Senior Registrar Dr.

Muhammad Akbar Javaid

MBBS, FCPS
Available at www.aeymon.tk

Department of Ophthalmology Nishtar Hospital Multan

4/17/12

ORBIT& Orbital diseases

4/17/12

4/17/12

Introduction

PEAR SHAPED CAVITIES CONTENTS.EYEBALLS ,MUSCLES,NERVES,MOST OF THE LACRIMAL APPRATUSFAT APEX DIRECTED POSTERIORLY,UPWARDS AND MEDIALLY MEDIAL WALL PARALLEL TO SAGITAL PLANE AND LATERAL WALL ANGLE OF 45

4/17/12

BONES FORMING THE ORBIT

SEVEN BONES

ZYGOMATIC SPHENOID LACRIMAL MAXILLA ETHMOID PALATINE FRONTAL

4/17/12

4/17/12

ORBITAL WALLS

ROOF..Frontal and lesser wing FLOORmaxilla,zygomatic,palatine LATERAL WALLZygomatic,sphenoid MEDIAL WALLfrontal process of maxilla lacrimal,ethmoid, body of sphenoid

4/17/12

ORBITAL DIMENSIONS

Height of orbital margin - 40 mm Width of orbital margin - 35 mm Depth of orbit - 40-50 mm Interorbital distance - 25 mm Volume of orbit - 30 cm3

4/17/12

4/17/12

Superior orbital fissure Cranial nerves (CN) III, IV, and VI Lacrimal nerve Frontal nerve Nasociliary nerve Orbital branch of middle meningeal artery Recurrent branch of lacrimal artery Superior orbital vein Superior

OPTIC CANAL
Click to edit Master subtitle style

Optic nerve Ophthalmic artery Central retinal vein

4/17/12

4/17/12

CLINICAL SIGNS

SOFT TISSUE INVOLVMENT PROPTOSIS DYSTOPIA ENOPHTHALMOS OPHTHALMOPLEGIA PULSATIONS FUNDUS CHANGES

4/17/12

SOFT TISSUE INVOLVMENT

LID AND PERIORBITAL OEDEMA PTOSIS CHEMOSIS( OEDEMA OF CONJUNTIVA AND CARUNCLE) EPIBULBAR INJECTION

4/17/12

4/17/12

Conjunctival injection

4/17/12

PROPTOSIS

DIRECTION(Axial, non axial SEVERITY(degree)

Hertel,s Exophthalmometer, Plastic ruler

PSEUDOPROPTOSIS

4/17/12

Muscle cone

Click icon to add picture

Conal lesions and extra conal lesions

4/17/12

Normal placement of eye > 21 mm is proptosis ball

Click icon to add picture

4/17/12

Bilateral proptosis
Click icon to add picture

4/17/12

Hertel,s Exophthalmomet Measurement of proptosis er

Click icon to add picture

4/17/12

Buphthalmos Myopia

Pseudoproptosis false impression of proptosis

Contralateral enophthalmos Contralateral Nan ophthalmos

4/17/12

4/17/12

dystopia

Non axial proptosis

due to extra conal lesions( outside the muscle cone)

4/17/12

4/17/12

ophthalmoplegia

A Orbital mass Restrictive Myopathy(Thyroid Eye Disease, Orbital Myositis Ocular Motor Nerve involvement Tethering of EOM( Blow out fracture)

4/17/12

4/17/12

Fundus changes

OPTIC DISC SWELLING OPTIC ATROPHY Choroidal folds Optocillary vessels

4/17/12

4/17/12

4/17/12

4/17/12

4/17/12

4/17/12

Investigations

C.T SCAN MRI ULTRASONOGRAPHY FINE NEEDLE ASPIRATION BIOPSY

4/17/12

4/17/12

4/17/12

4/17/12

ORBITAL DISEASES

THYROID EYE DISEASE(TED)

(TED)

4/17/12

TED

Thyrotoxicosis (Grave,s Disease), it is an autoimmune disorder 3rd and 4th deacades Women> men TED OCCURS IN 25-30% of Grave,s disease 5% have severe involvment TED may precede,coincide with OR follow hyperthyroidisim relation with severity of thyroid

4/17/12 No

TED

RISK FACTORS

1-SMOKING 2-RADIOACTIVE IODINE used for hyperthyroidisim

4/17/12

Thyroid eye disease Pathogenesis

Involves an organic specific autoimmune reaction in which an humoral agent(IgG antibody produces following changes 1-Inflammation of EOM, 2- Inflammatory cellular infiltration with lymphocytes, plasma cells, macrophages, mast cells of interstitial tissues and orbital fat

4/17/12

4/17/12

THROID EYE DISEASE

PRESENTATION 12345LID RETRACTION PROPTOSIS SOFT TISSU INVOLVMENT RESTRICTIVE MYOPATHY OPTIC NEUROPATHY

4/17/12

LID RETRACTION

PATHOGENESIS(Fibrotic Contracture of Levator,Secondary over action of levator plus superior rectus, sympathetic overactivity causing Muller muscle SIGNS(Dalrymple,Kocher,vonGraefe MANAGEMENT(Observation,Mullerotomy, Recession of lower lid retractors,Botulinum Toxin Injection

4/17/12

4/17/12

PROPTOSIS

Pathogenesis(Inflammation of EOM,Inflammatory cellular infilteration with lymphocytes,plasma cells,macrophages, mast cells of interstitial tissues and orbital fat Signs(Axial,uni/bilateral Management(systemic steroids,radiotherapy,surgical decompression

4/17/12

4/17/12

Soft tissue Involvement

Symptoms(Grittiness,Photophobia,Lacrim ation and retrobulbar discomfort Signs(Epibulbar hypremia,periorbital swelling,dry eyes Management(Lubricants, Head Elevation and Eyelid tapping

4/17/12

4/17/12

Restrictive Myopathy

Diplopia Defects in elevation,abduction,depression, and adduction TREATMENT

INDICATION,DIPLOPIA IN primary gaze or reading positions Surgical recessions of muscles Botulinum toxins
4/17/12

4/17/12

Optic neuropathy

Presentations Signs (optic nerve functions i.e. va,visual fields,pupil, color vision Treatment I/V Steroids orbital decompression

4/17/12

4/17/12

ORBITAL INFECTIONS

PRESEPTAL CELLULITIS BACTERIAL ORBITAL CELLULITIS FUNGAL ORBITAL INFECTIONS(RHINOORBITAL MUCORMYCOSIS)

4/17/12

PRESEPTAL CELLULITIS

Infection anterior to orbital septum Causes ..Skin trauma, spread of local infection i.e. sty,dacryocystitis From remote infection i.e. RTI SIGNS

UNILATERAL TENDER, RED PERIORBITAL OEDEMA TREATMENT Antibiotics

4/17/12

4/17/12

ORBITAL CELLULITIS

Life threatening infection of soft tissue of orbit behind the septum ANY AGE S,Pneumoniae, S.Aureus, S.Pyogenes and H.Influenzae

PATHOGENESIS
1) 2)

Sinus related Extension of preseptal Local from Sac

4/17/12 3)

ORBITAL CELLULITIS

Severe visual loss due to optic nerve involvement Painful Ophthalmoplegia FEVER RAISED LEUCOCYTE COUNT

COMPLICATIONS
OcularExposure,Glaucoma,CRAO, CRVO,
Enophthalmitis,Optic Neuropathy ORBITAL ABSCESS 4/17/12

BACTERIAL ORBITAL CELLULITIS

PROPTOSIS OPHTHALMOPLEGIA SIGNS OF OPTIC NERVE INVOLVMENT SOFT TISSUE INVOLVMENT CORNRAL EXPOSURE KERATOPATHY

TREATMENT Admission,Antibiotics,Optic Nerve function monitoring, and Surgical Intervention If Required

4/17/12

4/17/12

4/17/12

4/17/12

4/17/12

4/17/12

RHINOMUCOR MYCOSIS

Rare opportunistic infection Diabetics, IMMUNOCOMPROMISED PATIENTS CAUSED Inhalation of spores,MUCORRACEAE

Gradual onset of facial and periorbital swelling Diplopia Ischemic infarction,Typical Black ESCHAR
4/17/12

4/17/12

ORBITAL INFLAMMATIONS
1-IDIOPATHIC ORBITAL INFLAMMATORY DISEASE

(IOID)

Previously known as Orbital Pseudotumor 2-Acute dacryoadenitis 3-Orbital myositis 4-Wegner,s granulomatosis
4/17/12

4/17/12

IDIOPATHIC ORBITAL INFLAMMATION

It is non-neoplastic, Non-infectious space occupying orbital lesions Inflammatory process may involve any or all of soft tissue of orbit Presentations is like Orbital cellulitis BUT without pain,fever and Raised TLC 3rd to 6th decade 4/17/12

PSEUDOTUMOR

Very good response to systemic steroids is diagnostic of pseudotumour Oral NSAIDS Radiotherapy Antimetabolites Surgery is rarely needed

4/17/12

4/17/12

VASCULAR MALFORMATIONS

Orbital varices Lymphangioma Direct Carotid Cavernous fistula Indirect ccf

4/17/12

ORBITAL VARICES

Consists of weakened segments of the orbital venous system of variable length and complexity Enlarged with increased venous pressure Unilateral Early childhood to late middle life Intermittent proptosis Visible lesion in the eyelid

4/17/12

ORBITAL VARICES

Conjuntival varices C.T Scan show Pheleboliths C.T Angiography Surgical excision if RECURRENT THROMBOSIS,PAIN, SEVERE PROPTOSIS and OPTIC NERVE COMPRESSION

4/17/12

4/17/12

LYMPHANGIOMA

Are not neoplasms,but abortive non functional benign vascular malformations Haemodynamically isolated from the circulation PRESENTATION

Early childhood Anterior lesions several soft bluish mass in upper nasal quadrant with an associated cystic conjunctival component Posterior Lesions may cause sudden or 4/17/12

LYMPHANGIOMA
TREATMENT SURGICAL Excision is difficult because of friability and non-encapsulation easily bleed and may infiltrate normal orbital tissue Persistant sight threatening choclate cysts should be drained or removed sub-totally

4/17/12

4/17/12

CAROTID CAVERNOUS FISTULA

An A/V fistula is an abnormal communication between artery and vein. The blood within the affected vein becomes ARTERIALIZED

venous pressure rises and venous drainage may be altered in both rate and direction Arterial pressure and perfusion are also reduced IT IS COMMUNICATION BETWEEN CAROTID ARTERY AND CAVERNOUS SINUS
4/17/12

Carotid cavernous Fistula

CAUSES Trauma :A basal skull fracture may cause tear in the intra-cavernous portion of Internal carotid artery Spontaneus : Rupture of intracavernous portion of carotid artery Aneurysm/Atherosclerotic artery

4/17/12

4/17/12

CYSTIC LESIONS

Dacryops Dermoid cyst Sinus mucocoele Encephalocoele

4/17/12

4/17/12

SINUS MUCOCOELE

USUALL SUPERO MEDIAL/MEDIAL NON-PULSATILE

4/17/12

4/17/12

ENCEPHALOCOELE

FEATURES USUALLY SUPERONASAL ORBIT PULSATILE NON-REDUCIBLE SINCE BIRTH DUE TO DEFECTIVE ORBITAL ROOF FORMATION

4/17/12

4/17/12

ORBITAL TUMORS

Capillary haemangioma Cavernous haemangioma Pleomorphic lacrimal gland adenoma Lacrimal gland carcinoma Optic nerve glioma Optic nerve sheath Meningioma Plexiform Neurofibroma Lymphoma sarcoma(Rhabdomyosarcoma

4/17/12 Embryonal

CAPILLARY HAEMANGIOMA
Hamartoma(Abnormal tissue at normal place)

Most common tumour of the orbit and periorbital areas in childhood Girls>boys PRESENTATION First few weeks of life But 30% at birth

COURSE 1- Rapid growth from 3-6 month

4/17/12

Capillary Haemangioma
1. 2. 3. 4.

Indications of treatment Amblyopia Optic nerve compression Exposure keratopathy A severe cosmetic blemish

TREATMENT Observation/resolves spontaneously

4/17/12 . Intralesional

steroids/hot water/almond

4/17/12

CAVERNOUS HAEMANGIOMA

Most common benign orbital tumor in ADULTS MIDDLE AGED FEMALE 70% 4th to 5th decade AXIAL PROPTOSIS INTRACONAL LOCATION/Extra conal SURGERY is easy because of encapsulation/CRYOPROBE may be used

4/17/12

4/17/12

OPTIC NERVE GLIOMA

Slowly growing astrocytoma 30% association with Neurofibromatosis ADOLOSCENT GIRLS PRESENTATION is first decade of life Visual loss is slowly progressive Intracranial spread may occur

4/17/12

4/17/12

OPTIC NERVE SHEATH MENINGIOMA

Arise from meningo-epithelial cells of arachnoid villi surrounding the intraorbital portion of optic nerve Typically affects middle aged women PRESENTATION Gradual decrease in visual impairment

CLASSICAL TRIAD
v v

Visual loss Optic atrophy

4/17/12

OPTIC NERVE SHEATH MENINGIOMA(TREATMENT)

OBSERVATION if good vision and progress is slow SURGERY in youngs in aggressive cases if the eye is blind

4/17/12

4/17/12

FRACTURES

BLOWOUT FRACTURES OF ORBIT Most common FLOOR then Medial Wall Fracture of Lateral Wall

SIGNS
ENOPHTHALMOS HYPOANESTHESIA OVER CHEEK DIPLOPIA PROPTOSIS? CHEMOSIS

LID 4/17/12

BLOWOUT FRACTURES OF ORBIT

INITIAL TREATMENT Antibiotics and Analgesics Avoid blowing Nose

INDICATIONS OF TREATMENT
1- Diplopia in primary gaze/reading gaze 2- enophthalmos more than 2 mm
4/17/12

4/17/12

THANKS

4/17/12