Dr. Ayesha Abdullah 13.09.2012

1. Diseases of the orbit- categories of orbital diseases, clinical presentation & evaluationOrbital cellulitis & Blow-out fracture of the orbit Dr. Ayesha Abdullah 13.09.2012

2. LEARNING OBJECTIVES By the end of this lecture the students would be able to; 1. Categorize orbital diseases, correlate the common symptoms & signs of orbital diseases with the underlying structural and functional disorder 2. Outline the protocol for the clinical evaluation of a patient presenting with orbital disorder 3. Differentiate between preseptal and true orbital cellulitis & explain why it is considered to be an ocular emergency 4. Describe the causes, clinical presentation, complications & line of management of orbital cellulitis 5. Explain the mechanism of BOF of the orbit, describe its clinical presentation, complications & outline the management.

3. REVIEW (mark as true/false) • Structures that enter the orbit through the annulus of Zinn include: • a. the nasociliary nerve • b. the lacrimal nerve • c. the frontal nerve • d. the trochlear nerve • e. the abducent nerve T F F F T

4. The following are true about the orbit: • it has a volume of about 300 ml • the nasal bone forms part of the medial orbital wall • the palatine forms part of the floor • the lateral wall is the thickest orbital wall • the lesser wing of sphenoid forms part of the lateral wall F F T T F

5. The orbital septum • Spreads like a sheet at the back of the orbit • Separates the lids from the intraorbital contents • If weak the intraorbital fat can herinate through it • Is a weak barrier to the spread of infection inside the orbit • Is attached to the trochlea F T T F F

6. CLASSIFICATION OF ORBITAL DISEASES • Congenital anomalies • Infections; orbital cellulitis • Inflammations; thyroid ophthalmopathy, orbital inflammatory syndrome ( pseudotumour) • Tumours; primary , secondary • Vascular malformations; Carotid-Cavernous Fistula (CCF), orbital varices • Traumatic disorders; blow-out fracture

7. Congenital abnormalities

8. A defect in the roof of the orbit

9. Infections

10. Inflammations

12. Tumours / neoplastic disorder

16. Vascular malformations

17. Traumatic disorders

18. COMMON SYMPTOMS & SIGNS OF ORBITAL DISEASES • Symptoms • Pain; orbital/ periorbital/ with ocular movements • Visual disturbances, loss/ blurring/ • Diplopia/ squint • Swelling of the eyelids/ periorbital area/ mass • Protrusion of the eyeball

19. Signs • Related to the eyeball • Proptosis; forward displacement of the eyeball • Dystopia; horizontal/vertical displacement of the eyeball in the coronal plane which may/ may not coexist with the forward displacement • Enophthalmos ; recession of the globe into the orbit • Nanophthalmos ; a very small eyeball

20. Proptosis & dystopia Vertical dystopia Proptosis Horizontal dystopia

21. Proptosis, diplopia, enophthalmos

24. Conjunctival & lid signs; swelling of the lid, conjunctival chemosis, injection ( redness) • Ocular motility disturbances; restrictive or muscle entrapment disorders, neurological disorders- strabismus • Corneal signs; secondary to exposure of the cornea • Posterior segment signs; venous dilatation & tortuosity , vascular occlusions, optic disc (OD) swelling, optic atrophy, choroidal folds

25. Conjunctival, lid & ocular motility signs

27. Fracture floor of the orbit Fracture of floor of the orbit The eye can’t move up, why? Patch of anesthesia

30. Other signs; bruit (carotid-cavernous fistula/CCF), pulsations (CCF, orbital roof defects), palpable mass • Sight threatening signs are exposure keratopathy, pupillary abnormalities ( RAPD) & optic disc or vascular changes in the retina

31. Common causes of proptosis in adults • Thyroid eye disease • Tumours • Common causes of proptosis in children • Orbital cellulitis • Tumours • Congenital malformations of the orbital bones

33. What is this?

35. Clinical evaluation of orbital disorders • History • Examination • Assessment of visual functions; Visual acuity & colour vision • Examination of the anterior segment • Examination of the pupils • Examination of the posterior segment • Examination of the Extra Ocular Muscles • Intraocular pressure measurements

36. Special tests • Exophthalmometry ( measuring globe protrusion & displacement – proptosis, dystopia) • Local palpation • Bruit & pulsations • Checking for cranial nerve dysfunctions • (II, III, IV, V, VI, VII,VIII)

37. Clinical test; measuring proptosis

38. HertelExophthalmometer Exophthalmometery

39. Looking for proptosis/enophthalmos over the patient’s head

40. IMAGING • Ultrasonography (US) • CT scan • MRI • Plain radiographs ( Caldwell & Waters view)- mostly taken over by CT & MRI

41. Summary ?

42. Case #1 A one-year old baby presented to the OPD of the department of Ophthalmology with the complaint of a red swollen left lower lid for the last two days. On examination the lid was red, warm & mildly tender to touch. His vision was normal, the eye had mild conjunctival redness, pupils were normal and the ocular movements were also normal. Watch the photograph….

44. Some questions • What kind of orbital condition is this? • What structures are affected? • What more information should we ask for to? • What possible causes can you think of? • Is the condition confined to the lids or has it involved the eyeball? • Why do you think so? • Would you like to have more information?

45. Some more information……… • The child had a history of insect bite on the lid two days ago, the swelling increased thereafter. The insect bite mark was visible • There was no history of trauma or symptoms suggestive of flu or URTI • His temperature was normal

46. Some more questions • What should be the management, keeping in mind the nature of the problem? • What could be the complications of such a case? • Is there any role of health education in this case?

47. Don’t’ forget simple things can get complicated • Let us see an other case……..

48. Case #2 • A 12 year old child was brought to the OPD of the department of ophthalmology with a history of red swollen left upper lid for the last 5 days. He also had fever for the last two days along with headache. On examination the child had a grossly swollen lid. His visual acuity was 6/18 OD & 6/6 OS. The lid was warm and tender. The eye was moderately proptosed with conjunctival chemosis. The pupil was slow to react to light and the ocular movements were painful & limited. The temperature was 1010 F & the child generally looked unwell……..

50. Ocular signs