The orbit is the bony eye socket that contains the eyeball, eye muscles and lacrimal gland.
There are also nerves, arteries, veins and orbital fat. Any disease process that can affect any of these tissues can cause disease in the orbit. In broad terms the commonest diseases can be divided into tumours, inflammation and infection.
Orbital inflammatory disease
The commonest cause of orbital inflammation is thyroid eye disease. It may also be part of inflammatory disease elsewhere in the body e.g.sarcoidosis or an unexplained isolated orbital inflammation - idiopathic orbital inflammatory disease.
Top - orbital myositis with redness in one quadrant of the eye; 2nd image - MRI scan of the orbits with an arrow showing the enlargement of one of the eye muscles; 3rd image - the incision made after an orbital biopsy; Bottom - the result after treatment with oral steroids
What are the symptoms and signs of orbital inflammatory disease?
The white of the eye is usually red due to dilated blood vessels. The surface of the eye may feel gritty and sore. Double vision, meaning seeing two images instead of one. Pain, which may be worse on eye movements. The eyeball may protrude from the eye socket. Vision may deteriorate. Symptoms may affect both sides, if so one side is usually worse than the other
How is orbital inflammatory disease treated?
An orbital biopsy may need to be performed to confirm the diagnosis. This is discussed below. Inflammatory disease is treated with anti-inflammatory drugs. These are usually tablets but may be given intravenously as a drip in hospital. Non Steroidal Anti Inflammatory Drugs (NSAID’s) are used for mild disease e.g. Ibuprofen. Moderate to severe disease is treated with steroids. These are given in a high dose at first and then once the condition starts to improve the dose is gradually reduced. Steroids may also be given intravenously. Other Drugs may be used to replace steroids. These immunosuppressants are reserved for difficult to treat cases. Depending on the severity of the disease you may be treated as an outpatient or on the ward.
Orbital tumours may be benign or malignant. Benign lesions include amongst others: haemangioma; dermoid cyst, meningioma, solitary fibrous tumour, pleomorphic adenoma of lacrimal gland. Malignant lesions include: lymphoma, leukaemia, metastasis, adenoid cystic carcinoma of lacrimal gland.
What are the symptoms and signs of orbital tumours?
Double vision, meaning seeing two images instead of one. Pain, which may be worse on eye movements. The eyeball may protrude from the eye socket. Vision may deteriorate. Almost always the symptoms affect only one side
How are orbital tumours treated?
An orbital biopsy may need to be performed to make the diagnosis. This is discussed below. Treatment depends on the diagnosis. A CT scan and / or MRI scan of the orbits will be carried out. Some benign orbital tumors do not need to be treated if they are not causing significant problems. Other benign lesions may cause significant symptoms by compressing healthy structures in the orbit. Malignant or cancerous tumours may be treated by surgical excision, chemotherapy, radiotherapy or a combination. Surgery may be carried out to make the diagnosis through biopsy, to debulk or partly remove the tumour and to completely remove a tumour.
What are the symptoms and signs of orbital infection?
Also known as orbital cellulitis, this is a medical emergency requiring urgent assessment and treatment in hospital. The eyelids are red, tender and very swolllen so that the eyelids may close completely. The skin of the eyelids may be warm to the touch. The white of the eye is usually red due to dilated blood vessels. The surface of the eye may feel gritty and sore. Double vision, meaning seeing two images instead of one. Pain, which may be worse on eye movements. The eyeball may protrude from the eye socket. Vision may deteriorate. Symptoms usually affect only one side, if so one side is usually worse than the other. You may feel unwell with a fever. There may be a history of sinus disease. Most orbital infections are caused by sinus disease.
Top - eyelid swelling and redness due to orbital infection and abscess; Middle - a CT scan of the orbits with the arrow showing and orbital abscess; Bottom - the abscess was drained via a scarless incision behind the eyelid and the condition rapidly resolved with the additional help of intravenous antibiotics
How is orbital infection treated?
Intravenous antibiotics should be started without delay. An urgent CT scan will be carried out. If you think you may have orbital cellulitis do not eat or drink until Mr. McCormick or your ophthalmologists tells you to. This is in case you need to go to theatre to have an orbital abscess drained. 6 hours must pass from last food and drink before a general anaesthetic may be carried out. If the CT scan shows a collection of pus in the orbit this may have to be drained surgically. If the CT scan shows sinus disease an Ear Nose and Throat Surgeon may be asked to manage this. Sinus disease management may involve nasal drops, antibiotics or surgery. Sometimes sinus surgery is carried out at the time of orbital abscess drainage. You will be managed as an inpatient on a ward. Nurses will monitor your vision and other clinical signs looking for signs of recovery or deterioration. This monitoring may be every hour, even through the night if necessary.
What is orbital biopsy?
Orbital biopsy is an operation to remove a small piece of abnormal tissue in the orbit so that a pathologist may examine it under the microscope and make a diagnosis. The incision used depends on the site of the abnormal tissue. Many lesions in the upper orbit may be approached through an upper eyelid skin crease incision. This helps to hide the incision post-operatively. Lesions in the lower orbit may be approached from the inside of the lower eyelid, sometimes with a small 7-10mm skin incision at the outer corner of the eyelids. Depending on the difficulty in obtaining the biopsy the procedure may be carried out as a daycase or with overnight stay. Three types of anaesthesia are used for these procedures: local anaesthetic; local anaesthetic with intravenous sedation and general anaesthesia. You will have the opportunity to discuss the risks of anaesthesia with Mr McCormick or anaesthetist prior to surgery. Sedation means that you are breathing for yourself and don’t have a breathing tube inserted but you are very relaxed and sleepy and often don’t remember the operation. General anaesthetic means you are completely asleep with a breathing tube inserted.
What is orbital tumour excision?
In some cases the correct management is to excise a tumour in its entirety. This may be for benign or malignant lesions. This requires a larger incision, determined by the position in the orbit of the tumour. To gain access to the tumour it may be necessary to remove part of the bone from an orbital wall. This bone is then replaced at the end of the procedure. Orbital tumour excision has the same risks as orbital biopsy. The procedure is longer and more involved so it could be said that the risks are slightly higher.
What is orbital abscess drainage?
If a collection of pus has formed in the orbit it usually needs to be drained surgically. This is done under general anaesthetic. The incision depends on the site of the pus but commonly this is from the inside of the eyelid or through the natural skin crease in the upper eyelid so that it is hidden. Sometimes a drain is left in place overnight to allow further pus to drain out of the orbit. A drain is simply a piece of rubber tubing that is placed into the abscess cavity and then out through the incision.
What are the risks and possible complications of orbital surgery?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in this operation.
Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics.
Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding.
A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department where Mr. McCormick or an on call Ophthalmologist will attend to you.
Any orbital surgery carries a very small risk of permanent loss of vision. This could be due to damage to the nerve of vision during the procedure or bleeding after the operation.
Any orbital surgery carries with it a risk of double vision. In most cases, if this occurs, it is temporary but rarely it is permanent. Permanent double vision may be corrected with surgery or prisms in spectacles.
Whenever the skin is incised a scar may form. Every attempt is made by Mr. McCormick to minimise and hide scars but sometimes they can be visible.
You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.
What will happen before surgery?
Before the operation you will be seen in the clinic by Mr. McCormick. He will ask you about the orbital problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). He will examine your eyes. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. You will be asked to read and sign a consent form after having the opportunity to ask any questions. You will need to have a CT or MRI scan. This will be booked by Mr. McCormick. If you are to have a general anaesthetic or local anaesthetic with sedation you will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise when you need to starve before the operation. If simple local anaesthesia is used you will not need any of these investigations and you will not need to starve prior to surgery.
What should I do about my medication?
Mr McCormick will want to know all the medication that you take and about any allergies you have. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin), dabigatran, apixaban, rivaroxaban, dalteparin, ticagrelor. This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.
What should I expect after surgery?
Usually a pad will be placed on the eye, which will remain until the following day when you can remove it. In some cases your eye will be examined at regular intervals after surgery to make sure there are no signs of post-operative bleeding. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls. After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks. It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve. Usually the skin sutures used are dissolvable and will be left to fall out by themselves. The time when you can return to normal activities varies from person to person. Many are happy to do so after 2 – 3 days and the vast majority after a week. Some biopsies are just beneath the skin and cause minimal postoperative problems. Compare this with a larger tumour excision where you would expect more post operative inflammation and a greater recovery time of up to 2 weeks for initial wound healing and 3 months for swelling.
If an eye pad is placed it should remain until the next morning when you may remove it. For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls. Chloramphenicol ointment to the eye and wound, three times a day for 2 weeks. Follow up appointment 1 week later.