Al-Mustansiriyah University
College of Medicine - Department of surgery
Ophthalmology
The Orbit
Learning objectives:
1) Identify the anatomical location and composition of the orbit.
2) Recognize the possible presentations of orbital disorders.
3) Identify certain important orbital disorders with there
management options.
Anatomy:
The Roof: frontal bone, lesser wing of sphenoid
The Lateral wall: greater wing of sphenoid, zygomatic
The floor: maxillary, zygomatic, palatine
The medial wall: maxillary, lacrimal, ethmoid, sphenoid.
Function:
Protection to the eye ball
Provide attachments to the ligaments which stabilize the eye ball
Clinical features of orbital lesions
1-Abnormal Displacement of the Eye Ball
Proptosis: Abnormal protrusion of the eye ball.
Distance between lateral orbital rim and the apex of the cornea is more
than 20mm, or difference of 2mm between the two eyes is suspicious.
Axial proptosis; axial displacement of the eye ball by Space occupying
lesion inside the muscle cone
Example : Optic nerve glioma ,Thyroid dysfunction
Non-axial proptosis (Eccentric proptosis); non-axial displacement of the
eye ball by Space occupying lesion outside the muscle cone
Example : Tumors of the lacrimal gland
Enophthalmos; Backward displacement of the eye ball
Causes :
a- Small globe, congenital anomaly e.g. microphthalmos or
nanophthalmos
b- Structural bony abnormalities ( blow out fracture )
c- Atrophy of orbital contents
d- Cicatrizing orbital lesions
2-Pain
Inflammatory or infective conditions
3-Ophthalmoplegia: impairment of eye movements
Causes : Inflammation (myositis), Fibrosis (thyroid dysfunction), Tethering
of the muscles (blow out fractures), Paralysis (ocular motor nerves
lesions).
4- Impairment of Vision
Exposure keratopathy secondary to proptosis
Optic nerve dysfunction: due to inflammation, or compression.
Acute stage; optic nerve congestion, swollen
Chronic stage; secondary optic disc atrophy
Orbital Cellulites
Infection of the soft tissue of the orbit, mostly by bacteria
Strep. pneumoniae, Staph. aureus, H. influenzae.
Vision threatening and can be life threatening condition
Causes; 1-spread of microorganisms from the adjacent structures,
paranasal sinuses, dental infection, lid infections.
2-Post traumatic, or post surgical
Clinical features:
Presentation; rapid onset
Symptoms:
1-Fever, malaise
2-Pain
3-Impairment of vision
Signs:
1-Unilateral red, tender, warm periorbital tissue
2-Lid edema,
3-Conjunctival congestion
4-Proptosis
5- Painful Ophthalmoplegia
6-Optic nerve dysfunction
-Impairment of vision,
-Diminished pupillary light reflex
-Optic disc:
Acute stage; optic nerve congestion, swollen
Chronic stage; secondary optic disc atrophy
Complications;
• Cavernous sinus thrombosis
• Orbital abscess
• Brain abscess
Management;
Hospital admission
Antibiotic therapy; started immediately with broad spectrum
antibiotics Third generation Cephalosporin (ceftazidime )1gm
every 8 hours + Metronidazole
Dysthyroid Ophthalmopathy ( Thyroid eye disease )
Autoimmune disorder usually associated with abnormal thyroid function
Pathogenesis;
Hypertrophy of extraocular muscles
Deposition of glycosaminoglycans
Infiltration with mononuclear cells, macrophage
Clinical features :
1-Exophthalmus; most common cause of unilateral and bilateral
proptosis
2-Conjunctival hyperemia and edema
3-Lid retraction; it is suspected when the sclera is exposed at the upper
and lower limbus.
4-Lid lag; retarded descent of the upper lid in down gaze
5-Ophthalmoplegia: Restrictive myopathy, inability to move the eye
opposite to the side of action of the involved muscle.
6-Optic nerve neuropathy: Impairment of vision,
Diminished pupillary light reflex
Acute stage; optic nerve congestion, swollen
Chronic stage; secondary optic disc atrophy
Orbital Tumors
Dermoid: Benign cystic teratoma
Growth of displaced ectodermal tissue in subcutaneous location
Presentation: during infancy
Painless nodule at the upper temporal or upper nasal angle of the Orbit
Firm non-tender, smooth surface, skin is freely mobile over it.
Treatment: excision in toto.
Capillary haemangioma:
most common benign tumor of the orbit.
Vascular hamartoma
Presentation: during perinatal period
Location: Skin, Strawberry naves on the eyelid, Subcutaneous,fornix
conjunctiva, or deep in the orbit causing proptosis
Course; 70% spontaneous resolution at age 7 years.
Treatment; for large lesions, oral beta- blockers, local injection of
steroids and occasionally surgery
Optic nerve tumors
• Optic nerve glioma
• Meningioma
Lacrimal gland tumors: causes Non axial proptosis
Rhabdomyosarcoma; commonest malignant orbital tumor in children
Carotid-cavernous fistula:
Abnormal communication between internal carotid artery and
cavernous sinus
Causes; rupture congenital aneurysm or post traumatic
Clinical features; Congested vessels, hyperemic disc, pulsating
exophthalmus
