D.

Hanan Darif 2016

The orbit
Anatomy : it`s pyramidal in shape , cavity having roof ,floor, medial ,
lateral wall .

- Apex posterior . base anterior.

- Orbital volume 30 ml.
- Globe volume 6-7ml .

Orbital fissure and foramina :

1- optic foramen (canal ) connection the orbit with middle cranial fossa .
It`s transmits: MCQ

 Optic nerve .
 ophthalmic artery .
 sympathetic twigs around the artery .
2- superior orbital fissure MCQ:
Live = lacrimal n
Free = frontal n Superior ophthalmic vien outside the ring
To = trochlear n

See= superior division

No = nasociliary n
Inferior ophthalmic vien inside the ring
Insult = intrerior division 3rd n .
AT ALL = abducent .

N.B no lymphatic’s inside the orbit .

- NB: there is relation between the orbit & the brain :
1- optic foramen .
2-Orbital roof separates the orbit from ant cranial fossa .

3- inferior orbital fissure : MCQ& SLID

Page
D.Hanan Darif 2016

1- maxillary division of trigeminal n ( zgyomaticn )

2- Infra orbital artery & n .
4- inferior orbital canal :MCQ?& SLID
 Infra orbital vassals .
 Infra orbital nerve .
Anatomy of the cavernous sinus :
Relation :
 medially : sella tursica ( pit .gland ) & sphenoid sinus.
 Laterally : temporal lobe .
Contents :
1. The cavity contains .
 Internal carotid artery ( surrounded by sympathetic plexus ) .
 Abducent n.
2. The lateral wall contains ( from above down wards )
 3rd n .
 4th n .
 Ophthalmic . n .
 Maxillary . n .
- So the infection come to cavernous sinus from :
- 1-face and orbit ( dangerous area ) via ophthalmic vein .
- 2- middle ear ( inf .petrosal sinus ) 3- mastoiditis
- 4- mouth and pharynx . 5- blood borne (metastatic).
- Organism : common staph & strepto .

Proptosis
Page
D.Hanan Darif 2016

Def : It`s protrusion of the eye ball outside the orbital rim .
Couses :
I) – congenital : e.g :
 Dermoid cyst painless , slowly growing .
 Meningo – encephalocele : herniation of apart of meninges & brain
through a defect in the orbital roof - proptosis .
. - pulsating .
- on crying .
II)- Acquired :
1- traumtic e.g
a) retro bulbar hematoma .
b) surgical emphysema .
c) carotid - Cavernous fistula (A- V shunt ) :
 Pulsatile protosis .
 Disappear on pressure on the carotid .
2- inflammatory :
Acute :
a) Orbital cellulites .
b) Cavernous sinus thrombosis = varices .
c) Panophthalmitis .
d) Sinusitis .
Chronic :
a)Specific : T.B, syphilis .
b)Non- Specific: orbital- pseudo tumor .
Orbital pseudotumor :
Def : - It`s uncommon (rare).
-non – neoplastic .
-non – infection .
-involved any soft tissue .
Cause : un known
presentation :

Page
D.Hanan Darif 2016

 30-60 years
 Painful onst & unilateral .
 Chemosis , proptosis , ophthelmoplegia .
 Binocular diplopia

TTT : - systemic steroid .

-radiation .
-immunosupressive ( cytotoxic ) .

3 - Neoplastic ( benign or malignant )

Primary :

 lacrimal gland tumors ( mixed tumor , adenoma ) .

 optic nerve tumors (e.g glioma , meningioma ).
 Rhabdomyo sarcoma , lymphoma , osteoma .
 Intra –tumors (e.g retinoblastoma ).
 Cancer maxilla .
 Intra – cranial tumors .
Secondary :

 From the breast (in female ).

 Bronchi & prostate ( in male ).
 From leukemia .

4- Other causes :
1. Vascular :
 Aneurysm & ophthalmic . a .
 Tumors .
 Varices .
 A-V . shumts .
2. cyst :

 Dermoid cyst .
 Hydatid cyst .
 Blood cyst .
3. endocrinal : - Dysthyroid .

Page
D.Hanan Darif 2016

4.paralysis of extra – ocular ms (3rd n . palsy ) .

N.B : pseudo protasis :

1- ipsilateral cause : - large eye ( high myopia ).
-shallow orbit .
-lid retraction ex. Thyrotoxicosis.
2- contralateral cause : enophthalmos , atrophic eye .

Dignosis :
1- history : onset , course , history of truma , systemic disease pain ,
diplopia .
2- Examination: a- ENT .
B- medical exam: thyroid , LN enlarged , look for
Primary tumore.
inspection :

 Unilateral = ( inflammation , trauma , tumors ).

 Bilateral = endocrinal

Direction :
a) Directly forward : e.g : - optic n. tumor .
- thyrotoxicosis .
- orbital cellulitis
b) Forward , down & in : lacrimal gland tumors .
c) Forward , down & out : frontal or ethmoidal mucocele .
d) Upward : cancer maxilla .

pulsation proptosis : (mcq)

 Oph. Artery aneurysms .
 Sarcoma .
 Carotid – cav. fistula .
 Meningo – encephalocele .
Ocular motility affection :
Pulpation :
 Consistency .
 Pulsation .

Page
D.Hanan Darif 2016

 Thrill = carotid – cavernous. fistula .

Auslultation : in A.V fistula = murmer ( bruit ) .

Measurement of proptosis :
1- the distance between lateral orbital margin & Apex of the cornea =
normally is 15 mm -18 mm (20 mm) .
N.B: difference between the 2 eye is 2mm
The measurement is done by OSCE
1- simple transparent ruler .
2- Hertels exophthalmometer.
VISUAL ACUITY : Vision due to optic n.compression
Pupil : dilated In case optic n . compression .
Fundus : intra –ocular tumor , optic atrophy .

Investigation :
Laboratory : - CBC - ESR .
-T3,T4, TSH . - Tuberculin Test
Radiological : - plain X-ray of skull - CT .
-U/S ( B-scan , A-scan) -MRI .
Surgical Blopsy : excisional or needle biopsy .
Auto refractometer : for error of refraction ( high myopia ) .

Complication of proptosis : SLID

 Exposure keratitis.
 Dry eye .
 Conjunctivitis .
 Lagophthalmos .

Treatment of proptosis : Treat the cause .

N.B : MCQ
- Axial proptosis :
1- orbital cellulites.
2- pan ophthalmitis .

Page
D.Hanan Darif 2016

3- Glioma of optic nerve .

4- Retrobulbar haemorrhage .
5- thyroid exophthalmoss.

Orbital cellulitis
100% SLID& MCQ
 Def : - It`s acute supportive inflammation of the orbital tissue behind
orbital septum ( Retro bulbar ) .
- Common in children .
- Common unilateral .
 Cause :
1- Penetrating wounds of eyelid .
2- Sinuses infection 60% (sinusitis ) .
3- Otitis media .
4- Stye .
5- Acute dacryocystitis .
6- Endo phthalimitis .
7- Teeth infection .
8- Septicemia .
 Organisms :
- Children  heamophillus influenza.
- Adults  staph , strept , preamo .
N.B fungi rare .

 C/P:.
Symptom : - Fever , Headach , malaise
-pain with eye movement .
-vision early good vision
Late poor vision due to optic neuritis
-Diplopia .

Signs: - Lid oedma , hyperemia & tenderness .

- Conjunctival chemosis & ciliary injection .
- Axial proptosis .
- Iimitation of ocular motility ( painful ophthalmplegia )

Page
D.Hanan Darif 2016

- Optic nerve dysfunction .

 Complication :
1- Brain abscess .
2- Cavernous sinus thrombosis danger complication
3- Meningitis .
4- Optic neuritis  papilloedma  O.N.Atrophy .
5- Pan ophthalmitis .
6- Septicemia & pyemia . - general spread .
7- Orbital apex syndrome : 3rd , 4th , 5th ,6th + O.N. affection .
8- CRVO, CRAO .
9- Axial proptosis - cornal ulcer &oadma .
D/D : 1- Endophtalmitis .
2-Panophtalmitis .
3-cavernous sinus thrombosis .

 Investigation :
1- Culture & sensitivity .
2- CT- scan .
3- Plain X- ray .
 Treatmeant :
- Hospitalization .
- Culture from nose & conjunctiva .
- Medical ttt :
1- I.V Antibiotic (systemic ) .
2- Topical antibiotic .
3- Hot Fomentations.
- Surgical TTT:
Drainage of abscess by incision .

Orbital infection
1- Preseptal cellulites .
2- Orbital cellulitis .

Page
 D.Hanan Darif 2016

OSCE& MCQ& SLID

Preseptal cellulitis Orbital cellulitis
Def Acut suppurative inflamation Acute suppurative inflammation
ant to the orbital septum Post (behind)the orbital septum
Cause Skin trauma Pantrating wound of eyelid
Spread of Sinusitis , stye , dacyocystitis
infectiondacryocystitis Endophthalmitis
Middle ear infection Septicemia
C/P: Fever , headache , malaise ,pain Fever , headache ,malaise , pain
Symptoms: Vision : good vision early &late Vision : good  early
No diplopia Poor  late
Diplopia
Lid oedma , hyperemia , Lid oedma , hyperemia , tendernes
Sings : tenderness Chemosis , ciliary injection
No proptosis Axial proptosis
No chemosis Limitation ocular motility
No affection of ocular motility O.N dysfunction
Complicatio Orbital cellulitis Brian abscess ,C.S.T , meningitis
n Covenous sinus thrombosis Optic neuritis
Panophthlmitis
Orbital apea sydrom
CRVO. CRAO
TTT -Systemic & topical antibiotics - Hospitalization
- Hot fomentations - Systemic &topical antibiotic .
- Hot Fomentation .
- Draingey abscess .

N.B orbital cellulitis more danger than preseptal cellulites why ?

 C.S.T  blindness  lead to death .

D/D : mcq& OSCE

Endophthalmitis Panophthalimitis Orbital cellilitis Cav.Sinus
Thrombosis
Def It`s suppurative It`s suppurative It`s sup It`s thrombo-

Page
 D.Hanan Darif 2016

Inflammation Inflammation inflammation Phlebitis of

Primarlly in uveal Primarlly in uveal of orbital tissue the cavernouns
tract tract &sclera behind orbital sinus
(sclera is free ) Orbital tissue sptum
Cause Post operative As As before orbital cellilitis
Post traumatic endophthalimitis Endophthalmitis
Iridocyclitis Panophthalimitis
Act dacryocytitis
Symptoms
(Fever& + (+++) (++) (++++)
Headach)

Pain Severe Severe Severe Severe

vision HM,PL or no PL No PL Good early Good early

Poor  late Loss lat
Sings : Unilateral Unilateral Unilateral Unilateral
Lid Oedma Oedma Oedma Oedma
Conj Chemosis+cili.inj Chemosis+ cill.inj Chemosis+cilia Chemosis+ciliay .

cornea Hazy +KPs Hazy+ring absses Clear clear

proptosis Absent Present Present present
o.motility
R.R Normal Normal Limitation limitation
Yellow Yellow Normal Normal
Panophthalimitis C.S.T DEATH See before Death
Complicat
C.S.T - blindness blindness CRVO
Keratopaty
-Antibiotic Evaceration See before -Hospitalization
TTT
Seeing eye: -Anticoagulant
(IV, topical& -Antibiotic
Intra.vitreal.) I.V& topical
No seeing eye: -Neuro surgical tt
Evaceration
No seeing eye
Eevaceration

Dysthyroid ophthamopathy
Def : - it is ocular & orbital change resulting from gland dysfunction .
-it is the commonest cause for unilateral &bilateral proptosis .

Page
D.Hanan Darif 2016

-it may occurs with :

- hyperthyroidism thyrotoxic exophthalmos (graves disease)
- hypo ,or euothyriod thyrotropic exophthalmos .
Pathogenesis :
- immunogenic deposition of MPS & collagen & lymphocytic
infiltration in orbit & EMOs volume of orbital content & ms
enlargement 8 times exophthalmos .
- fibrosis restrictive myopathy .
- mullers ms spasm upper &lower lid retraction .

Incidence :
1- Age : average 35 years .
2- Sex : mainly in women .
3- Usually bilateral .

C/P :
a- General manifestation of thyrotoxicosis :
( loss of weight , heat intolerance ,palpitation ,sweating ,tremors
,nervousness ) .

b- Ocular manifestation :
1) Proptosis (exophthalmos ):
( usually axial , occurs gradual , unilateral or bilateral ).
2) Lid : a- lid retraction (commonest sign ): fibrosis of SR&levator
b- Edema .
c- lagophthalmos .
d- Dalrymples sign : lid retraction scleal rim .
e- Stellwags sign : infrequent blinking starring look .
f - Von graefes sign ( lid lag ) : upper lid does not follow
The eye on looking down .
g- Mobius sign: weakness of convergence .

3) Conjunctiva : chemosis & hyperemia .

4) Cornea : may be ulcerated (exposure ) .
5) IOP : duo to episcleral venous pressure .
6) Restricted extra ocular ms : IR MR SR LR .
7) Compressive optic neuropathy .

Investigation :
Page
D.Hanan Darif 2016

a- Laboratory : T3 , T4 , TSH .
b- Radiological : CTscan show thick extra-ocular ms
( except tendon).

Treatment :
1- Medical TTT of thyrotoxicosis .
2- Protect the cornea : lubricant – dark glasses .
3- Orbital infiltration : systemic steroids – cytotoxic drugs .
4- Surgical TTT: a- severe proptosis : orbital decompression .
b-Diplopia : ms surgery (recession of restricted ms)
c-lagophthalmos : tarsorraphy .

enophthalmoses
def: retraction of eyeball in orbit .
cause :
1- congenital micro phthalmos .
2- traumatic (common cause) fraction of orbital floor , rupture globe .
3- senile eno phthalmos ( atrophy of orbital fat ).
4- Pos-operative : after removal of a large orbital mass .
5- Horner syndrome apparent enophthalmos.
6- pthisis bulbi .
7- marfans syndrome .

Operations of the orbit

1- Enuclation :
- Principle : the eye ball is excised , while coni ,op.n , emos are left
Usually an artificial eye is inserted in place .

Page
D.Hanan Darif 2016

- Indication :
A- to stop pain ex. In absolute glaucoma .
B- to save life ex. In intraocular malignancy .
C- to save other eye ex . in sympathetic ophthalmitis .
D- to improve appearance ex. In total ant. Staphyloma .
- 2- Evisceration :
- Principle : cornea is excised and all (content )of the eyeball are
evacuated , while the sclera is left .
- Indication :
A- endophthalmitis
B- panophthalmitis .

NB: Enucleation can not be done for fear of extension along the
sheath of optic .N. brain .
Advantage : cosmetically better .

3- orbital exentration :
- Princible : it is operation where content of the orbit are removed
inside the orbital periosteum . the lids &conj .may be
also removed all in one mass.
- Indication :
A- malignant orbital tumors .
B- malignant tumors of lid , conj , globe , (invading the orbit )
- Provided that : - periosteum is free - no metastasis .

NB: Exentration = remove globe + orbital tissue .

Good luck
Dr: hanan darif ( 2016)

Page
D.Hanan Darif 2016

Page
D.Hanan Darif 2016

Page
D.Hanan Darif 2016

Page