The orbit comprises the bones and tissues that surround the eye. Much delicate anatomy including nerves, blood vessels and muscles are contained in the orbit. The bones of the orbit make a confined space, like a box that only opens from the front. When masses grow in the orbit,the eyeball is often pushed forwards (PROPTOSIS) or pushed to the side (DISPLACEMENT).
The most common orbital disease causing proptosis in an adult, either in one eye or both eyes is GRAVES OPHTHALMOPATHY. Graves ophthalmopathy is usually characterized by lid retraction (the white of the upper eye shows because the muscles of the upper eyelid are overacting / scarred.) Orbital CT and MRI are usually NOT essential to establish the diagnosis of Graves ophthalmopathy, but are extremely helpful if surgery is being planned. If the patient’s proptosis is not due to Graves ophthalmopathy, many tumors, inflammations and infections must be considered, and orbital imaging (CT or MRI), and biopsy are usually required. LYMPHOMA is the most common malignant orbital lesion in adults, and may appear as a salmon coloured patch underneath the conjunctiva, or as a lump underneath the eyelid skin. In children with orbital tumours RHABDOMYOSARCOMA should be excluded.
ORBITAL BIOPSY If the abnormal orbital tissue can be seen or felt by the doctor, and is not covered by bone, then an ANTERIOR ORBITOTOMY can usually be performed. The incision site is over the skin or conjunctiva of the eye. If the abnormal tissue is deep, removal of orbital bone may be required to access the lesion.
If the pathology is located toward the ear side, a LATERAL orbitotomy is often performed.
Occasionally a needle can be placed in to the tumor, and a small sample withdrawn (FINE NEEDLE ASPIRATION BIOPSY) The amount of tissue obtained from needle biopsy is small and the pathologist (cytopathologist) may have a very difficult job making an accurate diagnosis.
POTENTIAL SEQUELAE OF ORBITAL SURGERY Double vision, droopy eyelid, vision loss / blindness, uncontrolled infection / bleeding, chronic discomfort and numbness, are potential sequelae of any orbital procedure. Double vision after orbital surgery is usually transient, but can be permanent. Eyelid asymmetry or skin scar may result following orbital surgery . Tearing and sinus complications may occur following orbital procedures. Following lateral orbitotmy, some patients complain of pain with chewing. If the surgery is performed in the lower part (floor) of the orbit, numbness of the cheek and even teeth may occur. Some patients may perceive chronic discomfort following surgery, especially if they have a poor pre-operative pain tolerance, require chronic narcotics, or use recreational street drugs. If drills or saws are required during surgery small bits of metal, not visible to the surgeon’s eye, may be retained (safely) in the orbit. Fine needle aspiration biopsy carries a small risk of needle perforation of the eyeball, and orbital bleeding. Anesthesia may be associated with a remote risk of cardiorespiratory compromise, stroke, or in exceedingly rare cases, death. If you are worried about surgery, Dr. Ing encourages you to bring a friend or family member to the office for a pre-operative discussion. To put things in perspective, the overall risks of orbital surgery is probably less than or equivalent to such activities as smoking cigarettes / marijuana, driving without a seat belt, or playing hockey without a helmet.
MANAGEMENT OF ORBITAL TUMORS monograph by Dr. E. Ing
The management of orbital tumors greatly depends on such factors as tumor type, tumor location, patient age and vision. However the following generalizations can be made: If the orbital lesion is well circumscribed, then surgical excision may be curative. Examples of discrete lesions include cavernous hemangioma, unruptured dermoid cysts, neurofibroma and schwannomas. If the orbital lesion infiltrates the tissue, complete excision may not be possible without harming the eye. Examples of infiltrative lesions include lymphoma, lymphangiomas, metastatic cancer, and orbital inflammatory syndrome (OIS). OIS is not uncommon and usually presents with sudden onset pain and a red “hot” orbit. It usually responds to long term oral steroids, but steroid injections or even radiation may be required. Depending on the type of tumor, further surgery, radiation, chemotherapy or a combination of the previous treatment modalities may be required. If the orbital tumor originates or spreads from the sinuses or brain, an ear nose and throat surgeon, or neurosurgeon may be involved in the case. Vascular orbital tumors composed of large blood vessels are difficult to address surgically because of their tendency to bleed. Some vascular lesions are amenable to embolization with the aid of an interventional radiologist.
ORBITAL FRACTURES Ophthalmologists are most frequently consulted when the bone at the bottom of the orbit (floor) is broken. Indications for repair of a floor fracture include persistent double vision, persistent loss of movement of the eye, a markedly sunken-in; eye, and nausea/cardiac problems with attempted eye movement.
ORBITAL FOREIGN BODIES Wood or vegetable foreign bodies are removed. Inert foreign bodies such as glass or metal in the orbit are usually left alone unless easily accessible or visible. Metallic foreign bodies that seem readily apparent on CT scans may be exceedingly difficult to find at surgery.
Deep ORBITAL INFECTIONS are usually very serious and require intravenous antibiotics. Orbital pus pockets (abscesses) may require drainage. If the adjacent sinuses are affected, they may have to be drained with an ENT surgeon. Multiple drainage procedures may be required.