Orbital disorders

Question 1

What are orbital disorders associated with ?

Answer 1

• Trauma
• Pre-septal and orbital cellulitis
• thyroid eye disease

Question 2

What is trauma caused by in the eye?

Answer 2

-by a blunt object striking the eye ( it could be = or larger diameter than the orbital aperture)

Question 3

What is trauma susceptible to?

Answer 3

susceptible to orbital floor fracture

Question 4

How does the blunt object striking cause injury to the eye ( TRAUMA) ?

Answer 4

the resultant force from that impact is transmitted through the orbital bones - causing. a fracture at the weakest point

Question 5

WHAT IS the weakest point ?

Answer 5

where bones are the thinnest and don’t have any underlying support - medial wall of the orbit and floor of the orbit

Question 6

What are the weakest points do?

Answer 6

medial wall of the orbit where the bones over line the esmoid sinuses and the floor of the orbit overlies the maxillary sinus - every little support and those bones are very thin

Question 7

What are orbital floor fractures called?

Answer 7

blow out fractures

Question 8

What do the blow out fracture affect commonly ?

Answer 8

most commonly affect the floor and less commonly the medial wall

Question 9

What are the sign and symptoms of orbital floor fracture ?

Answer 9

• can vary - sometimes asymptomatic with some swelling or bruising - PERIORBITAL haemotoma and subconjunctival haemorrhage
• to also experiencing Diplopia- double vision
• eye may be sunken in as the eye falls into the fracture of the floor -enophthamlos
• hypoesthesia - reduced sensation (of the cheek on the affected side )- due to branches of the infraorbital nerve (trig menial nerve) pass this along the orbital floor- sometimes this nerve is damaged leading tor reduction in sensitivity of the cheek on affected side- therefore air can get into the orbit and allows air from sinuses to come in.

Question 10

How does the orbital floor fracture ?

Answer 10

from trauma

Question 11

What are the common things that happen from an orbital floor fracture/blow out fracture?

Answer 11

impairment of eye movement - due to entrapment of eye tissues- eye muscles and surrounding fat- causing mechanical restriction of eye movements.

• and nerve trauma- affect skin of cheek of the side of trauma
• they would experience diplopia

Question 12

What is the investigation for the px with orbital floor fracture ?

Answer 12

• CT SCAN
• VA
• Check for RAPD - relative afferent pupillary defect
• ocular motility/ hess chart

Question 13

What is the management for the px with orbital floor fracture ?

Answer 13

• conservative ( monitor natural progression of px over time)
• possibly prescribe prophylactic antibiotics to reduce the risk of infection
• Corticosteroids to reduce swelling

significant enophthalmos
50% of floor involved
persistent diplopia

Question 14

What are the indications for surgery being needed?

Answer 14

• px significant enophthalmos
• 50% of floor of orbit is involved
• persistent diplopia and doesn’t improve

Question 15

What is the surgical management for the px with orbital floor fracture?

Answer 15

• is to create an artificial floor of the orbit and then repaired via a variety of different synthetic implants for e.g polyethylene or metallic mesh

Question 16

What is orbital cellulitis ?

Answer 16

• infection of soft tissue of the orbit behind the orbital septum

Question 17

Where is the location of the orbital septum

Answer 17

acts as a barrier- membranous bit of connective tissue that runs from the orbital rim to the top of the tarsal plate in the upper lid to the bottom of the tarsal plate in the lower lid.
-the barrier hold back the orbital contents

Question 18

How does the orbital cellulitis occur ?

Answer 18

from bacterial infection spread via the paranasal sinuses

Question 19

What is the orbit surrounded on the 3 sides?

Answer 19

by airfield cavities

• Frontal sinus above
• Ethmoid sinus medially
• maxillary sinus below

Question 20

What can the bacterial infections of these sinuses ?

Answer 20

can track and spread into the orbits from the infected sinuses - medical emergency-

Question 21

What is an ophthalmic emergency ?

Answer 21

orbital cellulitis- as can be a sight threatening and life threatening emergency.- fatal cerebral complications

Question 22

What is a related condition to orbital cellulitis ?

Answer 22

pre-septal cellulitis - infection infont of the orbital septum)- much less severe condition however hard to differentiate from orbital - assume the cellulitis is the more severe one (orbital) and is referred immediately.

Question 23

What is the reason for the orbital cellulitis to be fatal ?

Answer 23

due to the direct communication between the orbital cavity and the cranial cavity - infections of the orbit can track into the cranium.

Question 24

What are the clinical features of orbital cellulitis ?

Answer 24

• Periorbital swelling
• Severe orbital pain
• Fever
• Conjunctivitis and chemosis
• Loss of colour vision
• Proptosis - eye intruding forward- eye pushed forward separating the lid- wide puerperal aperture
• Impaired movement of the eye
• +/- RAPD

Question 25

What is the treatment for the orbital cellulitis?

Answer 25

• Hospital admission
• Imaging
• High dose iv antibiotics
• May need surgical intervention

Question 26

Why is orbital cellulitis more dangerous ?

Answer 26

because its behind the septum

Question 27

Is proptosis present in preseptal cellulitis?

Answer 27

absent - eyes being pushed forward- no

Question 28

How is ocular motility, Visual acuity, colour vision and RAPD in preseptal cellulitis ?

Answer 28

Normal

Question 29

Is proptosis present in orbital cellulitis?

Answer 29

Present

Question 30

How is ocular motility in orbital cellulitis?

Answer 30

Painful ,restricted

Question 31

How is Visual acuity, colour vision in orbital cellulitis ?

Answer 31

Reduced in severe cases

Question 32

How is RAPD in orbital cellulitis ?

Answer 32

Present in severe cases

Question 33

What is the most common cause of thyroid eye disease ?

Answer 33

Graves disease - autoimmune disease

Question 34

What is graves disease ?

Answer 34

its associated with hyperthyroidism -increase in secretion of thyroid hormones

Question 35

What is graves disease caused by ?

Answer 35

Auto antibodies to the TSH receptor

• those antibodies trigger the production of the thyroid hormone
• Autoimmune inflammation of extraocular muscles swell (increase in orbital fat - the swollen retro orbital tissues which push the eyes forward) ( swollen retrobulbar tissues)- gives appearance of exophthalmus.

Question 36

What does the person with thyroid eye disease have ? (graves disease)

Answer 36

-have proptosis- eye eye pushed forward separating the lid- wide perpebral aperture

Question 37

What is the difficulties of graves diseases ?

Answer 37

interferes with the wet ability of the ocular surface

• lids are unable to close fully
• tears aren’t spread evenly over the ocular surface

Question 38

What are some of the symptoms of the graves eye disease ?

Answer 38

grittiness, photophobia and lacrimation, loss of VA and colour vision if optic nerve involvement

Question 39

What can the graves disease lead to ?

Answer 39

sight threatening condition

- lead to optic neuropathy with a reduced vision and reduced colour vision

Question 40

What is the thyroid eye disease clinical signs ?

Answer 40

-Periorbital oedema
-Lid retraction – upper and lower
-Lid lag
Proptosis (exophthalmos)
Optic neuropathy
- can then see chemises (conjunctival oedema)- associated with corneal desiccation (drying)
- if to put fluroscene into the eye - would see staining along the inferior conjunctiva.
- can also have tumours a t the back of the eye which can give rise to proptosis and push the eyes forwards

Question 41

What is the management of the thyroid eye disease ?

Answer 41

• conservative
• immunosuppression
• decomprression surgery