Treatment

Orbital Cellulitis
 Hospitalization + Anti-biotics ( IV or IM broad
spectrum G+/G- and anaerobes ) & Hot foment’s
and analgesics
 prophylaxis and treatment of corneal exposure
Acute diffuse suppurative Inflammation of the (antibiotic ointment)
orbital soft tissue { ie behind the orbital  If Abscess  Drain.
septum}
Incidence: mc cause of unilateral proptosis
in children
Causative agent
 Bacterial ; usually mixed
 Fungal (mucormycosis) : in
immunosuppressed individuals esp diabetic
Differential diagnosis
ketoacidosis & renal failure – corona virus
Source of infection 1. preseptal cellulitis ( no proptosis nor plegia )
1. Sinusitis esp. ethmoidal
NB: the medial orbital wall is very thin ( lamina paprycea)
2. Surgery eg. scleral buckle or squint
3. Penetrating (+/- orbital FB )
4. Spread eg. panopathlmitis
Clinical picture
 Fever e
 Severe pain + hot - tender skin
 Lid – conjunctival edema and congestion 2. embryonal sarcoma ( rhabdomyosarcoma) : not hot
 Diplopia + opthalmoplegia
or tender – CT shows bone erosion – biopsy
 Proptosis
 In mucormycosis = black necrotic eshcars +/- in
palate

 other causes of acute painful proptosis

o cavernous sinus thrombosis
o panopthalmitis
o infiltrative stage of dysthyroid

Complications
1. Spread
 Optic neuritis
 cavernous sinus thrombosis
2. Exposure keratitis
3. Localization : Orbital abscess
4. Healing by fibrosis ( enophthalmus )

Investigations
1. CBC : Leucocytosis.
2. CT scan :
 Sinusitis.
 +/- Abscess.

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 cardinal features :
Cavernous sinus 1) Proptosis : may lead to exposure keratitis

2) Soft tissue signs (infiltrative ophthalmolopathy)

thrombosis With Hyperemia along recti muscle insertions

Thrombo-phlebitis of the cavernous Sinus dt Infection in

dangerous area of face eg. orbit: cellulitis - acute 3) Eyelid signs :
dacryocystitis - panophthalmitis - stye {rare} o Lid retraction
o Lid lag on downgaze
Clinical picture
Severe illness + fever + cerebral signs (drowsiness –
disturbed consciousness ) +
1) Other eye affection usually starting by 6th nerve
palsy  diplopia & esotropia
2) Mastoid edema dt emissary vein

4) Restrictive myopathy
The commonest muscle to be
affected is the Inferior Rectus
leading to limited upgaze.
Followed by the medial rectus
(defective abduction and
convergence)

NB: high Mortality rate dt spread eg meningitis

Investigations: MRV with contrast

Treatment:
 Hospitalization + Anti-biotics ( IV broad spectrum
G+/G- and anaerobes ) + 5) Compressive Optic neuropathy
 Anti-coagulants ( heparin 5000 iu/ 12 hr ) By the enlarged crowded EOM at the orbital apex
 prophylaxis and treatment of corneal exposure
(antibiotic ointment) Investigations
Ocular signs usually occur
1) Thyroid function tests (T3, T4, TSH)
in hyperthyroid function but
2) CT - MRI  EOM enlargement they may appear also in a

Dys-thyroid eye patient with normal or even

subnormal function

disease
More common in young adult / middle aged females
The most common cause of adult proptosis
Pathogenesis: Auto-immune cellular Infiltration of the orbit
by plasma cells and lymphocytes with mucoploysacharide
Treatment:
deposition and retention of fluid & edema leading to
1) stop smoking
Extraocular muscles (EOM) enlargement (infiltrative
2) treatment of thyrotoxicosis
stage) followed by fibrosis (restrictive stage)
3) prophylaxis against corneal exposure
4) Systemic steroids +/- immunosuppressive
5) orbital decompression : if severe exposure or
compressive optic neuropathy
6) relieving prisms: if diplopia in primary or reading

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 Proptosis (exophthalmos) Proptosis workup
Abnormal protrusion of the globe History
dt increased orbital pressure Examination
 Exclude pseudoproptosis
Causes :  Laterality
1. Endocrine = dysthyroid
 Degree: From lateral orbital
margin to the corneal apex by
transparent plastic ruler or
2. Retrobulbar haematoma exophthalmometer eg. Hertel
eg. retrobulbar anaesthesia .  Direction
Risk of optic nerve o Axial In intraconal lesions eg optic nerve Proptosis if > 20mm
compression. or >2mm difference
tumours
between both eyes
o Non- axial in extraconal lesions eg.
lacrimal gland tumours
3. Carotid cavernous fistula  Motility for ophthalmoplegia
 Causes :  slit lamp with fluorescein for corneal exposure
a. Fracture skull base  light reflex for RAPD if optic nerve affection
b. Spontaneous in old  Lid signs = thyroid
hypertensive  Pulsating = carotid cavernous fistula
atherosclerotic females  Intermittant = varices
 Clinical features:
a. Severe congestion Investigations:
(cork screw vessels )  Lab : CBC - TFT
b. pulsating proptosis  Imaging : CT - MRI
c. Audible bruit  Biopsy : in tumours
d. Palpable thrill

4. Orbital varices: intermittent

proptosis that increases with
increased venous pressure eg.
Valsalva
Pseudo-proptosis
Ipsilateral
 large globe eg. buphthalmos - high
5. Inflammatory : axial myopia
 orbital cellulitis  Lid retraction
 panophthalmitis Contralateral : enophthalmos
 cavernous sinus thrombophlebitis
 dacryoadenitis

6. Neoplastic
 Haemangioma = most common
 Rhabdomyosarcoma
 Lacrimal gland eg. pleomorphic adenoma
 Optic nerve tumours eg. glioma
 Metastasis

Lacrimal gland swellings cause

 infero-nasal dystopia or
globe displacement
 S shaped ptosis

Optic nerve tumours affect vision early !

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 Treatment :
Enopthalmos 1) Avoid nose blowing & prophylactic oral antibiotics
2) Surgery (within 2 weeks ) if:
 enophthalmos ( > 2mm)
Retraction of the globe in the orbit
 large fracture ( > 2 cm )
Causes:  Diplopia in the primary position or reading
1) Senile (involutional) atrophy of the fat  trapdoor fracture with muscle entrapment ( risk
2) Post inflammatory or postsurgical fibrosis of vasovagal )
3) Cicatrizing metastasis eg schirrus breat carcinoma
4) Blow-out fracture of the orbital floor.
Blunt trauma by an object bigger than the orbital margin
(4.5mm) eg tennis ball or a fist . The rise of the intraorbital
pressure causes fracture of the thin orbital walls esp the
floor ( at the infraorbital canal)

Pseudo-enophthalmos
1) Mild ptosis eg. Horner's syndrome
2) Small globe eg.Atrophia bulbi

Signs:

1) Enophthalmos (due to herniation of the orbital fat &

soft tissue in the maxillary sinus.)

2) Hypotropia
3) Limited upgaze & vertical diplopia (dt entrapment
of the inferior rectus in the fracture site)

4) Surgical (subcutaneous) emphysema with

crepitus sensation
5) Infraorbital anaesthesia (injury of the infraorbital
nerve)

Investigations : CT
Fracture site seen + tear drop sign