Orbital Disorders Students Notes

ORBITAL DISORDERS • PRIMARILY FROM WITHIN ORBIT • ADJACENT STRUCTURE • DISTANCE SOURSE VIA THE VASCULAR PATHWAY • PART OF SYSTEMIC DISORDER

ANTONIO SAY, MD

Orbital Walls (7 bones) • • • • • • •

Ethmoid Frontal Lacrimal Maxillary Palatine Sphenoid Zygomatic ANTONIO SAY, MD

• Relations Above – frontal sinus Below – maxillary sinus Medially- ethmoid and sphenoid sinus

• Orbital septum - barrier between the eyelids and the orbit - anterior limit of the orbital cavity

ANTONIO SAY, MD

Roof of the Orbit •

Frontal bone and lesser wing of sphenoid

•

Landmarks: – Lacrimal gland fossa – Fossa for the trochlea of the sup oblique tendon and muscle – Supraorbital notch or foramen

•

Adjacent to anterior cranial fossa & frontal sinus ANTONIO SAY, MD

Lateral Wall of the Orbit

• Zygomatic bone(strongest) and greater wing of sphenoid • Superior Orbital Fissure - separates the lateral wall from the roof - separates lesser from the greater wing of the sphenoid

• Landmark: – Lateral orbital tubercle of whitnall(lat canthal tendon, lat palpebral tendon, check lig is attached – Frontozygomatic suture located 1cm above the tubercle

• Adjacent to middle cranial fossa & temporal fossa • Lateral orbital rim is usually at the equator of the eye allowing wide peripheral vision • Globe is vulnerable to trauma laterally (wall protect posterior half of the ANTONIO eye) SAY, MD

Medial Wall

• Ethmoid bone (paper-thin) • Lacrimal bone • Body of the Sphenoid - most posterior aspect • Landmark:

– Frontoethmoid suture (Ant & post ethmoid arteries) – Cribriform plate lies at frontoethmoid suture

• Adjacent to ethmoid, sphenoid sinus & nasal cavity ANTONIO SAY, MD

Lacrimal Crest 1. anterior lacrimal crest frontal process of the maxilla 2. posterior lacrimal crest formed by the angular process of the frontal bone 3. lacrimal groove between the two crests contains the lacrimal sac frequently fragmented result from indirect blowout fracture Infections of ethmoid sinuses commonly extend through lamina papyracea(ethmoid foramen) to cause orbital cellulitis & proptosis

ANTONIO SAY, MD

Frontal bone

Superior Orbital Fissure Inferior Ophthalmic vein Lateral

Lesser wing Greater w

e

lacrimal

Superior ophthalmic vein Lacrimal, Frontal and Trochlear nerves Outside Annulus of Zinn

Medial zygoma

maxilla

Superior and Inferior divisions of the oculomotor nerve Abducens nerve Nasociliary nerve Within Annulus of Zinn

ANTONIO SAY, MD

Floor of the Orbit • Maxillary, palatine & zygomatic bones • Form the roof of the maxillary sinus • Landmark: – Infraorbital groove & canal

ANTONIO SAY, MD

Orbital Floor • Inferior Orbital Fissure - separates the lateral wall from the orbital floor • Orbital plate of the Maxilla - central area of the floor - most frequent site of blowout fracture • Inferior Orbital Rim - frontal process of the maxilla medially ANTONIO SAY, MD - zygomatic bone laterally

Six P’s Orbital disorder evaluation • Pain (inflammation, infection, hemorrhage, malignant lacrimal gland tumors, NP CA) • Proptosis (forward displacement of the eyeball) • Progression • Palpation • Pulsation • Periorbital changes ANTONIO SAY, MD

• Proptosis forward displacement of the eyeball

• Pseudoproptosis obvious proptosis in the absence of orbital disease

ANTONIO SAY, MD

Proptosis • Axial displacement (eyeball is displaced straight ahead , retrobulbar lesion) • Non axial displacement (eyeball displaced sideways or vertically, outside the muscle cone)

• Superior displacement (maxillary sinus tumors) • Inferomedial displacement (dermoid cyst and lacrimal gland tumors)

• Inferolateral displacement (frontoethmoid mucocoeles, abscess, osteomas or sinus ca)

• Bilateral proptosis (graves, pseudotumor, metastatic tumor etc.) ANTONIO SAY, MD

• Pulsating Proptosis - reflects the pulse of an orbital vascular malformation - transmission of the cerebral pulsations in the absence of orbital roof • Positional Proptosis changes with valsalva’s maneuver seen in orbital varices or menigocoele • Intermittent Proptosis sinus mucocoele ANTONIO SAY, MD

Progression • Onset occur over days to weeks – Idiopathic orbital inflammatory disease – Cellulitis – Hemorrhage – Thrombophlebitis – Rhabdomyosarcoma – Thyroid ophthalmopathy – Neuroblastoma – Metastatic tumors or granulocytic sarcoma ANTONIO SAY, MD

Progression • Onset occurring over months to years – Dermoids – Benign mixed tumors – Neurogenic tumor – Cavernous hemangiomas – Lymphoma – Fibrous histiocytoma – osteomas ANTONIO SAY, MD

Palpation • Masses palpable in the superonasal quadrant – Mucocoeles, mucopyoceles, encephaloceles, neurofibromas, dermoids or lymphoma

• Masses palpable in the superotemporal quadrant – Dermoid, prolapsed lacrimal gland, lacrimal gland tumor, lymphoma or inflammatory

• Lesions behind the equator – not palpable ANTONIO SAY, MD

Pulsation • Pulsation without bruit – Neurofibromatosis, meningoencephaloceles

• Pulsation with or without bruits – Carotid cavernous fistula, dural arteriovenous fistula or orbital arteriovenous fistula

ANTONIO SAY, MD

ANTONIO SAY, MD

ANTONIO SAY, MD

Orbital infection • • • • • •

Cellulitis Necrotizing fasciitis (bacterial inf fascia strep) Phycomycosis (most virulent fungal disease) Aspergillosis (fungal inf) Orbital tuberculosis (periostitis cold abscess) Parasitic diseases (trichinosis & echinococcosis)

ANTONIO SAY, MD

Cellulitis • Pre septal cellulitis • Orbital cellulitis

ANTONIO SAY, MD

Pre septal cellutiis • • • • • • • • •

Inflammation and infection- eyelids and periorbital structures ant to orbital septum Eyelid edema, erythema Globe not involved Pupillary reaction, visual acuity & ocular motility not affected Absent of pain on eye movement & chemosis Due to penetrating trauma or cutaneous source Children –sinusitis < 5 yrs old – bacteremia, septicemia, meningitis (h. influenzae) Teens & adult – superficial source eg traumatic inoculation, infected chalazion or epidermal inclusion cyst (staph aureus most common)

ANTONIO SAY, MD

Orbital cellulitis • Infection posterior to the orbital septum • 90% secondary extension of acute or chronic bacterial sinusitis • Fever, leukocytosis, proptosis, chemosis, restriction of ocular motility & pain on movement of the globe • Decreased vision & pupillary abnormalities suggest orbital apex involvement • Delay may result to orbital apex syndrome or cavernous sinus thrombosis ANTONIO SAY, MD

• Intravenous antibiotics • Culture and sensitivity of the blood, nasal and conjunctival secretions (H. influenza, Staph, anaerobes) • Nasal decongestants, vasoconstrictors, ENT consult • Early surgical drainage of abscess ANTONIO SAY, MD

Necrotizing Fasciitis Uncommon severe bacterial infection Potentially fatal occurrence Anesthesia or disproportionate pain Patient may rapidly deteriorate if not treated early

ANTONIO SAY, MD

Phycomycosis Also called mucormycosis Extension from sinuses Proptosed eye, orbital apex syndrome Common in systemically ill/ debilitated patients

ANTONIO SAY, MD

Aspergillosis From fulminant sinus infection with orbital spread Infection can be destructive to the bones Fungus ball formation Treated by excision and fungicidal drugs administration

ANTONIO SAY, MD

Parasitic Disease Includes trichinosis and echinococcosis Infestation may cause lid and extraocular muscle inflammation Cysticercosis from tapeworm may present as mass lesion in the orbit

ANTONIO SAY, MD

Orbital inflammation • Graves ophthalmopathy • Idiopathic orbital inflammation(orbital pseudotumor) • Sarcoidosis • Vasculitis – giant cell arteritis, polyarteritis nodosa

ANTONIO SAY, MD

Congenital Anomalies • • • •

Anophthalmos Microphthalmos Cranifacial Clefting Tumors

ANTONIO SAY, MD

Orbital neoplasm • • • • • • • •

Congenital orbital tumor Vascular tumor Neural tumor Mesenchymal tumor Lymphoproliferative disorders Lacrimal gland tumor Secondary orbital tumors Metastatic tumors ANTONIO SAY, MD

ANTONIO SAY, MD