Aside from the traumatic hematomas above mentioned extravasation occurs, due to constitutional or vascular disease, as atheroma, especially when coupled with violent straining efforts. Subconjunctival effusion and exophthalmos, with limitation of motion, will be unfailing expressions of such damage. Orbital aneurysms, spontaneous or traumatic, are occasionally seen. They will cause a more or less pulsating exophthalmos, while, in some instances, a bruit may be detected with the stethoscope. Cases may be imagined where it would be suitable to cut away the external wall of the orbit and expose such a tumor. Ordinarily, however, ligature of the internal or common carotid will be required. Angiomas occur also in the orbit, producing exophthalmos, usually without pulsation. Such tumors will prove compressible and the globe may be gently pressed backward into the orbit to immediately protrude again when pressure is removed. These lesions will prove very difficult, usually impossible of treatment, and no general rule can be made therefor.
Orbital cellulitis, i. e., infection of the cellular and other tissues in the orbit, may occur, either from without or from within, but usually in connection with some traumatism. Sometimes this involves first the cornea or the structures of the globe; at other times infection is by a more direct method, through the conjunctival sac or the orbital coverings. It varies in intensity between extreme limits. It may even be bilateral. While cases occasionally undergo resolution it usually terminates by formation of abscess. It is met with in the infectious fevers, in facial erysipelas, by extension upward of infection from diseased teeth, after primary infection of the ethmoidal or sphenoidal sinuses, or by extension from external phlegmons. There will be edema of the lids, usually with chemosis, fixation and protrusion of the eyeball, commonly with divergence. In proportion to the severity of the lesion there will be present septic symptoms, with deep-seated pain and headache. Vision is disturbed in proportion to the pressure upon the nerve and globe, as well as the involvement of the ocular structures proper. When the disease is begun within the eye it will usually terminate by a combination of panophthalmitis with orbital abscess.
Treatment.
—The application of the compound ichthyol or Credé’s silver ointment, with ice, preceded perhaps by the use of leeches, will be suitable local treatment unless the presence of pus be distinctly made out or until tension threaten serious harm. In either of these events, however, free incisions are required at points of greatest tension, the knife being so directed as to avoid the globe. These incisions should be free and sufficiently deep. Should there be accompanying panophthalmitis the eyeball itself should be freely incised through its anterior aspect and its contents completely evacuated. Such emptying of the contents of the sclerotic is called evisceration of the globe. While theoretically indicated, experience has shown that it is a disastrous practice to enucleate the eye at such a time; evisceration first and enucleation later, should it prove desirable.
TUMORS OF THE ORBIT.
The orbit is the site of many primary tumors which originate within its proper tissues as well as those which encroach upon it from neighboring cavities or from the face. Prognosis is better in the former than in the latter, but unfavorable in all malignant cases.
Of the primary cystic tumors there may be nearly all the known varieties, including those of parasitic origin. The pseudocysts of the cranial cavity sometimes project into the orbit, forming orbital encepholacele. Dermoid cysts are not at all uncommon. Around the bursæ of the orbital muscles exudation cysts occur, while the retention cysts, including the cholesteatomas, are not infrequent. The true dermoid cysts may contain all the ordinary epithelial products, just as in any other part of the body. Parasitic cysts include the echinococcus and the cysticercus, the latter being rare, while the former may extend into the frontal sinus or cranial cavity. It produces almost constant ciliary neuralgia. Vascular tumors of all types are found in the orbit and the various expressions of telangiectasia of the lids and orbit are often seen. These are always of congenital origin. Of the more simple types of mesoblastic tumors the osteomas are perhaps as common as any. These assume all the types described in the chapter on Tumors, and are of all degrees of hardness. Sarcoma and osteosarcoma, originating within the orbit, are unfortunately too common. Naturally they spread to and involve all the adjoining structures. True endothelioma is rarely recognized as such until after removal and microscopic examination. Epithelioma commencing upon the surface of the eye, or about the skin and spreading inward, is also quite common.
Exophthalmos is an expression of intra-orbital tension common to all forms, while by the extent of protrusion and its direction the site of the tumor may to some extent be determined. Other disturbances of position, with limitation of motion and consequent diplopia, are further expressions of pressure and dislocation. Ptosis, or drooping of the upper lid, is a feature of tumors which proceed from the upper part of the orbit. The vascular tumors, as already mentioned, produce more or less pulsation. Ocular tension is usually increased, and when circulation and enervation have been seriously affected necrosis and even perforation of the cornea may occur. Pain is a variable feature, but is sometimes pronounced. An exploring needle may be passed into a tumor which seems to be cystic, but it should be done with every precaution, both against infection and injury to the eye.
Tumors of the optic nerve proper originate more often in its sheath than in its true neural tissue. They may occur at any point, but usually within the orbit. These tumors are usually of the sarcomatous, gliomatous, or endotheliomatous type. Cystic changes are not infrequent; they occur usually in the young. All of these tumors will involve the optic nerve in such a way as to produce signs easily recognizable with the ophthalmoscope, such as optic neuritis and nerve atrophy. Moreover, they affect or completely destroy vision. They are not so painful as most of the other intra-orbital tumors, and, while causing a direct forward protrusion of the eye, affect its motility less than other forms. Nevertheless they grow with great rapidity and evince destructive tendencies. In theory the treatment for all tumors of the orbit is complete extirpation, while the malignant tumors require emptying of the orbital contents. Benign tumors and cysts are usually successfully treated by this method. Of most malignant tumors it may be said that the prognosis is unfavorable. The lymphatic and vascular connections are so free, and extension into surrounding cavities so easy, that recurrence takes place in the larger proportion of cases. Too often by the time a patient is willing to sacrifice the eye and the orbital contents it is too late to effect a radical cure.