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

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

3. Anatomy

4. Bones

5. Orbital Compartments

6. Sinuses

7. Blood Supply

8. Annulus of Zinn(Tendinous ring)

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

10. Pain
Infection
Inflammation
Hemorrhage
Malignant Lacrimal Gland Tumor

11. Progression Minutes to Hours
Hemorrhage
Lymphangioma

12. 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

13. 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

14. 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.

15. Orbital cellulitis

18. Allergic Eyelid Swelling

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

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

22. 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

23. 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

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

25. 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

26. Proptosis
Axial
Non- axial

29. Pseudoproptosis

30. 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)

33. 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

34. Past Medical History

35. Imaging options
Plain films
CT scan
MRI
Ultrasound

36. Lacrimal

38. 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.

39. DDT

40. 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).

41. 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.

42. Management:
Abs
DCR(dacryocystorhinostomy)

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

47. Lacrimal gland fossa lesions

48. Thank you for your time and attention