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ORBIT

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14 views

ORBIT

Uploaded by

mbbs-20-13-056
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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ORBIT

DR SIDRAH RIAZ
ASSOCIATE
PROFESSOR
A pyramidal
cavity with
roof, floor,
medial and
lateral wall +
apex
Rectangle or Pyramid
Orbital 4
walls
ROOF
Orbital plate of frontal bone
Lesser wing of sphenoid
Frontal bone
LATERAL WALL/ strongest wall
Frontal process of zygomatic
orbital surface of greater wing of sphenoid posteriorly
Thickest wall of the orbit
Separated posteriorly by superior orbital fissure
ORBIT
FLOOR
 Orbital plate of maxilla
 Zygomatic bone
 Orbital process of palatine bone,
It roofs maxillary sinus, Its thin
and is most commonly fractured.
MEDIAL WALL / weakest wall
Orbital plate of ethmoid
bone(lamina
papyracia)
lacrimal bone, At the apex – body
of sphenoid, Lacrimal bone
contains fossa for nasolacrimal sac
Proptosis
 Proptosis refers to
forward protrusion of
the globe with
respect to the orbit.
There are many
causes of proptosis
which can be divided
according to location
and it is worth
remembering that it
is not just orbital
disease processes
that cause proptosis
Proptosis causes
Remember the main causes of Proptosis using the mnemonic THE-I .
THE I (I~eye)
 Tumor (Rhabdomyosarcoma, Retinoblastoma)
 Hemorrhage (traumatic posterior orbital
hematoma)
 Endocrinopathy (Graves’ disease/TED)
 Infection
(pre septal cellulitis, orbital cellulitis,
Cavernous sinus thrombosis, orbital abscess)
Orbital
septum
ORBITAL
SEPTUM

The orbital septum (palpebral
ligament) is a membranous
sheet that acts as the anterior
boundary of the orbit. It extends
from the orbital rims to the
eyelids. It forms the fibrous
portion of the eyelids.
Pre septal cellulitis
Pre septal cellulitis
 Preseptal cellulitis is an inflammation and infection of the
eyelid (also of the periorbital soft tissues), anterior to orbital
septum, characterized by acute eyelid erythema and edema
 It may result from the spread of the upper respiratory tract
infections, external eye infections (Stye), or eyelid trauma
(laceration)
 Patients with periorbital edema, erythema and increase in
local hyperemia but without proptosis, ophthalmoplegia and
visual impairment
 Treatment: Antibiotics, Analdesics, Drainage of abscess
Orbital cellulitis
Clinical features
 Impaired vision or sudden vision loss, RAPD POSITIVE
 Pain, restricted ocular movement/ ophthalmoplegia
 A red, swollen eyelid, chemosis
 Proptosis
 Discharge from the infected eye
 Fever
 Fatigue
 Loss of appetite
 Headache
Causes
 The main cause of orbital cellulitis is sinusitis, which is an
infection of the sinuses, up to 86–98 % people with orbital
cellulitis also have sinusitis. Without treatment, sinus
infections can spread to the fat and muscle surrounding the
eye socket
 Bacteria such as the Staphylococcus aureus and Streptococci
species are the most common
 An injury to the eye that penetrates the orbital septum
 Complications of eye surgery
Indications for imaging

 Eyelid edema that makes a complete examination impossible


 Presence of CNS involvement (ie seizures, focal neurologic
deficits, or altered mental status)
 Deteriorated visual acuity or color vision
 Proptosis
 Ophthalmoplegia
 Clinical worsening or no improvement after hours
investigation
Complications of orbital cellulitis

 Intracranial extension of infection (i.e subdural


empyema, intracerebral abscess, extradural abscess
and meningitis)
 Cavernous venous sinus thrombosis
 Septic emboli of the optic nerve
 Optic nerve ischemia (due to compression) may result
in visual loss
Difference
between
pre septal
& orbital
cellulitis
Thyroid eye disease
Proptosis and
exophthalmos
Exophthalmos also describes forward
protrusion of the globe
Proptosis and exophthalmos are often
used interchangeably
Exophthalmos used to refer to severe
(>18 mm) proptosis
Exophthalmos used to refer to
endocrine-related proptosis
Enophthalmos is the opposite,
displacement of the globe posteriorly
Thyroid
eye
disease
(TED)
Clinical
features
Pathophysiology

Infiltration of
Activation of CD4+ and
connective tissue with Release of pro-
CD8+ T-cells and
mononuclear cells Accumulation of GAG in
(lymphocytes,
integration with B cells, inflammatory the EOM and fat.
plasmas cells and cytokines.
macrophages , plasma
macrophages.
cells)

CD34 + fibrocytes TSHR is found on


Antigen in orbit :
key in the thyroid follicles and
Thyroglobulin orbital fibroblasts
pathogenesis
Treatment of TED
 Quit smoking
 Medical Management of Hyperthyroidism• Anti-thyroid drugs
: Thinoamides (PTU), Carbimazole, Methimazole • Need 6-8
weeks to achieve euthyroid state.
Side effects : Skin rash , urticarial , arthralgia , Fever
 Corticosteroids • Intravenous , Oral , Topical
• IV pulse for Moderate to severe TED : 71% respond to IV steroid
• IV steroids for compressive ON
Orbital Radiation
• Mechanism : lymphocyte sterilization, destruction of tissue monocytes • 20 Gy in
10 divided sessions over 2 weeks • More suited for patients > 35 years of age •
Contra-indicated in pre-existing retinopathy (diabetes , hypertensive)
Rituximab (for steroid resistant cases)
• it Targets CD20 • CD20 is expressed on more than 95% of B cells and plasma cells
• RTX depletes 95% of mature B cells , blocks Ab production , and decrease
inflammatory cytokine release
Botulinum Toxin / for proptosis
• Neurotoxin , inhibits acetylcholine release • For upper lid retraction
(transconjunctival , transcutaneous route) • Effect on Muller’s muscle and LPS
• Side effects of Botox : bruising , ptosis and diplopia
Orbital Decompression for TED
• 2 wall or 3 wall • Decompression usually in stable phase of disease.
Squint surgery: later on/inactive disease
Blow out fracture
 The term Blow-out fracture
refers specifically to the
fracture of an orbital wall in
the presence of an intact
orbital rim
 Mc Kenzie (1844) describe
floor fracture Smith and
Converse (1956) blow out
fracture
External sign: Lid edema, subcutaneous or orbital
emphysema

Ecchymosis

Subconjunctival hemorrhage

Clinical Enophthalmos
features
Inferior floor fracture; Diplopia due to IR entrapment

Infraorbital nerve hypesthesia (gum, side of nose)

Ocular Motility defects


Evaluation

intraocular
Visual acuity Pupil
pressure

Check Ocular motility


Biomicroscopy sensation on test, Diplopia
and fundus face(infraorbita chart & visual
l Nerve) fields

Force duction
Photographs as
test paretic and
documentation Radiology: X
restrictive
for patients to ray , CT scans
motility
appreciate
patterns
Treatment of BOF
 Conservative approach
 Urgent surgical treatment
Early repair Indication
 1. Symptomatic persistent diplopia with
positive force ductions.
 2. CT evidence of orbital tissue or muscle
entrapment
 3. No clinical improvement over 1 -2
weeks
 4. Enophthalmos of 3 mm or more, globe
ptosis, floor defect > 50%
Conservative/ observation: if minimal diplopia with good
motility, no CT evidence of tissue entrapment, absence
enophthalmos or globe ptosis (give NSAIDs, antibiotics)

Surgical Repair: within 7 -10 days to allow swelling and


hemorrhage to subside , patient advised not to blow nose

Anesthesia: General (GA)


Approach: Transantral or transconjunctival via orbital
rim, periosteum elevated off the orbital floor until the fracture
site is identified, entrapped tissue is freed carefully and
elevated from the defect insert material for floor
reconstruction

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