Anatomy.-The shape of the orbit is that of a quadrangular pyramid, the base or facial opening, the four walls and the apex. The axes of the orbits converge posteriorly at an angle varying in different individuals. The entering into formation of the orbital walls are the frontal, sphenoid, superior maxillary, malar, palate, ethmoid and lachrymal. The optic foramen, situated at the apex of the orbit, transmits the optic nerve and the ophthalmic artery.
The superior orbital fissure transmits the third, fourth and sixth nerves, ophthalmic branch of the trigeminus, the superior and inferior ophthalmic veins, few sympathetic filaments from the cavernous plexus, the recurrent lachrymal artery and sometimes orbital branches of the middle meningeal artery. The inferior orbital fissure gives passage to the malar and infra-orbital nerves, infra-orbital vessels, a facial branch of the ophthalmic vein, and the ascending branches of the sphenopalatine ganglion notch, at the upper and inner margin of the orbit, contains the supra-orbital nerve, artery and vein as they pass to the forehead. The orbit, in addition to the eyeball, vessel, muscles, etc., contains considerable adipose tissue.
Tenon’s Capsule is the limiting membrane between the cellulofatty tissue and the globe and conjunctiva. It ensheaths to some extent the muscles, vessels, nerves, etc., that pass through it, and is continuous with the periosteum of the orbit as well as with the conjunctiva. It is somewhat analogous to the pleura, and serves as a cup in which the globe revolves. It constitutes a secondary attachment for the ocular muscles, and by this attachment it renders it possible to severe the tendon of a muscle without losing its entire action upon the eye, for it still remains in connection with the eye through Tenon’s capsule, unless too extensive lateral cuts have been made, separating the tendon from the capsule.
The dura matter is firmly attached at the sphenoidal fissure and optic foramen and is continuous with the outer sheath Of the optic nerve and with the periosteum of the orbit.
Cellulitis Orbitae (Abscess or Phlegmon of the Orbit).- Inflammation of the cellular tissue of the orbit may occur as a simple oedematous cellulitis or in a far more active form as a phlegmonous cellulitis.
SYMPTOMS.- In oedematous cellulitis the eye will be slightly bulged forward, its movements limited and sometimes diplopia is complained of. There is usually in these mild cases little or no swelling or redness of the lids or conjunctiva, and but little dull pain, except on pressure upon the globe. This form of cellulitis generally occurs in young and delicate children, and usually subsides within a few days.
In the severer form, or phlegmonous cellulitis, the onset is apt to be accompanied with a chill and rise in temperature. There will be swelling and dusky discoloration of the lids, especially the upper, and a more or less intense pain, greatly increased by pressure upon the globe. The eyeball is protruded directly forward, and its movements limited in all directions; in some severe cases it will have absolutely no motion. (In periostitis, which it closely resembles, there is greater swelling and redness and the protrusion of the eye and the limitation in its movement is in but one direction.) The conjunctiva is chemosed and the cornea completely or partially anaesthetic. Diplopia is usually present and the vision may be greatly impaired from optic neuritis and atrophy. Digital examination will find the tissues firm, tense and very painful to the touch. In extreme cases the eyeball may become involved and end in panophthalmitis.
CAUSES.-Various and frequently obscure. May be metastatic from phlebitis, septicaemia, puerperal fever, etc. It is often coincident with facial erysipelas. May result from cold, from injuries, periostitis and inflammation of the lachrymal gland.
PROGNOSIS.-Is always serious as vision may be lost from neuritis, slough of the cornea, or panophthalmitis. It may terminate fatally through meningitis and abscess of the brain, though the large majority recover. TREATMENT.-When due to a foreign body, it should be removed, and the ice bag employed to subdue if possible the inflammatory symptoms. But if suppuration has already set in, poultices should be applied to promote the discharge of pus, which should be evacuated at an early period, by a free incision through the conjunctiva if practicable, if not, through the lid itself. Care should be taken that the pus has free vent at all times. Noyes (loc. cit.) advises an early incision, even before pus forms, claiming its value “as a means of arresting the phlegmonous inflammation and the formation of pus” as by the incision “the oculo-orbital fascia is relieved, the vessels are unloaded, serum finds vent and the tissues are relaxed.” Diet and rest should be prescribed according to the general tone of the patient and severity of the attack.
Rhus tox.- This is a remedy of the very first importance in this form of inflammation. The lids are oedematously swollen, as well as conjunctiva, and, upon opening them, a profuse gush of tears takes place. The pains are especially severe at night, vary in character and may be greatly influenced by any change in the weather. Panophthalmitis is liable to complicate the trouble.
Hepar sulph.-Especially after pus has formed. Lids swollen and very sensitive to both touch and cold. The pains are usually of a throbbing character.
Phytolacca.-Inflammation of the cellular tissue of the orbit without much pain, slow in its course and with little tendency to suppuration. The eye will be protruded and the infiltration into the orbit and lids will be hard and unyielding to touch.
Aconite.-In the first stage, when the lids are much swollen, with a tight feeling in them; chemosis, with much heat and sensitiveness in and around the eye, and a sensation as if the eyeball were protruding, making the lids tense, associated with general Aconite fever.
Apis Melilotus-Before the formation of pus. Lids oedematously swollen, with stinging, shooting pains. Patient drowsy, without thirst.
Lachesis.-Orbital cellulitis following squint operation, point of tenotomy sloughing, with a black spot in the centre; chemosis, and much discharge, with general Lachesis condition.
Mercurius-In the later stages after pus has formed, and even after it has discharged for some time and has become thin in character, especially if occurring in a syphilitic subject. There is often much pain in and around the eye, always worse at night.
Other remedies may be thought of, as Arsenicum, Belladonna, Bryonia, Kali iod., Silicea, Sulphur.
Tenonitis.-Inflammation of the capsule of Tenon is a comparatively rare disease which may follow operations for strabismus and less frequently occurs idiopathically, especially, in those of a rheumatic diathesis.
SYMPTOMS.-There may be slight swelling of the lids, chemosis of the conjunctiva, exophthalmos and diminished mobility of the eye. Pain more or less severe, especially on pressure or movement of the eye, is apt to be present.
TREATMENT.- Internal medication is all sufficient in this disease and the most serviceable remedies are Kalmia lat., Kali iod., Rhus and puls.
Periostitis Orbitae.-Inflammation of the orbital periosteum may result from injuries or occur idiopathically in rheumatic, syphilitic or scrofulous subjects. The disease is most commonly found in early life and its usual location is the margin of the orbit.
SYMPTOMS.-There is present pain, especially from pressure on the bone, oedema of the lids, chemosis and a tense, swollen, sensitive spot in which fluctuation may be detected later. In the acute form there may also be fever, vomiting, delirium, etc. Periostitis in its acute form resembles very closely a phlegmonous cellulitis, and must be differentiated by the acute pain on pressure upon the orbital margin; by less swelling and redness of the lids; the inflammation is more circumscribed, so that the displacement of the eyeball is in one direction and its mobility is more restricted in one direction.
In the chronic form of periostitis there is simply slight swelling of the upper lid and supra-orbital pain, together with localized swelling at the seat of the inflammation. This is the more frequent form, and especially found in young scrofulous subjects.
COURSE.-When chronic, it is very tedious, lasting months or years, and is apt to result in caries of the bone, fistulae, deformity of the lids, etc. In the acute form, if the abscess is near the surface and promptly opened, it may heal in a short time; but if deep and neglected, or if occurring in one of a syphilitic or scrofulous constitution, will usually be much more serious.
PROGNOSIS.-When near the orbital margin it is favorable, but if deep in the orbit it is much less so, as it may result in atrophy of the optic nerve, paralysis of the orbital muscles, or meningitis.
TREATMENT.-See Caries.
Caries and Necrosis of the orbital walls is almost universally a result of periostitis or an injury, although it may occur in the bone itself without a previous inflammation of the periosteum, especially in syphilitic or scrofulous subjects. After the abscess has opened, a fistula is formed which leads to the roughened and denuded bone. The discharge of pus through the fistula has the peculiarly fetid odor of osseus caries. The general symptoms of periostitis are present in caries, and, in addition, the diseased bone can be detected by the probe. Caries is most commonly found in children and necrosis in adults.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.