Diseases of the Orbit

Orbital fracture

• commonly from blunt trauma

• Onset: 21-30yrs old

• males > females

• Orbital floor fractures make up 48% of all orbital fractures (near infraorbital canal) - energy displaces inferior from impact of greater sized object

• Medial wall fractures make up 25.2% of all orbital fractures

Orbital Floor Fracture

• Orbital floor fractures make up 48% of all orbital fractures (near infraorbital canal) - energy displaces inferior from impact of greater sized object

• Symptoms: pain with eye movements, diplopia

• Presentation:

  • Lid ecchymosis (bruising) and edema

  • Subcutaneous emphysema/crepitus: crackling sensation on palpation due to air in the subcutaneous tissue

  • Infraorbital nerve anesthesia: will involve the lower lid, cheek, side of the nose, upper lid, upper teeth and gum

  • Limited extraocular muscle motility: inferior rectus and inferior oblique will be involved

    • Can be the result of a hemorrhage or edema

    • Can be due to entrapment

    • Can be due to entrapment

  • Bone step off: present when the orbital rim is involved; A portion of the rim near the fracture will appear lower

  • Enophthalmos: posterior displacement of the globe (if severe)

  • proptosis

  • Other ocular findings: traumatic iritis, corneal abrasion, hyphema, increased intraocular pressure, lens subluxation or dislocation, retinal pathology

• Work up: CT scan

• Treatment

  • Nasal decongestants: individuals are advised to avoid blowing their nose for 14 days post injury

  • Systemic antibiotics

  • Systemic corticosteroids for severe edema

  • Surgical repair: done 2 weeks after initial trauma

Orbital Floor fracture Treatment

• Nasal decongestants: individuals are advised to avoid blowing their nose for 14 days post injury

• Systemic antibiotics

• Systemic corticosteroids for severe edema

• Surgical repair: done 2 weeks after initial trauma

Medial wall fractures

• Medial wall fractures make up 25.2% of all orbital fractures

  • Typically associated with orbital floor fractures

• Presentation:

  • Periorbital ecchymosis

  • Subcutaneous emphysema

  • Medial rectus entrapment will result in limited adduction and abduction

  • Cerebral spinal fluid rhinorrhea

• Work up: CT scan

• Treatment:

  • Nasal decongestants-individuals are advised to avoid blowing their nose for 14 days post injury

  • Systemic antibiotics

  • Systemic corticosteroids for severe edema

  • Surgical repair: done 2 weeks after initial trauma

Medial wall fracture Treatment

• Nasal decongestants-individuals are advised to avoid blowing their nose for 14 days post injury

• Systemic antibiotics

• Systemic corticosteroids for severe edema

• Surgical repair: done 2 weeks after initial trauma

Intraorbital foreign bodies

• foreign body that occurs within the orbit but outside the globe

• Occur after high velocity injury

  • BB gun pellet is the most common type of metallic intraorbital foreign body

• Onset: younger individuals

• males > females

• Symptoms:

  • Decreased vision

  • Diplopia, pain

• Presentation (depends on foreign body):

  • Orbital mass

  • Proptosis

  • Proptosis

  • Restricted extraocular muscle motility

• Work up: determine if the globe is open or closed

  • MRI or CT scan

    • MRI is contraindicated with metallic foreign bodies

• Treatment

  • Tentanus prophylaxis

  • Oral antibiotic (Consider anti-fungal medication if foreign body is organic)

  • Observation for small inert foreign bodies that are deeply embedded

  • Surgery (if large, inflamed, other ocular problems, composition that the body reacts to)

Intraorbital foreign body Treatment

• Tentanus prophylaxis

• Oral antibiotic (Consider anti-fungal medication if foreign body is organic)

• Observation for small inert foreign bodies that are deeply embedded

• Surgery (if large, inflamed, other ocular problems, composition that the body reacts to)

Intraocular foreign body

• foreign body within the globe

• Cause: typically caused by metal on metal tasks

• Onset: 21-40 years old

  • males > females

• Symptoms: dependent on the type of foreign body

  • Decrease vision, foreign body sensation, hyperemia, tearing, flashes or floaters

• Presentation:

  • Scleral entry: conjunctival injection, chemosis, hemorrhage or laceration

    • Might lead to a deep anterior chamber d/t loss of aqueous from posterior chamber

  • Corneal entry: corneal edema surrounding entry site or a positive Seidel sign

    • If the wound is self sealing a negative Seidel sign may be seen

  • Iris entry: iris transillumination and heterochromia may be seen

    • A peaked pupil may be present: the peak will point to the entry site

  • EOM restriction

  • Anterior chamber: focal area of corneal edema will be over the foreign body

  • Lens: focal lens opacities

  • Retina: most of the intraocular foreign bodies rest on the retina

    • Have worst prognosis

• Complications:

  • Endophthalmitis, vitreous hemorrhage, retinal detachment, corneal scar, cataract, glaucoma and sympathetic ophthalmitis

  • Siderosis bulbi: caused by a retained intraocular foreign body that contains iron

    • Will occur as early as 18 days post traumatic event

    • Presentation: iris heterochromia, pupillary mydriasis, cataract formation, glaucoma & retinal pigmentation changes

  • Chalcosis: caused by retained intraocular foreign body that contains copper

    • must contain 85% copper

    • Presentation: chronic endophthalmitis, sunflower cataract, blue-green deposits on Descemet membrane, copper particles in the anterior chamber and reversible retinal toxicity

• Work up: CT scan or MRI

• Treatment:

  • Ideally foreign bodies are removed within 24 hours

    • Small inert foreign bodies may not be removed and observed

  • Systemic antibiotics (oral or intravenous-dependent on the foreign body)

  • Surgical removal

Intraocular foreign body Treatment

• Ideally foreign bodies are removed within 24 hours

  • Small inert foreign bodies may not be removed and observed

• Systemic antibiotics (oral or intravenous-dependent on the foreign body)

• Surgical removal

Phthisis Bulbi

• shrinkage and disorganization of the eye; functional loss of eye

• Cause by: trauma, surgery, infection, inflammation, malignancy, retinal detachment or vascular lesion

• Presentation: eye will have a square shape

  • Cornea will be thick and opaque, white

  • Sclera will be thickened

  • Iris neovascularization

  • Bad cataract

  • Retinal detachment

• Treatment:

  • Cosmetic rehabilitation = fit w/ prosthetic shell

  • Pain management (meds depend on cause)