bony cavity containing the eye and its...

Brian Bronzo, 2003Gillian Lieberman, MD

rbital Cellulitis

Brian Bronzo, Harvard Medical School Year III, Gillian Lieberman, MD

October 2003

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The Orbit

• Bony cavity containing the eye and its adnexa.*

*Stedman’s Medical Dictionary

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Anatomy

• Bones

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Anatomy

• Bones:• Frontal

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Anatomy

• Bones:• Maxilla

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Anatomy

• Bones:• Zygomatic

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Anatomy

• Bones:• Ethmoid

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Anatomy

• Bones:• Sphenoid

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Anatomy

• Bones:• Lacrymal

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Anatomy

• Bones:• Palantine

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Anatomy

• Foramen• Superior

Orbital Fissure

• Optic Foramen

• Inferior Orbital Fissure

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Anatomy

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Anatomy• PeriorbitaEach bone comprisingthe orbit has its ownperiosteum. Together,these form acontiguous lining ofthe orbit called theperiorbita. Theperiorbita is looselyadherent the bones ofthe orbit, except at thesutures, and can beeasily dissected awayby blood or pus.

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Anatomy• Extraconal

Muscles

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Anatomy

• Intraconal Muscles

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Anatomy

• Nerves

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Anatomy

• Branches of CN V

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Anatomy

• Arteries

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Anatomy

• Eyeball and appendages

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Anatomy

• Chock-a- block with fat.

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Anatomy

• SeptumThe orbitalseptum is areflection of theperiorbita thatinserts into thetarsal plates.

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Anatomy

• Venous Supply

The orbit andsinuses aresupplied bya network ofvalve less veinsthat drain into thecavernous sinus.

* Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Anatomy

• SinusesThe orbit isseparated from theethmoid sinus by athin piece of bonecalled the laminapapyracea. Thisbone is only 0.5mmthick at its thinnestpoint.

* Rohen JW, Yokochi C, Lutjen-Drecoll. Color Atlas of Anatomy. Lippincott Williams &Wilkins 1998. Philadelphia PA

Lamina Papyracea

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Infections of The OrbitChandler’s Classification of bacterial infections:Type 1: Preseptal cellulitisType 2: Inflammatory edemaType 3: Subperiosteal abscessType 4: Orbital abscessType 5: Cavernous sinus thrombosis

Types 2-5 can progress very rapidly and can lead to blindness, cerebritis, meningitis and death. Before the antibiotic era orbital cellulitis carried a 20% mortality rate

* Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Infections of The Orbit

• Preseptal cellulitis: Infection is limited to the skin and subcutaneous tissues anterior to the orbital septum. Characterized by erythema and swelling, without proptosis, chemosis, or dysfunction in ocular movement.

* Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Infections of The Orbit

• Inflammatory edema: The first manifestation of orbital involvement is edema of fatty retinaculum and adjacent tissues. Characterized by proptosis, pain and diminished extraoccular movement.

* Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Infections of The Orbit

• Subperiosteal abscess: Collection of pus between the periorbita and bony wall of the orbit.Characterized by proptosis, usually inferotemporal, and painful, restricted extraoccular movement.

* Rohen JW, Yokochi C, Lutjen-Drecoll. Color Atlas of Anatomy. Lippincott Williams &Wilkins 1998. Philadelphia PA

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Infections of The Orbit

• Orbital Abscess:True intraconal abscesses are rare since the adventof antibiotics.Characterized by markedproptosis, chemosis, andvisual acuitydisturbances.

*Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Infections of The Orbit

• Cavernous Sinus Thrombosis:

Originates from a septic thrombophlebitisin the ophthalmic veins. Characterized byophthalmoplegia, VAchanges, hyperesthesia,and ptosis.

*Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Imaging Modalities

• Imaging is only necessary when there is suspicion of postseptal involvement, deteriorating condition, or treatment failure.

• CT: Method of choice. Best visualization of bony structures. Good tissue differentiation because of high fat content. Can be used with stereotactic headset for surgical planning.

• MRI: Good for further characterizing soft tissue masses, and evaluating CN II. Not reliable for stereotactic imaging.

• US: Can be used to follow size of SPA. Requires a highly trained tech. Very difficult to interpret. Inadequate visualization of the orbital apex.

*Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.

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Patient NK

• HPI: Patient awoke on the day of admission with a swollen, painful right eyelid. Patient reported that his right eye was “itchy” for the past two days. He also reported that he had had right sided sinus pressure that began after he had his wisdom teeth extracted one month ago. He had no other significant past medical history.

• PE: Patient had a tender, swollen, erythematous right upper eyelid without discharge, chemosis, or injection. There was a mild amount of proptosis in the right eye. Duction in the right eye was limited superomedially. His visual acuity was 20/20 OU.

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Patient NK

*Courtesy of Brian Bronzo

Brian Bronzo, 2003Gillian Lieberman, MD

33*Courtesy of Brian Bronzo

• Patient NK

• DDX:• Allergic reaction• Dysthyroid

exopthalmos• Orbital tumor• Orbital

pseudotumor• Chandler II-V• Ruptured Dermoid

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• Patient NK

• Orbital CT

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• Patient NK

• Orbital CT with contrast

Findings:Ovoid, 1.5 cm, softtissue density mass,with a raggedslightly attenuatingborder.PansinusitisRightwardlydeviated nasalseptum

*BIDMC

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• Patient NK

• Orbital CT with contrast

Findings:Isoattenuating,homogeneous masswith hyper-attenuating border. Frontal sinusitis.

*BIDMC

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• Patient NK

• MRI• T1 Pre

ContrastFindings:Right sidedintraorbital mass ofintermediate signalintensity with acentral area of hypo-intesity.

*BIDMC

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• Patient NK

• MRI• FLAIRFindings:Suppression of fluidsignal rendersidentification of thepresumably fluidfilled mass difficult.

*BIDMC

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• Patient NK

• MRI• T2Findings:The right sidedorbital contents arehyperintense relativeto the left sidedcontents, likelyrepresenting edemasecondary toinflammation.

*BIDMC

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• Patient NK

• MRI• T1 Post

ContrastFindings:Right sided orbitalcontents are highlyenhancing.

*BIDMC

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• Patient NK• MRI• Susceptibility

Findings:Area of susceptibilityrepresented bymottled hypointensity in theright orbit. This mostlikely representsblood that is instasis.

*BIDMC

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• Patient NK

• MRI• T1 Pre

ContrastFindings:Hyperintensehomogenous mass insuperomedial orbit.

*BIDMC

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• Patient NK

• MRI• T1 Post

ContrastFindings:Nonenhancing masswith an enhancingborder. Rightsinuses stronglyenhancing.

*BIDMC

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• Patient NK

• MRI• IRFindings:Center of the masshas a hyperintensesignal, this likelyrepresents fluid.

*BIDMC

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• Patient NK

• MRI• IR

*BIDMC

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• Patient NK

• CT with contrast

Findings:Mass size stablecompared toprevious CT, with

lessintraorbital fatstranding.

*BIDMC

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• Patient NK

• CT with contrast

• VTI HeadsetFinding:VTI headset wasused for possibleendoscopic surgicalevacuation of thelesion.

*BIDMC

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• Patient NK

• CT with contrast

Finding:Mass is slightlysmaller compared toprevious CT.

*BIDMC

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• Patient NK

• CT with contrast

• Two week follow-up

Findings:Mass nearlyresolved. Sinuseson right side nowfilled with air.

*BIDMC

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• CT w/ con• Initial

• CT w/ con• Two days

post initial

• CT w/ con• Four days

post initial

• CT w/ con• Two

weeks post initial

*BIDMC

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Patient NK

• DDx post imaging: Postseptal, extraconal phlegmon/abscess.

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Patient PS

• HPI: Patient presented with a fever and a sore eye of two days duration.

• PE: Tender, swollen, erythematous left upper eyelid. VA 20/20 OU. EOMI. No proptosis.

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Patient PS

* www.revoptom.com/handbook/sect1c.htm

• DDX:• Allergic reaction• Preseptal cellulitis• Chalazion• trauma

Brian Bronzo, 2003Gillian Lieberman, MD

54* Maun L, Jordan DR, Donahue SP. Occuloplastic Surgery Update. Preseptal and Orbital Cellulitis. Opthalmology Clin of North Am 2000. 13(4)

• Patient PS

• CT with contrast

Findings:Soft tissue density swelling anterior toleft eye. Nointraorbitalmasses, fatstranding or sinusinvolvement.

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Patient PS

• DDx post imaging: Preseptal cellulitis.

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Patient SR

• HPI: Patient presented with fever and eye pain of 4 days duration.

• PE: Swollen, tender, erythematous, left eyelid. Moderate proptosis with impaired duction medially in the left eye.

• DDX:• Allergic reaction Chandler II-V• Dysthytoid exopthalmos Ruptured Dermoid• Orbital tumor• Orbital pseudotumor

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Patient SR

• CT pre- contrast

Findings:Poorly demarcated,soft tissue densitymass in medialportion of left orbit.

*Courtesy of Steve Reddy, MD

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Patient SR

• CT post contrast

Findings:Lens shaped hypo-attenuating massapposing the medialwall of the orbit witha sharp,hyperattenuatingborder.

*Courtesy of Steve Reddy, MD

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Patient SR

• DDx post imaging: Subperiosteal abscess.

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References• Curtin HD, Rabinov JD. Extension to the Orbit from Paraorbital Disease. The Sinuses. Rad

Clin North Am 1998; 36(6): 1201-13.• Eustis HS, Mafee MF, Walton C, Mondonca J. MR Imaging and CT of Orbital Infections in

Acute Rhinosinusitis. Rad Clin North Am 1998; 36(6):1165-83.• Maun L, Jordan DR, Donahue SP. Occuloplastic Surgery Update. Preseptal and Orbital

Cellulitis. Opthalmology Clin of North Am 2000. 13(4)• Rohen JW, Yokochi C, Lutjen-Drecoll. Color Atlas of Anatomy. Lippincott Williams &Wilkins

1998. Philadelphia PA slides# 23,25,26,27,28• Stedman’s Concise Medical Dictionary. Lippincott Williams & Wilkins 2001. Philadelphia PA• www.revoptom.com/handbook/sect1c.htm• www.vesalius.com

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Acknowledgements

• Johnathan Kleefield, MD• Rama Jager, MD• Steve Reddy, MD• Larry Barbaras, Webmaster• Gillian Lieberman, MD• Pamela Lepkowski

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The

End