PROPTOSIS
• The normal distance between the apex of the
cornea and the lateral orbital rim is usually less
than 20 mm .
• A reading of 21 mm or more is regarded abnormal.
• A difference of 2 mm between 2 eyes is suspicious.
• The amount of proptosis is measured with a hertel
exophthalmometer or a plastic ruler placed at the
lateral canthus and resting on the bone.

17.  Axial e.g. Cavernous haemangioma
 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
-Days to weeks: inflammatory diseases. Infectious
diseases, metastatic tumors
-Months to years: dermoids
DIRECTION OF
PROPTOSIS
PROGRESSION

18.  Palpation
 Superonasal: Mucoceles, neurofibromas dermoids
 Superotemporal: lacrimal gland tumor- pseudo
tumor
 Pulsations
 with bruit : CCS Fistula
 without bruit: meningoencephalocoeles

19. ENOPHTHALMOS
• ENOPHTHALMOS: RETRACTION OF THE EYE INTO THE ORBIT
• NORMAL IN : ELDERLY PEOPLE THAT IS DUE TO SENILE
ATROPHY OF THE ORBITAL FAT.
• THE MOST COMMON CAUSE OF ENOPHTHALMOS IS
TRAUMA.
• FRACTURE OF THE ORBITAL FLOOR RESULTS IN
HERNIATION OF THE ORBITAL CONTENT INTO THE
MAXILLARY SINUS.
Pseudoenophthalmos: causes :
microphthalmos, phthisis bulbi

20. If you forget clinical picture of
orbital disease try this scheme
• 6 P’S
• PAIN HISTORY
• PERIORBITAL CHANGES ANTERIOR
SEGMENT
• PROPTOSIS
• PROGRESSION
• PALPATION
• PULSATION

21. VISUAL AFFECTION
• CORNEAL EXPOSURE
• OPTIC NERVE COMPRESSION

22. 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

23. ORBITAL DISEASES
1. INFLAMMATORY:
1. THYROID EYE DISEASE (ALSO CAN BE CLASSIFIED AS
ENDOCRINAL)
2. IDIOPATHIC ORBITAL INFLAMMATORY DISEASE
2. TUMORS AND CYSTS
3. INFECTION
4. TRAUMA

24. ENDOCRINAL PROPTOSIS
THYROID EYE DISEASE
Main Clinical Manifestation
1. Eyelid retraction
2. Soft Tissue involvement
3. Proptosis
4. Optic Neuropathy
5. Restrictive Myopathy

25. 1-EYELID RETRACTION 50% OF PATIENTS
• VON GRAEFE SIGN: LID LAG
• KOCHER SIGN: ATTENTIVE FIXATION
2-Soft Tissue Involvement
(infiltration)
1. Conjunctival Injection
2. Chemosis
3. Eyelid swelling
4. Kerato-conjunctival Sicca

26. 3-PROPTOSIS
• AXIAL
• BI OR UNI
• NOT SYMMETRICAL
4-OPTIC NEUROPATHY
• DIRECT COMPRESSION BY RECTI
5-Restrictive Myopathy
IR>MR>SR>LR

27. CT SCAN
• EOM
HYPERTROPH
Y WITH
TENDON
SPARING

28. PRESEPTAL
CELLULITIS
• INFECTION CONFINED TO THE
EYELIDS AND PERIORBITAL
TISSUES ANTERIOR TO THE
ORBITAL SEPTUM
• GLOBE IS UNINVOLVED:
PUPILLARY REFLEXES
VISUAL ACUITY
EOM’S ARE NORMAL
• NO CHEMOSIS
• NO PAIN
• NO PROPTOSIS

29. ORBITAL CELLULITIS
• Clinical picture:
• fever, proptosis, chemosis, EOM restrictions, pain on eye
movement, decrease visual acuity, pupillary reflex
abnormalities RAPD
• Commonest cause is ethmoiditis

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

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

32. Rhabdomyosarcoma
 Most common primary orbital malignancy of childhood
 age-onset is 7-8 y/o
 rapid onset of proptosis

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

34. 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. MENINGO-
ENCEPHALOCELE

36. FRACTURES OF THE
ORBITAL FLOOR
• Clinical features
• Periocular changes:
ecchymosis, edema,
subcutaneous
emphysema
• Enophthalmos
• Infraorbital nerve
anesthesia
• Diplopia

38. ‫المليون؟‬ ‫سيربح‬ ‫من‬

39. THANK YOU
THANK YOU