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Orbital Pseudotumor

Definition: Lymphocytic orbital tumor of unknown origin.

Symptoms and findings. Painful, moderately severe inflammatory reaction

with eyelid swelling, chemosis, and unilateral or bilateral exophthalmos.

Involvement of the ocular muscles results in limited motility with diplopia.

Diagnostic considerations. The CT and MR images will showdiffuse soft-tissue

swelling. A biopsy is required to confirm the diagnosis.

Occasionally the CT image will simulate an infiltrative tumor.

Differential diagnosis. Various disorders should be excluded. These include

Graves disease and orbital cellulitis, which is usually bacterial. Special forms

of orbital pseudotumor includemyositis and Tolosa–Hunt syndrome (painful

total ophthalmoplegia produced by an idiopathic granuloma at the apex of

the orbit).

Treatment. High-dose systemic cortisone (initially 100mg of prednisone)

usually leads to remission. Orbital radiation therapy or surgical intervention

may be indicated in patients with no response to treatment.

Myositis

This a special form of orbital pseudotumor in which the lymphatic infiltration

primarily involves one or more ocular muscles. Aside from significant pain

during motion, symptoms include limited ocular motility with double vision

(diplopia). Depending on the extent of the myositic changes, exophthalmos

with chemosis and eyelid swelling may also be present. Ultrasound studies

(Fig. 15.6) will reveal thickening of the ocular muscles with tenonitis (inflammation

of Tenon’s capsule).

Orbital Periostitis
This is an inflammation of the periosteum lining the orbital cavity, usually due

to bacterial infection such as actinomycosis, tuberculosis, or syphilis. Less frequently, the


disorder is due to osteomyelitis or, in infants, tooth germ inflammations.

The clinical symptoms are similar to orbital cellulitis although significantly

less severe and without limitation of ocular motility. Liquefaction of

the process creates an orbital abscess; large abscesses may progress to orbital

cellulitis.

Mucocele

These mucus-filled cysts may invade the orbital cavity in chronic sinusitis.

They displace orbital tissue and cause exophthalmos.

Treatment is required in the following cases:

_ Displacement of the globe causes cosmetic or functional problems, such as

lagophthalmos or limited motility.

_ Compression neuropathy of the optic nerve results.

_ The mucocele becomes infected (pyocele).

Mycoses (Mucormycosis and Aspergillomycosis)

These rare disorders occur primarily in immunocompromised patients, such

as those with diabetes mellitus or AIDS. The disorder often spreads from

infected paranasal sinuses. The clinical picture is similar to those of inflammatory

orbital disorders.

Gerhard K. Lang, MD

Lang, Gerhard K.[Augenheilkunde. English] Ophthalmology : a pocket textbook atlas /


Gerhard K. Lang ; with contributions by O. Gareis ... [et al.]. – 2nd ed., rev. and enl.p. ; cm.
Khurana, A K. 2007. Comprehensive ophthalmology. Fourth edition. Regional institute of
ophthalmology. Rothak-124001,India.

IDIOPATHIC ORBITAL INFLAMMATORY

DISEASE (PSEUDOTUMOURS)

The term ‘pseudotumour’ was coined for those conditions of the orbit which clinically
presented as tumours but histopathologically proved to be chronic inflammations. However,
recently, the use of this term has been restricted for an idiopathic localized inflammatory
disease consisting principally of a lymphocytic infiltration associated with a
polymorphonuclear cellular response and a fibrovascular tissue reaction that has a variable
but self-limiting course. Presently, idiopathic orbital inflammatory disease (IOID) is a term
being preferred to denote this condition.

Clinical features (Fig. 16.10): Pseudotumour can occur throughout the orbit from the region
of lacrimal gland to the orbital apex and thus produce varied clinical presentations. The most
commonly noted features are:

_ Swelling or puffiness of the eyelids, proptosis, orbital pain, restricted ocular movements,
diplopia, chemosis and redness.

_ Most cases are unilateral, although both sides may be involved occasionally.

_ The condition typically affects individuals between 40 and 50 years; however, age is no bar.

_ Spontaneous remissions after a few weeks are known in pseudotumour.

_ Recurrences are also common. In some patients severe prolonged inflammation may cause
progressive fibrosis of the orbital tissues leading to a frozen orbit with visual impairment.

Fig. 16.10. Pseudotumour involving the right orbit.

Diagnosis. Clinically pseudotumour is suspected only by exclusion of the known conditions.

_ Ultrasonic and CT-scanning show a diffuse infiltrative lesion with irregular ill-defined
margins and variable density.

_ Fine-needle aspiration biopsy may give histological clue.


_ Incisional biopsy may be needed to confirm the diagnosis.

Treatment. It consists of a course of systemic corticosteroids (60-80 mg of prednisolone per


day for 2 weeks, initially and then gradually tapered). Usually, more than half of the patients
show a positive response. In non-responsive patients, radiotherapy is usually effective. A few
recalcitrant cases may require treatment with cytotoxic agents.

ETIOLOGY

Important causes of proptosis in each clinical group

are listed here:

A. Causes of unilateral proptosis include:

1. Congenital conditions.

These include: dermoid cyst, congenital cystic eyeball, and orbital teratoma.

2. Traumatic lesions.

These are: orbital haemorrhage, retained intraorbital foreign body, traumatic aneurysm and
emphysema of the orbit.

3. Inflammatory lesions.

Acute inflammations are orbital cellulitis, abscess, thrombophlebitis, panophthalmitis, and


cavernous sinus thrombosis (proptosis is initially unilateral but ultimately becomes bilateral).
Chronic inflammatory lesions include: pseudotumours, tuberculoma, gumma and sarcoidosis.

4. Circulatory disturbances and vascular lesions.

These are: angioneurotic oedema, orbital varix and aneurysms.

5. Cysts of orbit.

These include: haematic cyst, implantation cyst and parasitic cyst (hydatid cyst and
cysticercus cellulosae).

6. Tumours of the orbit.

These can be primary, secondary or metastatic.

7. Mucoceles of paranasal sinuses.

Especially frontal (most common), ethmoidal and maxillary sinus are common causes of
unilateral proptosis.
B. Causes of bilateral proptosis include:

1. Developmental anomalies of the skull:

craniofacial dysostosis e.g., oxycephaly (tower skull).

2. Osteopathies:

Osteitis deformans, rickets and acromegaly.

3. Inflammatory conditions:

Mikulicz’s syndrome and late stage of cavernous sinus thrombosis.

4. Endocrinal exophthalmos:

It may be thyrotoxic or thyrotropic.

5. Tumours:

These include symmetrical lymphoma or lymphosarcoma, secondaries from neuroblastoma,


nephroblastoma, Ewing’s sarcoma and leukaemic infiltration.

6. Systemic diseases:

Histiocytosis, systemic amyloidosis, xanthomatosis and Wegener’s granulomatosis.

C. Causes of acute proptosis.

It develops with extreme rapidity (sudden onset). Its common causes are: orbital emphysema
fracture of the medial orbital wall, orbital haemorrhage and rupture of ethmoidal mucocele.

D. Cause of intermittent proptosis.

This type of proptosis appears and disappears of its own. Its common causes are: orbital
varix, periodic orbital oedema, recurrent orbital haemorrhage and highly vascular tumours.

E. Causes of pulsating proptosis.

It is caused by pulsating vascular lesions such as caroticocavernous fistula and saccular


aneurysm of ophthalmic artery. Pulsating proptosis also occurs due to transmitted cerebral
pulsations in conditions associated with deficient orbital roof. These include congenital
meningocele or meningoencephalocele, neurofibromatosis and traumatic or operative hiatus.

Investigation of a case of proptosis

I. Clinical evaluation

(A) History.
It should include: age of onset, nature of onset, duration, progression, chronology of orbital
signs and symptoms and associated symptoms.

(B) Local examination.

It should be carried out as follows:

1. Inspection.

(i) To differentiate proptosis from pseudoproptosis which is seen in patients with


buphthalmos, axial high myopia, retraction of upper lid and enophthalmos of the opposite
eye; (ii) to ascertain whether the proptosis is unilateral or bilateral; (iii) to note the shape of
the skull; and (iv) to observe whether proptosis is axial or eccentric.

2. Palpation.

It should be carried out for retrodisplacement of globe to know compressibility of the tumour,
for orbital thrill, for any swelling around the eyeball, regional lymph nodes and orbital rim.

3. Auscultation.

It is primarily of value in searching for abnormal vascular communications that generate a


bruit, such as caroticocavernous fistula.

4. Transillumination.

It is helpful in evaluating anterior orbital lesions.

5. Visual acuity.

Orbital lesions may reduce visual acuity by three mechanisms: refractive changes due to
pressure on back of the eyeball, optic nerve compression and exposure keratopathy.

6. Pupil reactions.

The presence of Marcus Gunn pupil is suggestive of optic nerve compression.

7. Fundoscopy.

It may reveal venous engorgement, haemorrhage, papilloedema and optic atrophy. Choroidal
folds and opticociliary shunts may be seen in patients with meningiomas.

8. Ocular motility.

It is restricted in thyroid ophthalmopathy, extensive tumour growths and neurological deficit.

9. Exophthalmometry.

It measures protrusion of the apex of cornea from the outer orbital margin (with the eyes
looking straight ahead). Normal values vary between 10 and 21 mm and are symmetrical in
both eyes. A difference of more than 2 mm between the two eyes is considered significant.
The simplest instrument to measure proptosis is Luedde’s exophthalmometer (Fig. 16.4).
However, the Hertel’s exophthalmometer (Fig. 16.5) is the most commonly used instrument.
Its advantage is that it measures the two eyes simultaneously.

(C) Systemic examination. A thorough examination should be conducted to rule out systemic
causes of proptosis such as thyrotoxicosis, histiocytosis, and primary tumours elsewhere in
the body (secondaries in orbits). Otorhinolaryngological examination is necessary when the
paranasal sinus or a nasopharyngeal mass apears to be a possible etiological factor.

Fig. 16.4. Luedde’s exophthalmometer.

Fig. 16.5. Hertel’s exophthalmometer.

II. Laboratory investigations

These should include:

_ Thyroid function tests,

_ Haematological studies (TLC, DLC, ESR, VDRL test),

_ Casoni’s test (to rule out hydatid cyst),

_ Stool examination for cysts and ova, and

_ Urine analysis for Bence Jones proteins for multiple myeloma.

III. Imaging Technique

(A) Non-invasive techniques

1. Plain X-rays.

It is still the most frequently used initial radiological examination. Commonly required
exposures are in the Caldwell view, the Water’s view, a lateral view and the Rhese view (for
optic foramina). X-ray signs of orbital diseases include enlargement of orbital cavity,
enlargement of optic foramina, calcification and hyperostosis.

2. Computed tomography scanning.

It is very useful for determining the location and size of an orbital mass. A combination of
axial (CAT) and coronal (CCT) cuts enables a three-dimensional visualisation. CT scan is
capable of visualising various structures like globe, extraocular muscles and optic nerves.
Further, this technique is also useful in examining areas adjacent to the orbits such as orbital
walls, cranial cavity, paranasal sinuses and nasal cavity. Its main disadvantage is the inability
to distinguish between pathologically soft tissue masses which are radiologically isodense.

3. Ultrasonography.

It is a non-radiational noninvasive, completely safe and extremely valuable initial scanning


procedure for orbital lesions. In the diagnosis of orbital lesions, it is superior to CT scanning
in actual tissue diagnosis and can usually differentiate between solid, cystic, infiltrative and
spongy masses.

4. Magnetic resonance imaging (MRI).

It is a major advance in the imaging techniques. It is very sensitive for detecting differences
between normal and abnormal tissues and has excellent image resolution. The technique
produces tomographic images which are superficially very similar to CT scan but rely on
entirely different physical principles for their production.

(B) Invasive procedures

1. Orbital venography.

It is required in patients who are clinically suspected of having orbital varix. It confirms the
diagnosis and also outlines the size and extent of the anomaly which facilitates proper
surgical planning.

2. Carotid angiography.

It is now performed only in cases of pulsating exophthalmos and in those associated with a
bruit or thrill. The principal role of carotid angiography in orbital diagnosis is to identify the
location and extent of ophthalmic artery aneurysms, and the pathologic circulation associated
with various arteriovenous communications along the ophthalmic artery–cavernous sinus
complex. It is also useful to identify the feeding vessels prior to undertaking surgery in
patients with vascular orbital tumours.

3. Radioisotope studies.

These are, nowadays, sparingly employed. Radioisotope arteriography has been found useful
in proptosis of vascular lesions. In this technique, sodium pertechnetate Tc 99 m is injected
intravenously and its flow is visualised by a gamma scintillation camera.
IV. Histopathological studies

The exact diagnosis of many orbital lesions cannot be made without the help of
histopathological studies which can be accomplished by following techniques:

1. Fine-needle aspiration biopsy (FNAB).

It is a reliable, accurate (95%), quick and easy technique for cytodiagnosis in orbital tumours.
The biopsy aspirate is obtained under direct vision in an obvious mass and under CT scan or
ultrasonographic guidance in retrobulbar mass using a 23-gauge needle.

2. Incisional biopsy.

Undoubtedly, for accurate tissue diagnosis a proper biopsy specimen a least 5 to 10 mm in


length is required. However, the scope of incisional biopsy in the diagnosis of orbital tumours
is not clearly defined. It may be undertaken along with frozen tissue study in infiltrative
lesions which remain undiagnosed.

3. Excisional biopsy.

It should always be preferred over incisional biopsy in orbital masses which are well
encapsulated or circumscribed. It is performed by anterior orbitotomy for a mass in the
anterior part of orbit and by lateral orbitotomy for a retrobulbar mass.

ANATOMI

BONY ORBIT

The bony orbits are quadrangular truncated pyramids situated between the anterior cranial
fossa above and the maxillary sinuses below (Fig. 16.1). Each orbit is about 40 mm in height,
width and depth and is formed by portions of seven bones : (1) frontal, (2) maxilla, (3)
zygomatic, (4) sphenoid, (5) palatine, (6) ethmoid and (7) lacrimal. It has four walls (medial,
lateral, superior and inferior), base and an apex.

The medial walls

of two orbits are parallel to each other and, being thinnest, are frequently fractured during
injuries as well as during orbitotomy operations and, it also accounts for ethmoiditis being the
commonest cause of orbital cellulitis.

The inferior orbital wall (floor)

is triangular in shape and being quite thin is commonly involved in blowout fractures and is
easily invaded by tumours of the maxillary antrum.

The lateral wall of the orbit


is triangular in shape. It covers only posterior half of the eyeball. Therefore, palpation of the
retrobulbar tumours is easier from this side. Because of its advantageous anatomical position,
a surgical approach to the orbit by lateral orbitotomy is popular.

The roof

is triangular in shape and is formed mainly by the orbital plate of frontal bone.

Base of the orbit

is the anterior open end of the orbit. It is bounded by thick orbital margins.

The orbital apex

(Fig. 16.2). It is the posterior end of orbit. Here the four orbital walls converge. It has two
orifices, the optic canal which transmits optic nerve and ophthalmic artery and the superior
orbital fissure which transmits a number of nerves, arteries and veins (Fig. 13.2).

ORBITAL FASCIA

It is a thin connective tissue membrane lining various intraorbital structures. Though, it is one
continuous tissue, but for the descriptive convenience it has been divided into fascia bulbi,
muscular sheaths, intermuscular septa, membranous expansions of the extraocular muscles
and ligament of Lockwood.

Fascia bulbi

(Tenon’s capsule) envelops the globe from the margins of cornea to the optic nerve. Its lower
part is thickened to form a sling or hammock on which the globe rests; this is called
‘suspensory ligament of Lockwood’.

CONTENTS OF THE ORBIT

The volume of each orbit is about 30 cc. Approximately one-fifth of it is occupied by the
eyeball. Other contents of the orbit include: part of optic nerve, extraocular muscles, lacrimal
gland, lacrimal sac, ophthalmic artery and its branches, third, fourth and sixth cranial nerves
and ophthalmic and maxillary divisions of the fifth cranial nerve, sympathetic nerve, orbital
fat and fascia.

Oculus (mata) dan apparatus lacrimalis

Struktur-struktur utama oculus termasuk sclera, cornea, iris, dan pupil. Cornea merupakan
bersinambungan dengan sclera dan merupakan daerah bening yang sirkuler penutup eksternal
oculus yang melaluinya pupil dan iris dapat dilihat. Sclera tidak transparan dan normalnya
berwarna putih. Palpebra superior dan palpebra inferior tiap oculus saling membatasi rima
palpebrarum/fissura palpebralis. Palpebrae tersebut berkumpul bersama di comissura
palpebrarum medialis dan lateralis pada tiap sisi masing-masing oculus. Pada sisi medial rima
palpebrarum dan lateral dari comissura palpebrarum medialis terdapat struktur segitiga kecil
jaringan lunak (lacus lacrimalis). Peninggian jaringan pada sisi medial lacus lacrimalis
disebut caruncula lacrimalis, dan tepi lateral yang berada di atas sclera disebut plica
lacrimalis. Apparatus lacrimalis terdiri dari glandula lacrimalis dan sistem ductuli dan
saluran-saluran yang mengumpulkan air mata dan mengalirkannya ke dalam cavitas nasi
(Gambar 8.67C). Air mata membasahi dan mempertahankan transparansi cornea. Glandula
lacrimalis berhubungan dengan palpebra superior dan berada di cekungan kecil pada pries
superior bagian lateral orbita, tepat di posterior dari margo orbitalis. Banyak ductulus kecil
glandula yang bermuara pada tepi atas saccus conjunctivalis, berupa celah kecil di antara
permukaan dalam palpebrae dan cornea. Air mata menyapu ke arah medial pada oculus
dengan kedipan dan dikumpulkan dalam celah kecil (punctum lacrimale), masing-masing
satu pada palpebra superior dan inferior, di dekat lacus lacrimalis (Gambar 8.67C).

Setiap punctum berada pada peninggian kecil jaringan (papilla lacrimalis), dan merupakan
muara saluran kecil (canaliculus lacrimalis) yang menghubungkannya dengan saccus
lacrimalis (Gambar 8.67C). Saccus lacrimalis berada pada fossa sacci lacrimalis di sisi medial
orbita. Dari saccus lacrimalis, air mata mengalir melalui ductus nasolacrimalis ke dalam
cavitas nasi.
Persarafan

Persarafan glandula lacrimalis meliputi komponen-komponen yangberbeda (Gambar 8.68).

Persarafan sensorium

Neuron-neuron sensorius dari glandula lacrimalis kembali ke sistem saraf pusat melalui
nervus lacrimalis cabang nervus ophthalmicus [V1].

Persarafan sekretomotorium (parasympathicum)

Serabut-serabut sekretomotorium dari pars parasympathicum divisi autonomicae sistem saraf


tepi merangsang sekresi cairan dari glandula lacrimalis. Neuron-neuron parasympathicum
preganglionares keluar dari sistem saraf pusat pada nervus facialis [VII], memasuki nervus
petrosus major (cabang nervus facialis dan bersinambungan dengan nervus tersebut hingga
menjadi

Nervus canalis pterygoidei (Gambar 8.68 ).


Akhirnya nervus canalis pterygoidei bergabung dengan ganglion pterygopalatinum, tempat
neuron-neuron parasympathicum preganglionares bersinaps dengan neuron-neuron
parasympathicum postganglionares (Gambar 8.68). Neuron-neuron postganglionares
bergabung dengan nervus maxillaris [V2] dan bersinambungan dengannya sampai nervus
zygomaticus keluar sebagai cabangnya, dan berjalan dengan nervus zygomaticus sampai
nervus zygomaticus memberikan cabang nervus zygomaticotemporalis, yang akhirnya
mendistribusikan serabut-serabut parasympathicum postganglionares dalam cabang kecil
yang bergabung dengan nervus lacrimalis. Nervus lacrimalis berjalan menuju glandula
lacrimalis.

Persarafan sympathicum

Persarafan sympathicum glandula lacrimalis mengikuti perjalanan yang serupa dengan


persarafan parasympathicum. Serabut-serabut sympathicum postganglionares berasal dari
ganglion cervicale superius yang berjalan sepanjang plexus yang mengelilingi arteria carotis
interna (Gambar 8.68). Serabut-serabut ini keluar dari plexus sebagai nervus petrosus
profundus dan bergabung dengan serabut-serabut parasympathicum dalam nervus canalis
pterygoidei. Berjalan melalui ganglion pterygopalatinum, serabutserabut sympathicum dari
titik ini selanjutnya mengikuti jalur yang serupa dengan serabut-serabut parasympathicum
menuju glandula lacrimalis.

Pembuluh-pembuluh darah

Suplai arterial menuju glandula lacrimalis oleh cabang-cabang dari arteria ophthalmica dan
drainase vena melalui venae ophthalmicae.

Suplai arterial

Suplai arterial terhadap struktur-struktur di orbita, termasuk bulbus oculi, oleh arteria
opthalmica. Pembuluh darah ini merupakan sebuah cabang arteria carotis interna, yang
memberi cabang segera setelah arteria carotis interna keluar dari sinus cavernosus. Arteria
opthalmica berjalan ke dalam orbita melalui canalis opticus bersama dengan nervus opticus.

Dalam orbita mulanya arteria ophthalmica terletak di sisi inferior dan lateral dari nervus
opticus (Gambar 8.80). Saat berjalan ke depan di dalam orbita, arteria ini menyilang di
superior dari nervus opticus dan berlanjut ke anterior pada sisi medial orbita.

Dalam orbita arteria ophthalmica memberikan beberapa cabang sebagai berikut:

- arteria lacrimalis, yang keluar dari arteria ophthalmica pada sisi lateral nervus opticus, dan
berjalan ke anterior pada sisi lateral orbita, menyuplai glandula lacrimalis, musculi, cabang
cilaris anterior untuk bulbus oculi, dan sisi lateral palpebrae;

- arteria centralis retinae, yang memasuki nervus opticus, terus ke bawah pusat nervus
menuju retina, dan jelas terlihat saat melihat retina dengan oftalmoskop—sumbata pembuluh
darah atau arteria induknya akan menyebabkan kebutaan;

arteria ciliares posteriores longae dan arteriae ciliares

posteriores breves, merupakan cabang-cabang yang memasuki bulbus oculidi posterior,


menembus sclera, dan menyupali struktur-struktur di dalam bulbus oculi;

- arteria musculares, merupakan cabang-cabang yang menyuplai musculi intrinsik bulbus


oculi; segera setelah menyilang nervus opticus, berlanjut ke anterior, dan keluar dari orbita
melalui foramen supraorbitale bersama dengan nervus supraorbitalis__arteria ini menyuplai
regio frontalis dan scalp saat berjalan menyilang daerah-daerah tersebut menuju vertex
cranium;

- arteria ethmoidalis posterior, keluar dari orbita melalui foramen ehmoidale posteriorus
untuk menyuplai cellulae ethmoidales dan cavitas nasi;

- arteria ethmoidalis anterior, keluar dari orbita melalui foramen ethmoidale anterius,
memasuki cavitas cranii memberikan cabang ramus meningeus anterior, dan baerlanjut ke
cavitas nasi menyuplai septum dan dinding lateral, dan berakhir sebagai arteria dorsalis nasi;

arteria palpebrae mediales, merupakan cabang-cabang kecil yang menyuplai daerah medial
palpebra superior dan inferior;

- arteria dorsalis nasi, merupakan satu dari dua cabang terminal arteria ophthalmica, keluar
dari orbita untuk menyuplai permukaan atas hidung;

- arteria supratrochlearis, merupakan cabang terminal lain arteria ophthalmica dan keluar
dari orbita bersama dengan nervus supratrochlearis, menyuplai dahi saat melintasi dahi ke
arah superior.

Drainase vena

Terdapat dua saluran vena dalam orbita, vena ophthalmica superior dan vena ophthalminca
inferior
Fissura dan foramina

Beberapa struktur masuk dan keluar orbita melalui beberapa tulang

Canalis opticus

Ketika bangunan tulang orbita dilihat dari posisi anterolateral, lubang bulat pada apex orbita
berbentuk piramida orbita adalah canalis opticus, yang membuka ke dalam fossa cranii media
dan dibatasi di medial oleh corpus tulang sphenoidale dan di lateral oleh ala minor tulang
sphenoidale. Yang melewati canalis opticus adalah nervus opticus dan arteria ophthalmica
(Gambar 8.70).

Fissura orbitalis superior

Tepat di lateral dari canalis opticus terdapat celah berbentuk segitiga di antara pules superior
dan pules lateralis bangunan tulang orbita. Struktur ini disebut fissura orbitalis superior dan
memungkinkan struktur-struktur untuk berjalan di antara orbita dan fossa cranii media (lihat
Gambar 8.69). Berjalan melalui fissura orbitalis superior adalah cabang-cabang superior dan
inferior nervus oculomotorius [III], nervus trochlearis [IV], nervus abducens [VI], nervus
lacrimalis, nervus frontalis, dan nervus nasociliaris cabang nervus ophthalmicus [V1], dan
vena ophthalmica superior (Gambar 8.70).

Fissura orbitalis inferior

Yang memisahkan paries lateralis orbita dari paries inferior orbita adalah celah longitudinal,
fissura orbitalis inferior. Batas-batasnya adalah ala major tulang sphenoidale dan maxilla,
palatinum, dan zygomaticum. Fissura panjang ini memungkinkan adanya hubungan antara:

- orbita dan fossa pterygopalatina di posterior

- orbita dan fossa infratemporalis di medial

- orbita dan fossa temporalis di posterolateral

Berjalan melalui fissura orbitalis inferior adalah nervus maxillaris [V2] dan nervus
zygomaticus, vasa infraorbitalis, dan vena yang berhubungan dengan plexus venosus
pterygoideus.

Foramen infraorbitale

Dimulai di posterior dan menyilang sekitar 2/3 bagian fissura orbitalis inferior, terdapat
sebuah sulcus (sulcus infraorbitalis) yang berlanjut ke anterior menyeberangi paries inferior
orbita. Sulcus ini berhubungan dengan canalis infraorbitalis yang membuka ke regio facialis
pada foramen infraorbitale. Nervus infraorbitalis, sebuah cabang nervus maxillaris [V2], dan
pembuluh-pembuluh darah berjalan melalui struktur tersebut untuk kemudian keluar ke regio
facialis.
Musculi

Terdapat dua kelompok musculi dalam orbita:

- Musculi ekstrinsik bulbus oculi (musculi extraoculare)

yang terlibat dalam gerak bulbus oculi aatau mengangkat palpebrae,

- Musculi intrinsik

dalam bulbus oculi, yang mengontrol bentuk lensa dan ukuran pupil.

Musculi ekstrinsik termasuk levator palpebrae superioris, rectus superior, rectus inferior,
rectus medialis, rectus lateralis, obliquus superior, dan obliquus inferior.

Musculi intrinsik termasuk musculi ciliaris, sphincter pupillae, dan dilator pupillae.