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

2. By the end of this lecture the students would be able to;
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
Describe the causes, clinical presentation, complications & line of management of orbital cellulitis
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
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
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. Hertel Exophthalmometer
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 ?
Orbital disease although are not common but can have sight threatening & at times life threatening sequelae
Common categories of orbital disorders include; Congenital anomalies, infections, inflammations, tumours, traumatic disorders
Commonest presentation is with proptosis, sight threatening signs include corneal exposure keratopathy, RAPD, optic disc changes
The commonest causes of proptosis in adults include TED & tumours while in children the commonest causes are orbital cellulitis, congenital disorders & tumours/ neoplastic disorders.
Clinical work-up includes complete history, ocular examination, special clinical test & assessment of the cranial nerves
Imaging tests are very useful in making the final diagnosis inclusive of US, CT & MRI

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 F & the child generally looked unwell……..

50. Ocular signs

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

52. 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…….

53. 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.

54. Orbital abscess

55. 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?

56. 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?....

57. Differential diagnosis of red swollen lids
Prespetal cellulitis
Orbital cellulitis
Contact dermatitis
Focal lesions like stye, chalazion ( especially if infected)
Allergic reaction ( angioedema)
Tumours ( specifically Rhabdomyosarcoma in children & malignant lid tumours, primary or secondary in adults)

61. Management Preseptal cellulitis
Symptomatic; analgesics & NSAIDS
Specific:
For mild infection oral antibiotics with antihistamines in case of dual pathology like in insect bite
Very severe infections may require intravenous penicillins to avoid true orbital cellulitis
Lid abscesses should be drained
Third generation cephalosporins in penicillin allergy
In general practice it requires oral antibiotics and referral to an ophthalmologist especially when more severe and in children

62. 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

63. Management Orbital Cellulitis
Surgical intervention in case of local abscess or unresponsive cases
Consultation with ENT specialist, neurosurgeon & paediatrician if required

65. 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

66. Both preseptal and orbital cellulitis may have:
Fever
Eyelid edema
Pain
Red eye
Child is ill-appearing

67. 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

68. 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

69. 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

70. Extraocular complications of OC
Brain abscess
Meningitis
Cavernous sinus thrombosis
Osteomyelitis of skull and orbit bones

71. Cavernous sinus thrombosis
Brain abscess

72. References
Orbit, eyelids & lacrimal system. American Academy of Ophthalmology;
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;
Newell F W. The orbit. In Ophthalmology principles & concepts.7th ed; 1992:259-69

73. WEB RESOURCES http://www.emedicine.com/oph/topic758.htm.