The orbit is the bony tissue that surrounds the eye socket. It consists of seven bones and is part of the bones of the skull. The anatomical structure of the orbit is extremely complex and contains muscles that move the eyeball, connective tissue, fat, blood vessels and nerves, a lacrimal gland, and passages to the air spaces around the eye (sinuses) and brain tissue. Therefore, various diseases in areas adjacent to the orbit can cause eye or orbital symptoms, and inflammation or injury to the orbit can involve the sinuses and brain tissue. The eye is the main organ that fills the contents of the orbit. The additional tissues in the orbit support the proper functioning of the eye and vision, as well as the timing of eyeball movements and binocular spatial vision.
A variety of diseases and conditions can involve the eye socket, ranging from infectious infections – orbital cellulitis / pre-septal cellulitis, traumatic fractures – orbital blow-out fractures that require follow-up or reconstruction surgery of the eye socket, tumor processes (benign, malignant or secondary to blood vessel proliferation), congenital / acquired disorders such as bulging eyes secondary to thyroid disease that require decompression surgery of the eye sockets. Processes in the tissues around the eye socket, such as the nasal cavities and sinuses, the upper jaw, and processes in the central nervous system can also give secondary expression in the eye socket. In quite a few cases, the first manifestation of the systemic disease will be in the eye or socket.
In certain diseases such as eye tumors or severe trauma to the eyeball (surgical or non-surgical), surgery will be required to remove the eyeball (see below). This unique condition is called enophthalmos, and it requires fitting a prosthetic eye to provide a natural appearance to the face and eye sockets.
Most orbital tumors are benign and can be managed without surgery. If there is an aesthetic or functional disturbance (double vision, bulging eye, decreased visual function), surgery to remove the tumor may be considered. The surgical incision is usually made in natural skin folds around the eye socket, and functional and aesthetic recovery is excellent. In children, the most common benign process is called a dermoid or epidermoid cyst and it usually appears on the lateral part of the upper eyelid or eyebrow. Other lesions in children are vascular disorders – capillary hemangioma, which presents as an oval shade of the eyelid, here the treatment is by administering beta blockers syrup or lymphatic malformations or venous-lymphatic malformations. These disorders can usually be treated by injections of sclerosing agents, with the most commonly used agent being bleomycin. In cases that are not suitable for conservative treatment, surgery can sometimes be considered.
Malignant tumors of the orbit are very rare, with the most common tumor being orbital lymphoma, which can involve the lacrimal gland, fatty tissue, extraocular muscles, and conjunctival tissue. In cases of orbital lymphoma, it is common to take a sample of the tumor (orbital biopsy) and decide on the treatment plan based on the pathology results.
The usual treatment, depending on the type of lymphoma, will be external beam radiation therapy (EBRT), biological therapy, or chemotherapy. The results of the treatment are usually excellent, leading to a complete cure in a high percentage of cases (complete response). The treatment is performed by hemato-oncologists.
There are other malignant tumors such as BCC or SCC that originate in the eyelids or nasal cavities, and when they penetrate the chimney, combined treatment can be considered – surgical, radiation or drug therapy depending on the type of tumor and systemic disorders.
Additional chimney surgeries include removal of the eyeball (enucleation) in the case of malignant tumors of the eye that are not suitable for drug/radiation treatment, or dark eye injuries with a lack of visual potential and pain – removal of the contents of the eyeball (evisceration). The condition of having no eye in the eye socket is called anophthalmos and requires follow-up with an ophthalmologist in the field of eye plastic surgery due to the possibility of reconstructive treatments. Fitting a prosthetic eye, which is similar to contact lenses, is performed in specialized eye clinics for prosthetic eyes (prosthetic eyes or epi-prosthesis) when the appearance of the prosthetic eye is natural, and it is very similar to the other eye. The eyeball movements are not as complete as the healthy eye, but it is usually not possible to tell that the patient is wearing a prosthetic eye.
Reconstructive surgeries to the eye socket such as fracture repair
(orbital fracture repair) או Correction of eye protrusion in thyroid disease (orbital decompression) are detailed on the appropriate pages.
Cavernous venous malformation, formerly known as cavernous hemangioma, is a benign, slow-growing tumor. If it does not cause aesthetic (protrusion of the eye, displacement of the eyeball) or functional (reduced vision, double vision, field defects), surgical removal may be considered. The surgical incision is made according to the location of the tumor, and the tumor can be frozen during surgery to facilitate removal.
Protruding eyes are typical of those suffering from Graves’ hyperthyroidism. When the disease is stable for at least a year or two, and the appearance of the eyes is stable, and the systemic disease is balanced, surgery to move the eyes back (orbital decompression) can be considered. The surgery involves tightening the bones at the borders of the socket with removal of socket fat, and is highly effective in the aesthetic correction of the eye socket. In many cases, more than one surgery is required for aesthetic and functional restoration, such as strabismus correction surgery or eyelid position correction surgery, depending on the existing disorder secondary to socket involvement.
Capillary hemangioma is a benign process of blood vessels with high flow, and appears in the newborn or in the first months of life. If it is small and there is no significant disturbance, it can be monitored since the tumor regresses by the age of one year. If there is extensive involvement of the chimney, it is common to treat with beta blocker syrup under the supervision of a pediatrician. The treatment is very effective in reducing the tumor. This treatment is also effective if the process causes the eyelid to droop, which may lead to the development of a lazy eye, or significant eye protrusion, strabismus, or other visual disturbance. If the treatment does not help, steroid injections for the process, or surgical removal, can be considered.
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