ORBITAL DISORDERS

The treatment of Orbital Disorders can be challenging.  A systematic approach in diagnosis is useful in planning specific management.
 

What are Orbital Disorders?
 

The orbit refers to the bony cavity in the skull that houses the eye and surrounding structures. Diseases of the orbit can arise from within the orbit or as part of a systemic illness that affects multiple tissues or organs. Some signs of orbital disorders include:

• Protrusion of the eyeball
• Pain
• Diplopia or double vision
• Loss of vision
• Redness and swelling of the eyelids

What are the various types of Orbital Disorders?

In general, the various types of orbital diseases can be classified into the following categories:

(I) Orbital Tumours

Orbital tumours can be benign or malignant. They can occur in both children and adults.

Some examples include:

Children		Adults
Benign	Malignant	Benign	Malignant
Dermoid cyst	Rhabdomyosarcoma	Meningioma	Lymphoma
Fibrous dysplasia	Ewings sarcoma	Optic nerve glioma	Mestatases

 Example 1:

(a)	Patient with left upper lid swelling and fullness	(b)	CT scan showing the lymphoma mass in the superonasal part of the orbit

Example 2:

(a)	Patient with left eye protrusion nnnnnccccccc nnnnn cccccc cccccc	(b)	CT scan showing the superolateral mass in the left orbit, the location and appearance of the mass suggest a type  of benign lacrimal gland tumour called pleomorphic adenoma.

            
As shown in the above examples, CT scan is helpful in diagnosis and biopsy is frequently warranted to aid in diagnosis and the management of these patients.

(II) Inflammatory disorders (infectious and non-infectious)

(IIa) Infections

Orbital infections or orbital cellulitis can be due to bacterial, fungi or parasitic organisms. It can result from adjacent sinus infections in the periocular region or trauma. This is an ophthalmic emergency requiring hospital admission and antibiotic treatment as spread of the infection to the cavernous sinus within the brain can be life-threatening. Surgery to drain orbital abscesses may be necessary.

Example :

(a)	Child with left orbital cellulitis presenting with fever and left eye swelling and redness	(b)	CT scan of the same patient showing the collection of pus (abscess) within the orbit and protrusion of the left eye

 
(IIb)  Non-infectious inflammatory disorders

Some causes of orbital inflammation include: Wegener’s granulomatosis, systemic lupus erythematosus, sarcoidosis and Sjogren’s syndrome. Inflammation that occurs within the orbit usually requires biopsy and blood tests to reach a specific diagnosis. However, no specific cause is found in 50 - 60% of cases. Treatment usually involves the use of immunosuppressive drugs.

Example : 

	Patient with left orbital inflammation  presenting with left eye swelling and redness  (non-specific inflammatory disorder of the  lacrimal gland)

(III) Structural Disorders

Structural disorders of the orbit include congenital deformities resulting in cyst formation, such as dermoid cysts as well as acquired disorders such as trauma to the orbit resulting in orbital wall fractures. Dermoid cysts are commonly present as painless lumps from childhood and do not always need excision unless it is affecting vision or causing unsightly swellings. Orbital wall fractures commonly affect the medial and floor of the orbit. These are located between the eye and the nose, and below the eye respectively. Not all fractures need to be repaired. Usually only fractures which cause disabling double vision due to entrapment of the muscles and large fractures are repaired.

Example :

(a)		The patient sustained an orbital   floor fracture resulting in severe  bruising of the surrounding eyelid  skin as well as entrapment of an  eye muscle.  This has resulted in  the patient's inability to look up  and double vision on looking up.
(b)		CT scan of the same patient showing  the floor fracture on the right with  prolapse of fat and the eye muscle  downwards.

(IV) Vascular disorders

Vascular malformations such as lymphangioma or venouslymphatic malformations are benign in nature but can cause visual loss due to compression of the optic nerve. They also often cause unsightly bulging of the eyes and may affect the eye position and movements resulting in double vision. Clinical assessment and imaging with CT scans or angiograms are crucial in making the right diagnosis. These lesions are often left alone if they are not causing any visual impairment or double vision.
 
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