Diseases of the orbitcategories of orbital diseases, clinical
presentation & evaluation
Orbital cellulitis & Blow-out fracture
of the orbit
Dr. Ayesha Abdullah
13.09.2012
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.
REVIEW (mark as true/false)
• Structures that enter the orbit through
the annulus of Zinn include:
T
• a. the nasociliary nerve
F
• b. the lacrimal nerve
F
• c. the frontal nerve
F
• d. the trochlear nerve
T
• e. the abducent nerve
The following are true about the orbit:
F
• it has a volume of about 300 ml
• the nasal bone forms part of the
F
medial orbital wall
• the palatine forms part of the floor T
• the lateral wall is the thickest orbital
T
wall
• the lesser wing of sphenoid forms
F
part of the lateral wall
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
CLASSIFICATION OF ORBITAL DISEASES
1. Congenital anomalies
2. Infections; orbital cellulitis
3. Inflammations; thyroid ophthalmopathy, orbital
inflammatory syndrome ( pseudotumour)
4. Tumours; primary , secondary
5. Vascular malformations; Carotid-Cavernous
Fistula (CCF), orbital varices
6. Traumatic disorders; blow-out fracture
Congenital abnormalities
A defect in the
roof of the orbit
Infections
Inflammations
Tumours / neoplastic disorder
Vascular malformations
Traumatic disorders
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
• 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
Proptosis & dystopia
Vertical
dystopia
Proptosis
Horizontal
dystopia
Proptosis, diplopia, enophthalmos
• 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
Conjunctival, lid & ocular motility signs
Fracture
Fracture of
floor
floorof
ofthe
the
orbit
orbit
The eye can’t
move up, why?
Patch of
anesthesia
• 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
• 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
What is
this?
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
• 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)
Clinical test; measuring proptosis
Hertel Exophthalmometer
Exophthalmometery
Looking for proptosis/enophthalmos
over the patient’s head
• IMAGING
– Ultrasonography (US)
– CT scan
– MRI
– Plain radiographs ( Caldwell & Waters
view)- mostly taken over by CT & MRI
Summary
?
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….
Some questions
1. What kind of orbital condition is this?
2. What structures are affected?
3. What more information should we ask for
to?
4. What possible causes can you think of?
5. Is the condition confined to the lids or has it
involved the eyeball?
6. Why do you think so?
7. Would you like to have more information?
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
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?
Don’t’ forget simple things can get
complicated
• Let us see an other case……..
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……..
Ocular signs
Some questions….
1. What kind of orbital condition is this?
2. What structures are affected?
3. What more information should we ask for to
get an idea about the cause of the problem?
4. Is the condition confined to the lids or has it
involved the eyeball?
5. Why do you think so?
6. What possible causes can you think of?
7. Would you like to have more information?
Some more information…….
• The child had a history of recurrent flu
and upper respiratory tract infections.
He had history of blocked nose and
thick greenish nasal discharge was
noted on examination.
• The child was put on intravenous
antibiotics but didn’t get better
• A subsequent CT scan was done which
showed…….
The antibiotics were changed to intravenous
ampicillin/sulbactam and after 5 days were changed to
oral amoxicillin/clavulanic acid for a total of 14 days of
antibiotics.
Orbital abscess
Some more questions
• What should be the management,
keeping in mind the nature of the
problem?
• What do you think can be done with the
abscess?
• Is there any role of health education in
this case?
Conclusion about the two cases
• What is the difference between the two
cases?
• We consider the second case an ocular
emergency, why?
• How did the subperiosteal abscess form in
the second case?
• What other complications could happen in
the second case? Ocular/intracranial/orbital
• What could be included in the differential
diagnosis?....
Differential diagnosis of red swollen lids
1.
2.
3.
4.
Prespetal cellulitis
Orbital cellulitis
Contact dermatitis
Focal lesions like stye, chalazion ( especially
if infected)
5. Allergic reaction ( angioedema)
6. Tumours ( specifically Rhabdomyosarcoma
in children & malignant lid tumours, primary
or secondary in adults)
Management Preseptal cellulitis
1. Symptomatic; analgesics & NSAIDS
2. Specific:
3. For mild infection oral antibiotics with antihistamines
in case of dual pathology like in insect bite
4. Very severe infections may require intravenous
penicillins to avoid true orbital cellulitis
5. Lid abscesses should be drained
6. Third generation cephalosporins in penicillin allergy
7. In general practice it requires oral antibiotics and
referral to an ophthalmologist especially when more
severe and in children
Management Orbital Cellulitis
•
•
•
•
Admit
Requires care by an ophthalmologist
Symptomatic; antipyretic, NSAIDS
Specific ; hospitalization & antibiotic therapy
–
–
–
–
Braod spectrum antibiotic (I/V); Ceftazidime or cefotaxime
Ampicillin for H Influenzae infection
Cloxacillin for Staphylococcus aureus infection
Metronidazole 500mg tds, PO when anaerobic infection is
suspected especially in adults
– Vancomycin in case of allergy to the above mentioned
Management Orbital Cellulitis
• Surgical intervention in case of local
abscess or unresponsive cases
• Consultation with ENT specialist,
neurosurgeon & paediatrician if
required
Let us summarize
• Preseptal orbital cellulitis & orbital
cellulitis are both infections.
• It is more common in children
• The route of infection could be from the
nearby infectious focus like infected
sinuses, skin wound or spread of
infection via blood
• The most common cause especially in
children is ethmoidal sinusitis
•
• Both preseptal and orbital cellulitis may
have:
– Fever
– Eyelid edema
– Pain
– Red eye
– Child is ill-appearing
• Orbital cellulitis signifies spread of
inflammation to the posterior orbital
contents that is the eyeball, extraocular
muscles: helpful signs to distinguish it
are:– Proptosis
– Decreased visual acuity ( may be normal in
the beginning)
– Red eye with conjunctival chemosis of
moderate to intense congestion
– Painful limited eye movements
– Afferent pupillary defect
Why is OC an emergency
• Prior to the availability of antibiotics, patients with
orbital cellulitis had a mortality rate of 17%, and
20% of survivors were blind in the affected eye.
However, with prompt diagnosis and appropriate use
of antibiotics, this rate has been reduced significantly
• blindness can still occur in up to 11% of cases.
Orbital cellulitis due to methicillin-resistant
Staphylococcus aureus can lead to blindness despite
antibiotic treatment.
• The infection can spread to the meninges and brain
& may cause death
• That is why it is an emergency
Ocular & orbital complications of OC
• Corneal scarring from exposure
Extraocular muscle palsies
Optic nerve damage
• Central retinal artery and central retinal
vein occlusion
• Orbital abscess
• Visual loss and blindness
Extraocular complications of OC
•
•
•
•
Brain abscess
Meningitis
Cavernous sinus thrombosis
Osteomyelitis of skull and orbit bones
Cavernous sinus thrombosis
Brain abscess
References
• Orbit, eyelids & lacrimal system. American
Academy of Ophthalmology; 1997-98
• Jack J Kanski. Clinical ophthalmology a
systematic approach. 5th ed;2003:557-89
• Parsons’ diseases of the eye. Diseases of the
adnexa-diseases of the orbit. 19th ed. 2004;
505-524
• Newell F W. The orbit. In Ophthalmology
principles & concepts.7th ed; 1992:259-69
WEB RESOURCES
• http://www.emedicine.com/oph/topic75
8.htm.
• http://www.emedicine.com/oph/orbit/e
xophthalmos
• http://www.ccmcresidents.com/wpcontent/uploads/2011/08/242.full_.pdf