Orbit thrombosis

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Orbit thrombosis Powered By Docstoc
					 Diseases of Orbit

    Dr Kavita Kumar
    Associate Professor
 Dr Sanjay Shrivastava
         Professor
Department of Ophthalmology
   Gandhi Medical College
          Bhopal
           Anatomical considerations
•    Walls
•    Apex
•    Openings
•    Spaces
•    Relations
•    Blood vessels



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                 Orbital Cavity
•    Dimensions- conical in shape
•    Depth- 40 mm
•    Height- 35 mm
•    Width- 40mm




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                       Anatomy of Orbit
                                 Frontal




                                           Optic Foramen
Lesser and Greater
wing of Sphenoid



                                                                                                             Lacrimal

       Sup Orbital Fissure                          Ethamoid

                                                                                                          Palatine




                     Zygomatic
                                                       Maxillary




                                                               Sketch of orbit by Dr Sanjay Shrivastava
Anatomy of Apex of Orbit
                                                LPS




 Sup Orbital Fissure



                                                                       Sup Oblique Mus




                                                                             Optic Nerve

                                                                   Med Rectus Muscle




Annulus of Zinn



         Lat Rectus Mus
                                                      Inf Rectus Muscle




                          Sketch of Apex of Orbit by Dr Sanjay Shrivastava
                        Walls

• Roof- is formed by the orbital plate of frontal bone
  and lesser wing of sphenoid
• Floor- is formed by the maxillary bone- orbital plate
  and maxillary process of zygomatic bone and orbital
  process of palatine bone
• Medial wall- is formed by the lacrimal and
  ethamoidal bone, frontal process of maxillary bone
  and body of sphenoid
• Lateral wall- is formed by the greater wing of
  sphenoid and zygomatic bone

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                      Apex

• Annulus of zinn giving rise to origin to extra
  ocular muscles
• Optic canal
• Part of superior orbital fissure




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                     Openings

• Optic canal- optic nerve with meninges and
  ophthalmic artery
• Superior orbital fissure-
  Outside tendinous ring – structures passing outside
  are:
  Lacrimal nerve –V1
  Frontal nerve -V2
  Trochlear nerve
  Superior and inferior veins
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                   Opening
• Inside tendinous ring- structures passing
   inside the ring are -
  Oculomotor (3rd cranial nerve) upper division
  Nasociliary nerve
  Abducent nerve (6th cranial nerve)
  Oculomotor lower division (3rd cranial nerve)
  Inferior orbital fissure-inferior ophthalmic vein

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                  Opening

• Foramen rotandum - maxillary nerve
• Superior orbital notch-supraorbital nerve and
  vessels
• Infra orbital foramen-infraorbital nerve and
  artery




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                       Spaces

•    Subperiostial space
•    Peripheral orbital space
•    Central space
•    Tenons space




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                      Relations

•    Frontal sinus
•    Sphenoidal sinus
•    Maxillary sinus
•    Ethamoidal air cells




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                Common lesions
•    Proptosis
•    Exophthalmos- endrocrinal
•    Enophthalmos
•    Pseudoproptosis-slight prominence of eyes
     like myopia, paralysis of extra ocular muscles,
     obese people, mullers stimulation by cocain



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           Proptosis and Exophthalmos
• Abnormal protrusion of eye ball is called
  proptosis or exophthalmos.
• The term exophthalmos is reserved for
  prominence of the eye secondary to thyroid
  disease




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                    Proptosis
• Abnormal protrusion of globe
• It may be Unilateral or Bilateral
• Unilateral – caused by orbital cellulitis, idiopathic
  orbital inflammatory disease, thrombosis of orbital
  vein, arterio-venous aneurysms, tumors of structures
  of orbit , orbital haemorrahge , emphysema.
• Bilateral – endocrine exophthalmos , cavernous sinus
  thrombosis , symmetrical orbital tumors, oxycephaly
  - diminished orbital volume


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Proptosis
Proptosis
             Proptosis in children
•    Dermoid and epidermoid cyst
•    Capillary haemangioma
•    Optic nerve glioma
•    Rhabdomyosarcoma
•    Leukaemias
•    Metastatic neuroblastoma
•    Plexiform neurofibromatosis
•    Lymphomas

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Mass lesion in Left orbit
    Due Retinoblastoma Stage III
           Proptosis in adults
• Metastases – (of malignancy) from breast,
  lung, GIT
• Cavernous haemangiomas
• Mucocele
• Lymphoid tumors
• Meningiomas



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              Types of Proptosis

   • Axial proptosis - eye is pushed directly
     forwards – lesions situated in optic nerve
     and central space
   • Non axial- situated elsewhere in orbit
     pushes eye in opposite direction




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           Causes of proptosis in different in
                  different locations
Extra conal lesions   Intra conal lesions     Muscular disorders
Dermoid cyst          Cavernous haemangioma   Thyroid
                                              ophthalmopathy

Rhabdomyosarcoma      Optic nerve glioma      Pseudo tumor


Extension of nasal    Meningioma              Cysticercosis
/sinus diseases

                      A-V malformations       Lymphoproliferative
                                              disorder

                                              Rhabdomyosarcoma

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           Clinical presentation
• Static- as seen usually in congenital causes
• Increasing – fast- as in cases of
  Rhabdomyosarcoma, neuroblastoma,
  haemopoetic
• Gradual- as in cases of meningiomas
• Pulsatile- as in cases of carotid cavernous
  fistula
• Intermittent- as in cases of orbital varicosity

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               Clinical signs
• Impaired mobility
• Diplopia
• Papilloedema
• Optic atrophy
• Hertel exophthalmometry – measures more
  than 18 mm
• Difference in two eyes of more than 2 mm is
  considered positive
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                  Investigations
•    Careful history recording
•    Systemic examination
•    ENT examination
•    Biochemical and haematological investigations
•    Imaging of bony structures- plain x ray
•    Imaging of soft tissues –CT scan, MRI
•    Vascular study- orbital venography, carotid
     angiography, MR angiography, digital subtraction
     angiography

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              Orbital cellulitis
• Definition: Purulent inflammation of the cellular
  tissue of the orbit
• Causes of Orbital Cellulitis:
  Spread of infection from neighbouring structures
  like nasal sinuses, eyelids, eyeball (like in case
  of panophthalmitis) facial erysiplas etc
  Also due to deep penetrating injuries (specially
  in cases of retained Foreign body) and
  metastatic infection in cases of pyaemia

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           Types of Orbital Cellulitis
• Two types- pre septal cellulitis and orbital
  cellulitis
• Pre septal –structures anterior to orbital
  septum, characterized by erythema,
  chemosis, conjunctival discharge without
  restriction of ocular movements and visual
  impairment


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           Types of Orbital Cellulitis
    • Orbital    –    behind     orbital   septum,
      characterized severe pain, fever, diminution
      of vision (due to retrobulbar neuritis or
      compression of optic nerve and /or its blood
      supply), massive swelling of lids, chemosis,
      proptosis, restriction of ocular movements,
      diplopia, an abscess may form pointing
      somewhere in the skin of the lid near the
      orbital margin or fornix


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                   Complications

  • Panophthalmitis
  • Extension into brain through meninges , cavernous
    sinus thrombosis may develop
  • In diabetic patients fungal superinfection may
    develop




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               Management

• Culture and sensitivity of pus, if present and of
  blood
• Treatment –Broad spectrum Intravenous
  antibiotics , and anti inflammatory
• If abscess has formed – Incision and Drainage
  under cover of antibiotics



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            Cavernous sinus thrombosis
• Due to extension of thrombosis from various feeding
  vessels
• Superior and inferior ophthalmic vein enter in front
• Superior and inferior Petrosal sinus leave from behind
• Cavernous sinus communicates with facial veins,
  lateral sinus, jugular vein, Mastoid emmisary vein-
  lateral sinus- superior petrosal sinus




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     Cavernous sinus thrombosis
• Cavernous sinus on one side communicates with
  other side through transverse sinus
• Because of connection with mastoid through mastoid
  emmisary vein, mastoid tenderness is diagnostic
  feature of cavernous sinus thrombosis
            Source of infection
• Orbital veins - as in cases of eryiepelas, septic
  lesion of face, orbital cellulitis , infective
  condition of face, mouth, nose, sinuses
• Furuncle of upper lip – dangerous area of face
• Metastatic infection or septic condition




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           Symptoms and Signs

• Patient may present with symptoms and signs of
  Orbital cellulitis, there is sever supra-orbital pain
• Systemic features – headache, fever ,altered
  sensorium, vomiting and cerebral symptoms
• Transference of symptoms and signs to other
  eye (bilateral orbital cellulitis with which it may
  be confused is very rare clinical condition).
  Mastoid edema and tenderness is present.

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         Symptoms and Signs


• In case of infection spreading to other eye,
  the first sign is involvement of lateral
  rectus of other eye
• Papilloedema
                   Treatment
•    Emergency
•    Broad spectrum Intra Venous antibiotics
•    Anti coagulants
•    Neurophysicians to be consulted




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              Exophthalmos
• Endocrine exophthalmos : Graves
  Ophthalmopathy (dysthyroid eye disease) is
  the commonest cause of uniocular or bilateral
  proptosis in age groups between 25 and 50
  years




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             Graves Disease
• Consists of Exophthalmos, and all signs of
  thyrotoxicosis (i.e. tachycardia, muscular
  tremors and raised BMR)
• In early stage the presentation may be
  unilateral, becomes bilateral. Palpabral
  aperture is wide open due to lid retraction
  (Dalrymple sign). Upper lid fail to follow
  downward movement of eye (von Graefe
  sign)
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           Summary of signs in Graves disease

• Lid retraction
• Lid lag (upper and lower
• Infrequent blinking and incomplete closure of lids (Stellwag sign)
• Lid edema
• Exophthalmos
• Conjunctival congestion over the insertion of recti muscles and
  chemosis
• Convergence insufficiency (Mobius sign) and Diplopia
• Raised intraocular tension may be present
• Superior limbic keratopathy

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    Werner classification of signs (NO SPECS)

• Grade 0 – No signs or symptom
• Grade 1 – Only sign (lid retraction)
• Grade 2 – Soft tissue involvement (Chemosis)
• Grade 3 – Proptosis (which may be minimum
  <23, moderate , marked >28)
• Grade 4 – Extraocular muscle involvement
• Grade 5 – Corneal involvement
• Grade 6 – Sight loss
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      Exophthalmic Ophthalmoplegia
• Is proptosis with external ophthalmoplegia
• Usually seen in middle aged people , it is of
  insidious onset, typically assymetrical limiting
  upward movement and abduction due to
  swollen, pale edematous, infiltrated ocular
  muscles . There is irreducible exophthalmos
  with risk of exposure keratitis , globe
  dislocation mechanical compression of optic
  nerve and ophthalmic vessels
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      Exophthalmic Ophthalmoplegia
• Disease is self limiting with intermissions and
  relapses, usually not affected by any
  treatment . Spontaneous resolution may take
  place which rarely is complete




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    Treatment of Exophthalmic Ophthalmoplegia

• Short term oral steroid therapy (with dose of 40-60
  mg) with radiotherapy (1000 rad ) are effective in
  controlling soft tissue inflammation
• Exposed cornea should be protected by doing
  tarsorrhaphy in less severe cases , by orbital
  decompression in more severe cases. Lateral
  tarsorrhaphy may also be needed.
• Residual muscle palsy is dealt with muscle
  adjustment surgery.

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                     Types
• Type – I : Characterized by symmetrical mild
  proptosis with lid retraction usually associated
  with thyrotoxicosis
• Type – II : Characterized by extreme
  exophthalmos, compressive neuropathy and
  extraocular muscle involvement. This form
  may be associated with any state of thyroid
  function, but usually with hypothyroidism,
  seen after thyroidectomy.

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           Cause of exophthalmos
• Due to edema, lymphocytic infiltration anf
  fibrosis of orbital contents and extra-ocular
  muscles
• Lid retraction is due to contraction of Muller
  muscle




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