Orbit Clinical Round

By/Mohamed Ahmed El –Shafie

Assistant Lecturer in ophthalmology department KafrELShiekh University

ANATOMY OF

ORBIT

Frontal Ethmoid SphenoidLacrimal PalatineMaxillary Zygomatic

pyramidal or conical in shape consists of an apex, a base and 4 sides: roof, floor, medial wall and lateral wall

WALLS OF THE ORBIT

Medial Lateral Floor Roof

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

Medial Wall ethmoid, lacrimal, maxillary and sphenoid bones

Floor of the Orbit maxillary, zygomatic bones palatine

SUPERIOR ORBITAL FISSURE

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

Orbital septum: Interconnecting / circumferential radial webs

of fascial system

support and transmit forces in trauma

Compressive optic neuropathy following trauma

CLINICAL EVALUATIONPatient Sheet 6 P’sHistory Complain PainVisual acuityAnterior segment Soft tissue Proptosis :

1. Severity: Hertl’s exophthalmometer, pen and ruler.

2. Direction3. Exclude pseudoproptosis.

Extra Ocular Motility Forced duction test Differential IOP

ProptosisProgressionPalpationPulsationPeriorbital changes

Posterior segment : fundus examinationSpecial investigation: CT, MRI, Needle aspiration biopsy

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)

SOFT TISSUE

PERIORBITAL LID SWELLING LID

RETRACTION CHEMOSIS

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 eye2. Very large ipsilateral globe e.g. : High myopia3. Facial asymmetry4. Retraction of upper eyelid on the ipsilateral side

(same side)

• Should be differentiated from psuedoproptosis

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.

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

Palpation Superonasal: Mucoceles, neurofibromas dermoids Superotemporal: lacrimal gland tumor- pseudo

tumor

Pulsations with bruit : CCS Fistula without bruit: meningoencephalocoeles

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

If you forget clinical picture of orbital disease try this scheme

• 6 P’S• PAIN HISTORY• PERIORBITAL CHANGES ANTERIOR

SEGMENT• PROPTOSIS • PROGRESSION• PALPATION• PULSATION

VISUAL AFFECTION

• CORNEAL EXPOSURE • OPTIC NERVE COMPRESSION

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

ORBITAL DISEASES

1. INFLAMMATORY: 1. THYROID EYE DISEASE (ALSO CAN BE CLASSIFIED AS

ENDOCRINAL)2. IDIOPATHIC ORBITAL INFLAMMATORY DISEASE

2. TUMORS AND CYSTS3. INFECTION4. TRAUMA

ENDOCRINAL PROPTOSISTHYROID EYE DISEASE

Main Clinical Manifestation1. Eyelid retraction2. Soft Tissue involvement3. Proptosis4. Optic Neuropathy5. Restrictive Myopathy

1-EYELID RETRACTION 50% OF PATIENTS• VON GRAEFE SIGN: LID LAG

• KOCHER SIGN: ATTENTIVE FIXATION

2-Soft Tissue Involvement (infiltration)1. Conjunctival Injection2. Chemosis3. Eyelid swelling 4. Kerato-conjunctival Sicca

3-PROPTOSIS• AXIAL• BI OR UNI• NOT SYMMETRICAL

4-OPTIC NEUROPATHY• DIRECT COMPRESSION BY RECTI

5-Restrictive MyopathyIR>MR>SR>LR

CT SCAN• EOM

HYPERTROPHY WITH TENDON SPARING

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

ORBITAL CELLULITIS

• Clinical picture: • fever, proptosis, chemosis, EOM restrictions, pain on eye

movement, decrease visual acuity, pupillary reflex abnormalities RAPD

• Commonest cause is ethmoiditis

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

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

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

Pleomorphic AdenomaMost common epithelial tumor of the lacrimal gland4th -5th decades of life, mostly menprogresssive, painless, downward & inward displacement

Epidermoid / Dermoid CystDermoid is a benign cystic teratomawell-encapsulated lined by stratified squamous & contain

dermal appendagesEpidermoid - does not contain dermal appendages

MENINGO-ENCEPHALOCELE

FRACTURES OF THE ORBITAL

FLOOR• Clinical features

• Periocular changes: ecchymosis, edema, subcutaneous emphysema

• Enophthalmos• Infraorbital nerve

anesthesia• Diplopia

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