Lacrimal System IV : Disorders of the Orbit

What is the Aetiology for Orbital Disease ?

• Inflammatory → TED

• Infectious → Orbital cellulitis

• Neoplastic → tumours

• Trauma → orbital fracture

• Malformation → skeletal abnormalities

• Vascular →Carotid

What are the symptoms of Orbital Disease?

• Eyelid swelling

• Bulging eye(s) → retracted

• Double vision → Extraocular muscles affected

• Pain

• Blurring → optic nerve compressed , blurring of central vision

• changes in colour vision

What are the critical signs of orbital disease which require URGENT referral?

• Globe dystopia

- Proptosis/exopathlmus → bulging eye

• Hyperglobus → eye directed upwards

• Hypoglobus → eye directed downwards

• Restricted ocular motility

What are other signs of orbital disease?

• Soft tissue involvement

• Eyelid & periorbital oedema

• Ptosis → droopy lid

• Chemosis → swelling of conjunctiva

What are Fundus changes of orbital disease ?

• Optic disc swelling/atrophy

• Collaterals → new blood vessels around disc , don’t tend to leak

• Choroidal folds → streaks

What is the Aetiology for Thyroid Eye disease?

• systemic autoimmune disease/condition

→ increased or decreased thyroid production

• ocular effects :

  • soft tissue around the eyes

  • muscles

What are early ocular symptoms of TED?

• Non-specific FB sensation

• Redness

• Tearing

• Photophobia

• Eyelid puffiness

What are late ocular symptoms?

• Persistent lid swelling

• Chemosis → swelling of conjunctive

• Prominent eyes → bulging, proptosis (cant close eyelids properly)

• Double vision → thickened eyelid muscles

• Loss of vision (optic nerve/corneal involvement)

What are the signs of TED?

• Eyelid retraction

- Eyelid lag on downgaze

- Lagopthalmos

• Uni or bilateral ptosis

- 50% of patients

- Choroidal folds

• Variable ocular motility restriction

- 40% of patients

- due to EOM fibrosis

Other signs of TED?

• Higher IOP in up gaze → restriction of muscles

• conjunctival lid hyperaemia /oedema

• superior limbic keratoconjucntivits

• optic nerve swelling /pallor → paleness

• RAPD + defective colour vision

What is the management of TED?

• Referral to GP or ophthalmologist

• Steroids

• Radiotherapy

• Surgical decompression

What is the Aetiology for Preseptal + Orbital Cellulitits?

• Bacterial INFECTION (Staphylococcus, Haemophilus)

• Periorbital or orbital tissue

• most commonly <10 years old

• severity varies from minor to life threatening

what is preseptal cellulitis caused by ?

• Tissues lying anterior to orbital septum

• high risk of extension into orbit in young children

What is orbital cellulitis caused by ?

• Tissues lying posterior to orbital septum (within orbit)

• Severe sight + life-threatening emergency

what does Preseptal cellulitis look like ?

What does Orbital cellulitis look like?

What is the optometric management for orbital cellulitis?

• Same day EMERGENCY referral

compare the predisposing factors + symptoms of preseptal + orbital cellulitis

Both PF:

fever, infection, ocular infection, trauma

Both Symptoms :

Lid swelling , redness + tenderness

Preseptal and orbital cellulitis signs difference?

Preseptal cellulitis :

Proptosis absent

Ocular motility, VA, colour vision + RAPD = normal

Orbital cellulitis:

Proptosis present

Ocular motility → painful + restricted

VA→ reduced in severe cases

Colour vision → reduced in severe cases

RAPD → present in severe cases

What is Preseptal and Orbital cellulitis management?

Optometrist :

• Emergency SAME DAY referral

• Not up to us to decide which is which

What is the secondary care of preseptal + orbital cellulitis?

• Systemic antibiotics

• Hospital admission

• Blood tests

• CT scan

• Co-management ENT

What is a Dermoid/epidermoid cyst?

• Choristoma (mass of normal tissue in an abnormal location)

• Thin walled, cystic lesion

• May contain sweat glands, sebaceous glands, hair follicles

• formed at birth but may not present until adulthood

What are the 2 types of dermoid cyst?

> Superficial

• painless slow growing nodule

• often around the eyelid/brow

> Deep

• Presents in adolescence or adulthood

• Increasingly protruding eye , acute inflammation

What is the Management for dermoid cysts?

• refer routinely for removal → slow growing + can rupture

What is a Blow out fracture?

• Blunt-trauma → fight, squash ball injuries → wear goggles

• Fracture an orbital wall

- Typically orbital floor or medial wall

• Tissue or muscle trapped

What are the symptoms + signs of a blow out fracture?

• Bruising, tenderness, periorbital swelling

• Double vision → eye tethered so won’t look up

• Loss of sensation in cheek → infraorbital nerve trapped

What is the management for a Blow out fracture?

• SAME DAY referral → make it clear that you’ve seen double vision or abnormalities in ocular motility

What is Mucromycosis?

• Rare aggressive fungal infection

• often fatal

• typically affects px with immunosuppression

• inhaled spores → URTI which spreads to orbit + brain

• gradual onset + periorbital swelling, diplopia

• appear similar to orbital cellulitis

• SAME DAYY REFERRAL