Anatomy
Orbital facia Periororbital facia Orbital septum Bulbar facia Muscular facia
Physiology of symptoms 1) Proptosis ( exophthalmos) Pseudoproptosis Axial Non axial Pulsating Positional Intermittent
2) Conjunctival and eye lid edema & redness 3) Diplopia 4) Retinal edema and venous engorgement 5) Choroidal fold 6) Visual loss
Diagnosis studies 1) Imaging CT & MRI 2) Ultrasonography 3) Venography 4) Angiography 5) Radiography 6) Fin needle aspiration
Disease & disorders of the orbit Inflammatory disorders 1) Grave's ophthalmopathy 2) Pseudo tumor
Orbital infections 1) Orbital cellulites 2) Mucormycosis
Grave's ophthalmopathy The most common cause of unilateral and bilateral orbital proptosis in adult is grave's disease Some degree of ophthalmopathy usually mild occurs in a high percentage of hyperthyroid patients Severe infiltrative orbital myopathy with significant proptosis and restricted motility occurs in about 5% of cases of grave's disease
This severe form can also occur with hypothyroidism or with no detectable thyroid abnormality Thyroid ophthalmopaty is thought to be an autoimmune disease It is often seen in autoimmune (Hashimotos ) thyroiditis ( antithyroglobulin antimicrosomal )
Clinical findings 1) Protosis with lid retraction ( corneal exposure) Ocular myopathy usually begins with infiltration & edema of the rectus muscles ( fibrotic restricted )
2) Diplopia ( usually ) begins in the upper field of gaze 3) Compressive neuropathy early signs include an afferent pupillary defect impairment of color vision and slight loss visual acuity & blindness
Treatment The goal of treatment of grave's ophthalmopathy is initially maintain corneal protection ( lubricant ) As the disease progresses it became to address the problems of diplopia proptosis & compressive optic neuropathy
1) Manage the thyroid status ( endocrinologist) 2) Oral corticosteroids ( 60-100 mg/d or 1-2 mg/kg) 3) Surgical decompression of the orbit ( neuropathy unresponsive to medical management ) 4) Orbital radiation ( active phase ) 5) Surgery ( strabismus lidretraction ( eye lid )
Pseudotumor A frequent cause of proptosis in adult and children Diffuse inflammation of any orbital structure( myositis dacryoadenitis lymphogranoloma ) ( Lymphocytes fibroblasts histiocytes plasma cells Pseudotumor : is usually unilateral
Differential diagnosis 1) Grave's disease 2) Orbital lymphoma
Treatment 1) Systemic NSAIDS 2) Systemic corticosteroid 3) Radiation 4) Surgery often exacerbates the inflammatory reactions
Orbital infections 1) Orbital cellulites 2) Mucormycosis
Orbital cellulitis is the most common cause of proptosis in children Immediate treatment is essential Orbital cellulitis frequently led to blindness
The orbit is surrounded by paranasal sinuses and part of their venous drainage is through the orbit Most cases of orbital cellulitis a viase from extension of sinusitis through the thin ethmoid bones
Organism 1) Hemophilus influenzae 2) Streptococcus pneumonia 3) Other streptococcoci and staphylococci
Clinical findings Orbital cellulitis : preseptal - postseptal Both present with edema, erythema, hyperemia pain and leukocytosis
Postseptal orbital cellulitis Chemosis Proptosis Limitation of eye movement Reduction of vision
Extention to the cavernous sinus may causes bilateral involvement of cranial nerves II- VI with severe edema and septic fever Erosion of the orbital bones may cause brain abscess cells and meningitis
Differential diagnosis 1) Rhabdomyosarcoma Pseudotumor Grave's disease
Treatment As soon as nasal conjunctival and blood cultures are obtained Intravenous antibiotics ( gram negative and gram positives Hot compresses Nasal decongestants and vasoconstrictors MRI is useful in deciding when and where to drain an orbital abscess Early consultation whit otolaryngologist
Mucormycosis Diabetics and immunocompromised patients have a propensity to develop severe and often fatal fungal infections of the orbit The organisms are of the zygomycetes Zygomycetes have a tendency to invade vessels and create ischemic necrosis ( muscle, bone and soft tissue )
Clinical findings Pain and proptosis Necrotic area of mucosa of the nose and palate
Without treatment, the infection gradually erodes in to the cranial cavity resulting in meningitis brain abscess and death
Treatment 1) Correction of the underlying disease 2) Surgical debridment 3) Amphotericin B intravenously recurrences are common
Cystic lesions involving the orbit -Dermoid -Epidermoidcyst -Dermolipoma Sinusmucocele -Meningocele
Vascular abnormalities involving the orbit Arteriovenous malformation Carotid artery cavernous sinus fistula
Primary orbital tumors 1) Capillary hemangioma 2) Cavernous hemangioma 3) Lymphangioma 4) Rhbdomyosarcoma 5) Neurofibroma 6) Optic nerveglioma
Lacrimal gland tumor Lymphoma Histocytosis
Metastatic tumors Metastatic tumors reach the orbit by hematogenous spread since the orbit is devoid of lymphatics Metastasis are usually from the breast women Metastasis are usually from lung in men The most common metastatic tumor is neurblastoma in children