ANTONIO SAY, MD
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 eye)
ANTONIO 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 fractureInfections of ethmoid sinuses commonly extend through lamina papyracea(ethmoid foramen) to cause orbital cellulitis & proptosis
ANTONIO SAY, MD
maxillazygoma
Lesser wing
Greater w e
Frontal bone
lacrimal
Superior Orbital Fissure
Inferior Ophthalmic vein Lateral Superior ophthalmic vein Lacrimal, Frontal and Trochlear nerves Outside Annulus of Zinn
Medial 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 - zygomatic bone laterally
ANTONIO SAY, MD
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
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