Dr. Halimah Pagarra SpMMedical Faculty, Hasanuddin UniversityMakassarOktober 2010

Diagnosis6 P : - 1. Pain 2. Proptosis 3. Progression 4. Palpation 5. Pulsation 6. Periorbital change

Clinical evaluation of the orbit History Ocular examination

History

History taking should begin with the most importantissue: the chief complaint of the patientThe answer may be pain around my eye, protrusion of my left eye, double vision, acute episode of redness and swollen eyelids and/or conjunctiva?

Did it begin as a painful episode? Did the pain ease afterward? Did the pain increase or decrease during the course of the disease? Is the pain intermittent, - Does the patient feel a dull pain behind the eye when moving the eyes from right to left and up and down? Was the proptosis totally painless?

Normal anatomyThe orbit contains the following structures which may be involved in pathological processes: globe and optic nerve muscles extraocular striated and smooth (Mllers) lacrimal gland nerves blood vessels connective tissue and fat.

Ocular examination

Best corrected visual acuity intraocular pressure applanationPrimary position and in different vertical and horizontal gazes. Neuro-ophthalmologic examination, including motor and sensory functions, pupillary examination, contrast sensitivity, color vision assessment,Confrontation visual fields, and central visual acuity with an Amsler grid should also be done

1. Pain inflammatory,infectious, orbital hemorrhage, and periorbital changes 2. Proptosis,indicates the location of a mass because the globe is usually displaced away from the site of the masss. Axial dislacement cav hemangioma, glioma, meningioma. Superior displacement maxillary sinus tumors. Inferomedial dermid cyst, lacrmal gland tumors. Inferolateral disp frontoethmoidal mucoceles, abscesses. Bilateral prop Graves ophthalmopaty, lymphoma, pseudotumor, leukemia

3. Progression onset occuring over days to week idiopathic orbital inflammatory disease, cellulitis, hemorrhage,thrombophlebitis, rhabdomyosarcoma, grave ophthlOver months to years dermid cysts, benign mixed tumors, cav hemangioma, lymphoma4. Palpation palpable superonasal mucocele, mucopyocele, neurofibroma, dermoids5. Pulsation without bruits neurofibromas. With bruits carotic cav fistulae6. Periorbital changes, underlying disorders

Signs and Symptoms of Orbital Disease.

Proptosis or enophthalmosConjunctival chemosis and injectionLid findings : -Lid retraction -Lid lag -Lid edemaPtosisVisual loss Exposure keratopathy, Optic neuropathyOphthalmoplegia and diplopia

Orbital Evaluation

Evaluation and Diagnosis of an orbital abnormality is guide by considering the most commont disorders that occur among children and adults. Clinical history should include question about the presence of malignant tumors and thyroid disease tha mild involved the orbitThe evaluation of the orbit should be proceded by careful ophthalmic examination

A.X-Rays provided technique for evaluating the orbital bone , but their use is limited because of poor soft tissue definitionB. Ultrasonography (USG) is a sensitive technique for evaluating intraocular details and visualizing many orbital lesions. However, the sound waves cannot penetrate bone, and some orbital masses may not be detected unless the waves strikes a perpendicular surface.C. Computed Tomography (CT) uses thin x-rays beams to obtain tissue density. Values, from wich detailed cross-sectional images of the body are produced by a computer./

D. Magnetic Resonance Imaging (MRI), is a method of visualizing thin anatomic sections by exposing patients to a magnetic field and then recording the radiofrequency emissions from proton. The advantages of MRI - Lack of ionizing radiation (as used in X-rays and CT) - Ability to distinguish among certain vasculer & neorologic abnormalities. Disadvantage The bone does not give magnetic resonance signals.

orbital lesions may be better evaluated by CT scans- MRI Intracranial disease

E. Arteriography is performed by injection of radiopaque dye into the carotids to visualized the orbital & intracranial arteries

Diseases of the orbit Anatomi (Congenital orbital anomali)TumorInflammation : - Infection - Non infection

1. Congenital orbital anomalie

AnophthalmosMicrophthalmosCraniofacial cleftingTumors

Duke-Elder Total absence of tissues of the eye.Orbital growth is dependent on the size & growth of the globeAnophthalmic orbits are small with hypoplastic eyelid & orbital adnexal structuresMicrophthalmic eyes have no potential for vision R/ cosmetically appearance symmetric

a. Anophthalmia Very rare condition, Characterized by the absence of any visible / Rudimentary ocular tissue USG, CT scan True anophthalmia failed or incomplete formation of the optic stalk and vesicle

(A) Photograph of 6-month-old with colobomatousmicrophthalmia and orbital cyst anomaly. Note the left lower eyelid cystcausing a mass in the lower lid, left blepharophimosis (small lids andnarrow lid fissure), and apparently normal right eye.

(B) Desmarres retractorsopen the eyelids in an attempt to expose the microphthalmic left eye.The only remnant of eye that could be seen externally was a small dimplejust nasal to the lid retractors b. Microphthalmia

Craniofacial clefts- --developmental arrest Failure of neural crest cell migration and a failure of fusion of facial processes

c. Craniofacial cleft

d. Congenital orbital tumorDermoid cyst of the orbit

2. Cellulitis* Common cause bacterial infection Delayed identification of non infectious autoimmune, malignan, foreign body Bacterial infections of the orbit or periorbital soft tissues occur from 3 primary sources - direct spread from an adjacent sinusitis (most cases) - direct inoculation following trauma or skin infection - bacteremic spread from distant focus(otitis media, pneumonia

Cellulitis

Periorbital infection Preseptal cellulitis Cellulitis orbita

a. Preseptal cellulitisInflammation and infection confined to :The eyelids Periorbital structures anterior to the orbital septum(orbital structures posterior to the septum are not infected but maybe secondarily inflamed), The globe is uninvolved.Eyelid edema, erythema, and inflammationPupillary reaction, visual acuity, and ocular motility are not disturbedPain on eye movement and chemosis are absent

b. Orbital cellulitisPosterior to the orbital septumOrbital sellulitis occurs as secondary extension of acute or chronic bacterial sinusitis >> 90%Clinical finding : Fever, leukocytosis (75%), proptosis, chemosis, ptosis, and restriction of and pain with ocular motilityVisual acuity, color vision, visual fieldcompressive optic neuropathyDelay in treatmentblindness,cavernous sinus thrombosis, cranial neuropathy, brain abscess, and death

- Infective orbital cellulits from sinusitis is extremely important to recognize as the juxtaposition to intracranial structures.- pathophysiologically, the infection originates from the sinuses and can spread readily to the orbit through the thin bony walls and foramina, or in a retrograde fashion by the interconnecting valveless venous system of the orbit and sinuses.

a Orbital cellulitis, massive swelling, and erythema of the upper lidb Orbital cellulitis, massive swelling of the conjunctiva with hemorrhage beneath; exophthalmos, limitedmobility of the globe

Inflammation/infectionOrbital inflammation

Clinical features :- ocular and orbital :- group 1 : inflammatory edema- lid edema- goup 2 : orbital cellulitis- increasing lid swelling- injection- chemosis- axial proptosis- venous congestion(choroid and retina)- increasing pain +/- increasing intraocular pressure

Orbital cellulitis with marked erythema, proptosis

B. Chemosis and hypo-ophthalmia are present

C. Vertical duction are impaired OS

Right orbital cellulitis. Note proptosis & exotropia

B. CT scan of right orbita subperiosteal abscess (arrow.) Note medial rectus displaced by abscess

General : +/- malaiseImaging :CT: Groups 1 & 2 - swelling of lid - sinus opacification - mucosal thickening +/- Obscuration and infiltration of orbital fatUSG: - clear spaces - change in fat densitiesRadiography : - sinus opacity +/- air fluid level

Diagnosis

Clinical diagnosis : imaging to identify abcess formation, accurate staging and location of lesion. CT or MR imaging : precise location & extent of the inflammatory process, follow improvement or worsening of the diseaseSinus pathology : mucosal wall thickening , opacification and air fluid level.

Management

Majority of children do not need sinus or abscess drainage.In contrast, adults more frequently require such, particularly if there is orbital tension and threat to vision.In adults, it is important to use adequat intravenous antibiotic theraphy.Drainage of an abcess should be emergent if there is a threat to the nerve optic, retinal function, or if there is a profoundly tense orbit in patients who have significant pain.In those with intracranial complications of frontal sinusitis, the abcess should be drained.

2. Thyroid orbitopathyThyroid associated orbitopathy

The CT Features of Graves DiseaseEnlargement of muscle body (7075% have muscle hypertrophy, mainly medial and inferior recti)Compression of optic nerve in the orbital apex by the enlarged extraocular musclesIncreased orbital fat volumeConvex shape of ethmoidal wall in chronic diseaseImage of the enlargement of the inferior rectus in back third of orbit in axial views may mimic orbital tumorElongation of the globe and stretch of the optic nerve secondary to proptosis

Graves disease (GD) is a type of orbital inflammation, certain clinical features may be confused with orbital tumors.The pathogenesis of GD is not completely understood;it is labeled an autoimmune process.

Systemic clinical features :Hyperthyroidism is the most frequent thyroid dysfunction related to orbital disease (90%), and its systemic signs and symptoms may include weight loss, smooth skin, tachycardia, pretibial myxedema and clubbing of the fingers and toes, and subperiosteal new bone formation (thyroid dermopathy and thyroid acropathy).

Systemic clinical features :Hyperthyroidism is the most frequent thyroid dysfunction related to orbital disease (90%), and its systemic signs and symptoms may include weight loss, smooth skin, tachycardia, pretibial myxedema and clubbing of the fingers and toes, and subperiosteal new bone formation (thyroid dermopathy and thyroid acropathy).

Orbital clinical features

Upper lid retraction is the most frequent orbital clinical sign in early GD (75% at initial diagnosis and 90% at some point in the clinical course) and may lead to the false impression of proptosis.

Typical multimuscle Graves disease with severe proptosis of both eyes and retraction of upper and lower eyelids.

Although the left medial rectus muscle reveals the most prominent enlargement, the bilateral involvement of all horizontal recti is clearly depicted in the T1-weighted MRI image

Management The orbital disease may have a self-limited course from 6 months to 3 years, but the evolution of the disease cannot be predictedR/Topical ocular lubricantsKeratokonjunctivitis siccaEmergent intervention orbital inflammation >>, corneal exposure,globe subluxation, optic neuropathy.R/Systemic corticosteroid,radiotherapy, orbital decompression,

C. Tumor 1. HemangiomaOne-year-old boy with a capillary hemangioma involvingthe left inferior orbit. (A) Facial photograph showing bluishdiscoloration, swelling of the left lower eyelid, and upward displacementof the eyeball by the inferiorly located orbital capillaryhemangioma. (B) T1-weighted coronal MR image demonstrating theinferiorly located capillary hemangioma with marked contrast enhancement.Note the signal-void areas representative of high flowvessels. (C) Postoperative facial photograph 6 months after excisionof the lesion. There is no superior displacement of the globe

2. Capillary Hemangioma (A) Large lower eyelid anterior orbit hemangiomaphotographed before steroid injection.

(B,C) Appearance and size ofthe lesion postoperatively, 8 and 13 months after injection, respectively

Massive proptosis and inferior dislocation of theright globe secondary to large hemangiopericytoma extending intothe cranium, perinasal sinuses, and nasal cavity. The histopathologyrevealed sarcomatous changes with high mitotic rate (6 per HPF

A 5-year-old boy with NF1 and bilateral optic nervegliomas. (A) Facial photograph demonstrating downward proptosisof the left eye.

(D) Axial orbital T1-weighted MR image showing bilateral optic nerve gliomas isointense to the extraocularmuscle and cerebral gray matter (arrows). Inset: Coronalorbital T1-weighted MR image demonstrating bilateral arachnoidalhyperplasia surrounding the optic nerve gliomas (arrows).

Facial prosthesis with glasses fitted to a patient following exenteration due to hemangiopericytoma.Patient is shown at the ages of 4 (A), 12 (B), and 15 (C) years. (Courtesy of Dr. Amin M.Nasr, Beirut, Lebanon.)

Seorang penderita 25 tahun datang ke poliklinik mata dengan keluhan palpebra kanan nyeri, proptosis, edem, hiperemi, konjungtiva kemosis, kornea jernih disertai dengan demam. Dari anamnesis riwayat sakit sinusitis. Pada pemeriksaan oftalmologi tajam penglihatan mata kanan menurun. Pergerakan bolamata kanan terhambat . hasil laboratorium darah tampak lekositosis.

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