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Orbital Swellings

Introduction

 

Periorbital swelling refers to tissue swelling around the eyes. Occasionally, it may give the face a bloated appearance and the eyes may be become partially closed by the swollen eyelids. Patients may present with unilateral or bilateral periorbital swelling, depending on the aetiology. In rare cases, it is associated with other systemic diseases; examples include Wegeners Granulomatosis, nephrotic syndrome, Graves' ophthalmoplegia etc.

 

Aetiology

Applied Anatomy

yellow = Frontal bone

green = Lacrimal bone

brown = Ethmoid bone

blue = Zygomatic bone

purple = Maxillary bone

aqua = Palatine bone

red = Sphenoid bone 

 

 

The orbit is a pear-shaped cavity - the stalk is the optic canal.

 

  1. The roof: made up of 2 bones: lesser wing of the sphenoid and the orbital plate of the frontal bone. A defect of the roof may cause a pulsatile proptosis due to transmission of cerebrospinal fluid pulsation to the orbit.
  2. The lateral wall: made up of 2 bones: greater wing of sphenoid and zygomatic.
  3. The floor: made up of 3 bones: zygomatic, maxillary and palatine. The weak position of the maxillary bone may be prone to a blow-out fracture.
  4. The medial wall: made up of 4 bones: maxillary, lacrimal, ethmoid and sphenoid. The thin wall of the ethmoid bone may cause an orbital cellulitis secondary to ethmoidal sinusitis.
  5. The superior orbital fissure: a slit between the greater and lesser wings of the sphenoid bone, through which important structures pass:
  • Superior portion – contains the lacrimal, frontal, and trochlearnerves and superiorophthalmic vein.
  • Inferior portion – contains the superior and inferior divisions of the oculomotor, abducens, the nasociliary and sympathetic fibres.

 

Inflammation at the superior orbital fissure may cause venous outflow obstruction resulting in oedema of the lids and proptosis.

 

CLINICAL ASSESSMENT

History taking

 

Elicit the following:

 

  • Palpable or visible mass - what is it that the patient has noticed? This may be subtle and require them to show/guide you to it.
  • Progression: how did this all start and when? How have the symptoms developed over time? Conditions may be acute (e.g. infection) or chronic (e.g. lacrimal adenoma). Remember to ask about past trauma, however trivial it seemed at the time. Surgical trauma is important to know about too (rarely, complications from the anaesthesia can cause orbital swellings).
  • Proptosis: this refers to the globe protruding. It is a common feature in orbital swelling.
    • Related to this is how the vision is doing: could the cornea be compromised by exposure due to proptosis?
    • Is there double vision (diplopia)? This suggests that the eyeball is not only protruding but deviating too, either as a result of mechanical pressure of the swelling or involvement of the extraocular muscles.
    • Ask specifically about any change in colour perception. Mention of things looking 'washed out' (especially red objects) may be the first warning that the optic nerve is stressed and potentially compromised. This is not a good symptom.

 

Very rarely, enophthalmos might be misconstrued as orbital swelling if it is subtle.

  • Pain: this important symptom may arise from inflammation, infection, acute pressure changes (such as haemorrhage) and bony or neural invasion. It may also be referred from neighbouring structures such as the sinuses in sinusitis.
  • Periorbital abnormalities such as sensory change or numbness, redness, tenderness, watering (epiphora) and lid abnormalities (e.g. ptosis).
  • Past medical history, particularly of sinusitis, thyroid problems (hyperthyroidism and hypothyroidism) and malignancy.

 

Clinical examination

 

  • First introduce yourself and explain to the patient that you are examining his/her eyes!
  • On general inspection of the eyes, look for other associated signs:

1. Lid and periorbital oedema. (see Figure 1.)

Figure 1.

2. Ptosis: drooping of the upper eyelid. (see Figure 2.)

Figure 2.

3. Chemosis: swelling of the conjunctiva. (see FIgure 3.)

Figure 3.

4. Conjunctival injection: (see Figure 4.)

Figure 4.

5. Proptosis (see Figure 5.)

Figure 5.

     

    • Palpate the orbital rim for any swellings, mass and delineate the size, location, and shape.
    • Check for globe pulsation or thrills (it may give clinicians a clue of a vascular origin.)
    • Assess the function of optic nerve of both eyes as it can be important in guiding for urgent ophthalmological referral:
    1. Visual acuity
    2. Confrontational visual field
    3. Relative afferent pupillary defect (RAPD)

     

     

    Investigations

     

    Urgent special investigations may be requested to look for other sinister causes of orbital swellings; examples are tumours, fractures, inflammatory eye disease etc.

     

      • Plain radiograph: Before CT and MRI, plain radiographs may be useful in delineating any orbital fractures. Two main views are used:

       

       

      1. The Caldwell: taken with patient’s nose and  forehead touching the film. 

       

      The Cardwell view (see figure 6.)

      Figure 6.

       

      2. The Waters: taken with the patient’s chin slightly elevated, which is useful in detecting orbital floor fractures.

       

      The Waters view (see Figure 7.)

      Figure 7.
      • CT: very useful to detect bony structural abnormalities, location and size of space-occupying lesions, orbital fractures, foreign bodies, and haematomas.
      • MRI: has clinical value in imaging any orbital apex lesions and intracranial involvement of orbital tumours.

         

        Referral

         

        There are currently no definitive guidelines for referral to the ophthalmology department, but the urgency of the clinical history may help to prioritise the referrals. These are a few tips that may help:

        • Urgent same/next day referrals - consider this for acute onset of symptoms, infections, trauma and evidence of optic nerve defect (decreased visual acuity, relative afferent pupillary defect (RAPD), red desaturation etc.).
        • Urgent same week referrals - suspicion of malignancy and most paediatric cases benefit from an early review.
        • Non-urgent referrals - for more longstanding conditions that require a routine referral, ask the patient to bring along old photos of themselves to the clinic.

         

        Summary

         

        It is true that focused clinical history is of utmost importance when encountered with a complaint of orbital swelling as it gives you 90% of the diagnosis. The rest of the 10% is complimented with focused eye examination, including testing visual fields, eye movements, accommodation and last but not least, using the ophthalmoscope. In addition to this, it is important to do a systematic review, including examining other affected areas of the body. Special investigations are useful for investigating other sinister causes, e.g. orbital traumas, space-occupying lesions, systemic eye disorders etc.

         

        Useful resource(s)

          1. http://www.patient.co.uk/doctor/Orbital-Swellings.htm
          2. http://emedicine.medscape.com/article/1218009-overview

          It is very informative, further reading about preseptal cellulitis and its management.

          Reference(s)

          1. Clinical Opthalmology: A Systematic Approach 5th edition; Jack J. Kanski.
          2. Moorfields Manual of Ophthalmology, Mosby (2008); Jackson TL.
          3. Oxford Handbook of Ophthalmology, OUP (2008); Denniston AKO, Murray PI.

           

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