The orbital cavity (eye socket) is the bony cavity that encloses the bulb and accessory organs of the eye, including the ocular muscles, lacrimal glands, nerves, vessels, and retrobulbar adipose tissue. Diseases of the orbital cavity include Graves ophthalmopathy, orbital cellulitis, rhabdomyosarcoma, and lacrimal sac disorders. Typical symptoms associated with these diseases include exophthalmos and diplopia. Treatment differs according to the underlying disease and includes conservative measures (antibiotics), surgery, radiotherapy, and chemotherapy.
are discussed in a separate article.
- Definition: Graves ophthalmopathy or orbitopathy (GO) (also known as thyroid-associated orbitopathy/ophthalmopathy, TAO) is an autoimmune condition that is generally associated with
- TSH autoantibodies are present in the orbital cavity; (eye socket) → bind TSH receptor antigen (autoimmune reaction) on cells; → lymphocytic infiltration into the orbital tissues → inflammation and release of cytokines from CD4+ T cells → stimulates fibroblasts to secrete glycosaminoglycans (hyaluronic acid); , which also pulls water into the interstitial space (osmotic effect) → expansion of retro-orbital tissue due to increased fluid in extraocular muscles, lymphocytic infiltration, and adipogenesis
- Exophthalmos : can be unilateral or bilateral, often asymmetric. Retropulsion (palpation of the globe while the eyelid is closed) enable adequate examination.
- Ocular motility disturbances
Lid retraction, also known as “thyroid stare”
- Dalrymple sign: retraction of the upper eyelid with visible sclera and extended palpebral fissure
- Von Graefe sign: lagging of the upper eyelid on downgaze (may occur with Grove sign: resistance to pulling the retracted upper lid down)
- Stellwag sign: infrequent and incomplete blinking (rare)
- Vigouroux sign: Eyelid fullness
- Lagophthalmos → keratitis (occurs with insufficient blinking)
- Joffroy sign: absent forehead creases during superior gaze
- Conjunctival injection and chemosis
- Ocular discomfort (pain or pressure)
- Photopsia on upward gaze
- Patient may be hyperthyroid, euthyroid, or hypothyroid.
- Laboratory analysis: ↓ TSH and ↑ free T3/T4; (to diagnose of hyperthyroidism), ↑ TSH receptor antibodies, which are specific and sensitive to Graves disease but not widely available
- Slit lamp examination
- CT: confirmatory test that shows exophthalmos, increased fat density and inflammation and enlargement of extraocular muscles, and helps monitor progression of disease
- MRI: alternative option to CT that can show similar findings to CT and, additionally, compression of the optic nerve
- Photo documentation
- Differential diagnosis: pseudoexophthalmos
- Usually a self-limiting disease, but intervention may be necessary because of severe symptoms or risk of complications.
- For all patients
- Conservative local measures
- Eye protection (e.g., artificial tears, sunglasses)
- Sleep with the head of the bed elevated
- Treat hyperthyroidism, if present
- Avoid smoking
- Conservative local measures
- Mild disease: transient or no diplopia, mild soft tissue involvement, lid retraction < 2 mm, proptosis < 3 mm
Moderate to severe disease: inconstant or constant diplopia, moderate to severe soft tissue involvement, lid retraction ≥ 2 mm, proptosis ≥ 3 mm
- High-dose IV steroids
Nonresponders or threatened/manifest vision loss
- Orbital decompression surgery (following steroid administration)
- Strabismus correction
- Lid-lengthening surgery
- For patients who are refractory to treatment or poorly tolerate glucocorticoids: teprotumumab, rituximab, cyclosporine, octreotide, intravenous immunoglobulin, and tarsorrhaphy 
Orbital and preseptal cellulitis
|Orbital cellulitis vs. preseptal cellulitis |
|Orbital cellulitis||Preseptal cellulitis|
|Epidemiology|| || |
In patients with orbital cellulitis, the development of headache, ophthalmoplegia, facial hypesthesia in regions innervated by V1 and V2, and/or seizures should raise suspicion for cavernous sinus thrombosis.
- Definition: malignant mesenchymal tumor of primitive skeletal muscle cells (rhabdomyoblasts) that have failed to fully differentiate
- Clinical features
- Open or core needle biopsy for light microscopy to look for rhabdomyoblasts (confirm the presence of rhabdomyosarcoma)
- X-ray of the primary site and chest: to determine any bone and lung involvement for staging
- CT of the primary site and chest: to search for any lung metastases and bone destruction and determine therapeutic response
- MRI: better to determine specific location of mass and any soft tissue invasion
- Prognosis: more favorable for localized tumors of the orbit, and less favorable for metastatic disease
- Definition: sight-threatening ophthalmological condition due to an acute increase in intraorbital pressure
- Etiology 
- Acute onset of significantly reduced visual acuity
- Eye pain
- Periorbital swelling and proptosis
- Marked resistance to retropulsion (tight orbit)
- Firm or rock-hard globe
- Increased intraocular pressure
- Subconjunctival hemorrhage
- Afferent pupillary defect and absence of light perception
- Diagnostics: The diagnosis is mainly based on history and physical examination.
- Treatment: emergency surgical decompression via lateral canthotomy
- Treatment within 2 hours of symptom onset: good chance of final visual acuity better than 20/40
- Treatment after 2 hours of symptom onset: usually poorer visual outcomes
Orbital compartment syndrome (OCS) is a sight-threatening ophthalmological emergency that can cause vision loss. If there is a high clinical suspicion of OCS, treatment should not be delayed for further diagnostic workup. Orbital imaging may be performed after decompression.