Orbital and Lacrimal disorders Saeed Alwadani, MD Assistant Professor Consultant Ophthalmologist Ophthalmology department King Saud University 26/1/16

Goals and objectives Orbit Lacrimal Anatomy and evaluation techniques Orbital trauma Proptosis Lacrimal Lesions

Anatomy

Bones

Orbital Compartments

Sinuses

Blood Supply

Annulus of Zinn(Tendinous ring)

Evaluation 7 P’s Pain Proptosis Progression Palpation Pulsation Periorbital changes Past medical history

Pain Infection Inflammation Hemorrhage Malignant Lacrimal Gland Tumor

Progression Minutes to Hours Hemorrhage Lymphangioma

Progression Days to Weeks Children: capillary hemangioma, rhabdomyosarcoma, retinoblastoma, neuroblastoma, leukemia Inflammatory disease: idiopathic orbital inflammatory disease, thyroid orbitopathy, recurrent inflamed dermoid Infection: orbital cellulitis, abscess, cavernous sinus thrombosis Trauma, post surgical, hemorrhage: orbital hemorrhage, lymphangioma Malignancy: rhabdomyosarcoma, metastatic tumors, adenoid cystic carcinoma Carotid-cavernous (C-C) fistula

Preseptal Cellulitis is an infection of only the lid and periorbital structures anterior to the orbital septum Symptoms: Signs: marked inflammation, erythema, edema of lids, with warmth and tenderness. EOM’s, Vision and Pupil reflexes are normal, Eye appears white and quiet Etiologic agents Staph, Strep, Hemophilus (in children); often from trauma, insect bites, impetigo Treatment Broad spectrum antibiotics Warm compress for comfort

Orbital Cellulitis This is a life-threatening infection of the soft tissues posterior to the orbital septum. It is more common in children. Symptoms: fever, pain and visual impairment. Etiology: Extension of an infection from the paranasal sinuses(90%). Trauma or surgery Hematogenous spread from bacteremia Signs: unilateral, tender, warm and red periorbital lid oedema, proptosis, painful ophthalmoplegia and optic nerve dysfunction. CT scan shows thickened periocular tissues. Management: admission and intravenous antibiotic therapy.

Orbital cellulitis

Allergic Eyelid Swelling

Progression Months to Years Dermoid cysts Benign mixed tumors Neurogenic tumors Cavernous hemangioma Lymphoma Fibrous histiocytoma Osteoma Lipoma Glioma Meningioma

Proptosis Primary orbital neoplasms usually unilateral Bilateral proptosis seen in inflammatory, immune processes or systemic diseases

Proptosis Inflammatory Infection (orbital abscess, cellulitis) Thyroid disease – most common cause Orbital pseudotumor Wegener granulomatosis Infection (orbital abscess, cellulitis) Vascular Orbital hemorrhage Lymphangioma (sudden) Tumor Benign: cavernous hemangioma, lymphangioma Malignant: adenoid cystic carcinoma, lymphoma, glioma Metastatic - lymphoma, leukemia, neuroblastoma Rhabdomyosarcoma

Inflammation Graves disease Most common cause of unilateral or bilateral proptosis in adult May occur with any thyroid status Treatment options steroids radiation optic nerve decompression

Inflammation Idiopathic orbital inflammation Sarcoidosis Vasculitis orbital pseudotumor myositis prompt response to steroids Sarcoidosis lacrimal gland Vasculitis GCA, SLE, Wegener’s granulomatosis

Lymphoproliferative Disorders Lymphoid hyperplasia and lymphoma 20% of all orbital mass lesions salmon patch appearance molds to orbital structures 50% arise in lacrimal fossa 17% bilateral Plasma cell tumors Histiocytic disorders

Proptosis Axial Non- axial

Pseudoproptosis

Pulsation Clinical correlation With bruits Without bruits Cavernous carotid fistula Orbital arteriovenous fistula Dural arteriovenous (a-v) fistula Without bruits Meningoencephaloceles Neurofibromatosis Orbital roof defect (condition after surgical removal of orbital roof, sphenoid wing dysplasia)

Rhabdomyosarcoma Highly malignant orbital tumor of striated muscles in children Most common primary orbital malignancy of childhood Symptoms: unilateral eye pain. Signs: reduced vision. Extremely sudden progressive exophthalmos or proptosis (bulging or protrusion of the eye ball), red eye. Management: referral to oncologists for radiotherapy and chemotherapy. Broad spectrum antibiotics

Past Medical History

Imaging options Plain films CT scan MRI Ultrasound

Lacrimal

Congenital NLDO Symptoms: Epiphora (watering eyes), sticky eyes and recurrent conjunctivitis. Differential diagnosis Congenital dacryocystocele. Congenital conjunctivitis. Corneal abrasion. Congental glaucoma Investigations: Fluorescein dye disappearance tes Treatment : In most cases, simple massaging of the ducts may be enough because of the high rate of spontaneous resolution.

DDT

Congenital dacryocystocele Symptoms: A benign, bluish-grey mass in the infer medial canthus that forms as a result of a narrowing or obstruction of the NL, usually during prenatal development. Treatment options is range from conservative (massage, observation) to surgical (probing of nasolacrimal system).

Acute dacryocystitis The tenderness is characteristically localized in the medial canthal region. purulent discharge is noted from the puncta Conjunctival injection and preseptal cellulitis often occur in conjunction with acute dacryocystitis. Epiphora. More serious sequelae include extension into the orbit with formation of an abscess an orbital cellulitis.

Management: Abs DCR(dacryocystorhinostomy)

Lacrimal Gland Masses Inflammatory Non-inflammatory Sarcoidosis Orbital Pseudotumor Vasculitis Non-inflammatory Lymphoproliferative Epithelial neoplasms Pleomorphic adenoma

Lacrimal gland fossa lesions

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