The dog's eyeball suddenly fell off! ! !

Orbit is a non-telescopic bone cavity composed of parietal bone and craniofacial bone. The opening in front of the bone cavity is only closed by eyeball and orbital septum. The orbital cavity contains eyeball, extraocular muscles, optic nerve motor and sensory nerves, sympathetic and parasympathetic nerves, blood vessels, lacrimal gland and fibrous adipose tissue. The position of eyeball in orbit depends on the interaction of soft tissue in orbit. For example, the normal tension of blood vessels and oblique muscle of fat in retrobulbar tissue is the force to push the eyeball forward, while the tension of orbital septum and its smooth muscle and medial canthus and lateral canthus ligament can prevent the eyeball from advancing. The orbital cavity is closely related to adjacent tissues. The orbital apex communicates with the cranial cavity through the optic foramen and supraorbital fissure. The upper, inner and lower sides of the orbit are separated from the frontal sinus, ethmoid sinus and maxillary sinus respectively, and the nerves and blood vessels communicate with each other. Therefore, inflammatory tumor vascular lesions can spread between the orbit and the skull, while sinus tumors and inflammation often spread to the orbit and return to the facial vascular system through the ophthalmic vein. From the superior and inferior ophthalmic veins back to the cavernous sinus and cerebrovascular system; There is no valve in the facial vein from infraorbital fissure down to pterygoid vein plexus, so facial furuncle is easy to invade orbit and cavernous sinus. Therefore, the decrease of orbital volume, orbital bone deformity, orbital tissue edema and congestion or space-occupying lesions caused by any reason can lead to the increase of orbital content volume or the decrease of extraocular muscle tension, thus leading to exophthalmos.

(1) inflammation

Acute orbital cellulitis, panophthalmia, orbital periostitis, suppurative periostitis, cavernous sinus thrombosis, inflammatory pseudotumor, syphilis and tuberculosis.

(2) Tumor

1. Primary hemangioma dermoid cyst meningioma neurilemmoma glioma lymphoma lacrimal adenoma rhabdomyosarcoma orbital osteoma

2. Secondary eyeball and ocular adnexal tumor spread (retinoblastoma choroidal malignant melanoma eyelid conjunctival squamous cell carcinoma eyelid basal cell carcinoma malignant melanoma meibomian adenocarcinoma) spread from sinus (ethmoidal sinus or frontal sinus cyst maxillary sinus or ethmoidal sinus carcinoma) and metastasis from other organ tumors or hematological diseases (lung cancer, breast cancer, prostate cancer, green tumor).

(3) Vascular

Orbital and cavernous arteriovenous fistula orbital varicose veins

internal secretion

Graves' disease or exophthalmos

(5) trauma

Intraorbital hematoma of orbital fracture

(6) Parasitism

(7) Others

Common exophthalmos syndrome, such as Croizon syndrome (congenital craniofacial dysplasia), Grouber syndrome (craniofacial dysplasia), Apert syndrome (syndactyly), etc.

Diagnosis of exophthalmos:

Is exophthalmos unilateral or bilateral? Inflammatory or non-inflammatory bilateral non-inflammatory exophthalmos are mostly endocrine exophthalmos, followed by hematopoietic tumors-green tumors are rare, such as congenital orbital malformation (pointed malformation), bilateral inflammatory exophthalmos are seen in pseudotumor cavernous sinus thrombosis, unilateral inflammatory exophthalmos are seen in orbital cellulitis, orbital periostitis, pseudotumor dacryocystitis, and unilateral non-inflammatory exophthalmos are more common in orbital tumors, including benign and malignant tumors, with rapid development, severe pain, eyelid edema and edema.

History of disease

Ask about the medical history in detail, and whether there is red pain in the eyes from the onset time. The relationship between the location of red pain and exophthalmos is fast or slow. Do you have a history of unilateral or bilateral injuries, especially head injuries? The possibility of arteriovenous fistula should be considered.

physical examination

A general physical examination is very important. It is necessary to check the endocrine and blood system that can cause exophthalmos, and pay attention to whether there is inflammation in the paranasal sinuses and whether the tumor has primary tumors of other organs.

Eye examination: Pay attention to measuring vision, whether the width of palpebral fissure is smooth, whether there is a mass around the orbit, whether the eyelid conjunctiva is swollen and congested, whether there is eye movement, whether there is pulsation and posture relationship in the protruding direction, whether there is noise, and whether there is a mass with elastic texture, which may be cyst, hemangioma, meningocele, hard tumor and pseudotumor. Most tumors inside are mucinous cysts. Lacrimal gland tumor and dermoid cyst should be considered. When exophthalmos, glioma, neurofibroma, sphenoid bone and other early central visual impairment occur.

3. Inspection fee

Thyroid function examination is helpful to distinguish endocrine exophthalmos. Serum thyroxine (T4), triiodothyronine (T3) and thyrotropin (TSH) should be determined.

Hemogram examination includes peripheral hemogram and bone marrow examination, tumor puncture or biopsy.

Four instrument inspection

(a) measurement of spherical protrusion

Exophthalmos refers to the vertical distance between the vertex of cornea and the outer edge of both sides of orbit, which can be measured by Hertel exophthalmos meter.

(2) Image inspection

X-ray examination can show the changes of bone and orbital cavity and optic canal. Benign tumors can enlarge the orbit due to the long-term increase of orbital pressure, suggesting that hemangiomas and meningiomas of retinoblastoma can have calcification points on plain films of malignant tumors, suggesting that retinoblastoma has metastasized to the brain through the optic nerve. Glioma or optic nerve sheath meningioma can also have this manifestation. Ultrasonic exploration can show the fatty optic nerve in orbit with good soft tissue resolution. Extraocular muscle and superior ophthalmic vein, such as multiple extraocular muscle hypertrophy muscle, have more echoes, which are often Graves' disease. Strong echo light cluster appears weak echo or no echo area, which can be used as tumor diagnosis standard. CT scanning has higher density resolution and spatial resolution. Tumor inflammation, vascular malformation and other orbital diseases all show high-density shadows, and both orbital and periorbital structures can show magnetic resonance imaging, which is basically consistent with CT. Its soft tissue resolution is better than CTr camera scintillation photography and ECT observation. The metabolic process of cell absorption, utilization and excretion of nuclides, but the selectivity of each lesion to absorb nuclides is poor. DSA selective angiography is rarely used except for metastatic cancer, which is an essential examination method for diagnosing arteriovenous thinness and observing tumor blood supply.

Differential diagnosis of exophthalmos;

Inflammatory exophthalmos

(i) Orbital cellulitis

It is acute inflammation of orbital soft tissue or subperiosteal tissue. Because of the close relationship between orbit and cranial cavity eyeball, it can cause permanent visual impairment and intracranial complications. Most of them are caused by the spread of infection in adjacent tissues or traumatic infection. The clinical manifestations are exophthalmos and dyskinesia, accompanied by eyelid redness, conjunctival congestion and edema. There may be optic papilla congestion and edema and retinal edema in the fundus. In severe cases, the body temperature rises and leukocytosis may occur. Due to the mind's eye reflection, the speed may be relatively slow. Intraorbital inflammation can spread to cavernous sinus through venous supraorbital fissure. Cavernous sinus embolism can be formed, and its ocular manifestations are similar to cellulitis, but the poisoning symptoms are more serious and faster than cellulitis, and the contralateral intracranial pathological symptoms such as headache, irritability, delirium, convulsion and coma appear. In addition to exophthalmos, some orbital malignant tumors can also appear eyelid redness, and eye movement limitation is difficult to distinguish from orbital cellulitis. Therefore, attention should be paid to medical history and physical examination, and imaging examination is helpful for diagnosis.

(II) Inflammatory pseudotumor

It is one of the common causes of monocular exophthalmos, because it has the symptoms of tumor but is essentially nonspecific chronic proliferative inflammation of the orbit, so the cause of inflammatory pseudotumor is unknown. At present, most scholars think that it may be a clinical manifestation of immune-reactive diseases: exophthalmos or eyelid masses are discovered after weeks or months with a history of eyelid swelling. Some patients often can't remember the history of eyelid swelling, and some patients have a groove along the orbital margin due to the contraction of deep orbital scar. This sign is characteristic and can cause pain recovery. Vision loss, conjunctival congestion and edema, inflammation caused by inflammation and adhesion of extraocular muscles, mainly in the orbital floor, can make the eyeball move up. Those with severe dyskinesia can touch a lump with unclear hard boundary in the deep orbit, and there may be papillae edema or optic atrophy in the fundus. Therefore, any clinical manifestations with tumor and inflammation indicate that the disease has no bone damage. CT scan shows that the eye muscles are hypertrophy and the eye wall is cast, which is helpful to diagnose orbital inflammatory pseudotumor and benign tumor. The latter develops slowly, without inflammation, and the early vision and eye movement are not affected. CT scan shows that the clinical manifestations and imaging examination of pseudotumor with localized space occupying lesions in orbit are similar to those of malignant tumor. Sometimes, we need to rely on biopsy to diagnose pseudotumor and severe endocrine exophthalmos. Both orbital tissues are hyperemia and infiltration, but abnormal thyroid function examination of upper eyelid retraction is the main point of diagnosis of endocrine exophthalmos.

Tumor exophthalmos

(1) hemangioma

It is the most common benign tumor of orbit, especially cavernous hemangioma, which is common in adults and painless chronic progressive exophthalmos. Its characteristic is that the tumor is mostly located in the muscle cone and the eyeball protrudes forward. Occurred in the orbital apex, early visual loss may occur. When they are located in the anterior part of the orbit, they can bulge locally, and smooth and moderate hardness tumors can increase eye movement. If the tumor compresses the optic nerve base, the optic nerve papillae edema or optic nerve atrophy will appear at the base. X-rays such as membrane edema and choroidal folds showed that the orbital volume increased and the density increased. B-ultrasound can show that the orbital boundary is clear and abnormal, and the internal reflection is strong, uniform and compressible. CT scan can show that there are often masses with quasi-circular density and high edge in orbit. When the CT value is between 40 and 60 hours, the orbital cavity often increases. The position and shape seen by magnetic resonance imaging are the same as those seen by CT. According to the medical history, signs and imaging examination, ultrasound and CT scanning are of great value in diagnosing how difficult it is.

This disease should be differentiated from intermittent exophthalmos. The latter can be divided into primary and secondary. The primary disease is congenital venous malformation, and exophthalmos appears when growing up. Followed by orbital or intracranial arteriovenous short circuit, pulsation or audible murmur. When the jugular vein is depressed, severe cough and deep breathing can cause obvious exophthalmos on the affected side. The eyeball recovers quickly in an upright state, usually showing enophthalmos. This is because the orbital fat has been compressed and shrunk for a long time, and the B-ultrasound image is normal in upright position or supine position. Only the orbital fat pad contracts. When the neck is compressed, the lesion is an irregular dark area with almost no reflection. CT scan may show venous stones. After the neck was compressed, the lesion showed irregular and high-density occupying unevenness. This disease needs to be differentiated from pulsating exophthalmos. The latter is more common in aneurysms with cavernous sinus and arteriovenous communication. Have a history of head injuries. 30% patients have headache, which is characterized by unilateral eyeball protruding forward and pulsating with the contraction and contraction mode of the heart. It is not difficult to distinguish between a cat's wheezing, auscultation and pulsation.

(2) lacrimal gland tumor

It is a common orbital tumor, which can be divided into lacrimal gland mixed tumor and lacrimal gland mixed tumor. It can be divided into benign tumor and malignant tumor. Benign tumors account for 80% of patients aged 35-50, and unilateral diseases progress slowly. In the early stage, most asymptomatic tumors begin in the eyelids. The tumor started from the orbit, located under the eyelid, without exophthalmos. When the tumor begins to grow from the orbit, the protrusion on the outer upper edge of the orbit squeezes the eyeball and shifts to the lower nose. In the late diplopia, it can compress the blood vessels of the eyeball and affect the retina or optic nerve. Malignant mixed lacrimal gland adenocarcinoma, also known as columnar tumor of lacrimal gland, has more middle-aged women than men, and its main feature is that the eyeball protrudes inward and downward. It has spontaneous pain and tenderness, and tumor tissue often infiltrates the surrounding tissues along nerves and blood vessels, destroying the bone wall. The prognosis is very poor. It can be diagnosed by distant metastasis or diffusion of blood or lymph. Puncture biopsy can be confirmed by pathology.

(3) dermoid cyst

Orbit is one of the most common parts of dermoid cyst, which is caused by skin invagination during embryonic development. It usually occurs at the seam of skull bone. The round surface is smooth, firm and elastic, and it grows slowly in adolescence, which is asymptomatic exophthalmos. Most cases can be correctly diagnosed by X-ray plain film. The orbital bone is thinned due to cyst, and there is a circle of well-defined white hardening line at the edge, which is characterized by frontethmoid suture or zygomatic fronto-suture at the pterygoid end of sphenoid bone.

Dermatoid cyst should be distinguished from encephalocele. The latter is that the skull contents protrude into the orbit through the defective skull, which is less common. It is most common in the upper orbital margin, and the nasal root touches the systolic pressure consistent with the pulse, accompanied by brain symptoms such as bradycardia, convulsions and coma. When coughing, the hardness of the tumor increases. X-ray plain film must have bone defect. Dermatoid cysts should also be distinguished from lateral fluid cysts. The latter is due to the accumulation of lateral fluid secreted by paranasal sinusitis, which leads to slow growth. Exophthalmos is unilateral. Patients with different frontal sinuses protruding toward the cyst make the eyeball move outward and downward, patients with anterior ethmoid sinus make the eyeball move forward and outward, and patients with posterior ethmoid sinus and sphenoid sinus make the eyeball protrude forward, which may cause nerve paralysis. X-ray shows that the enlarged bone plate of paranasal sinuses is thin and bubbly.

(4) Meningioma

1/ 3 or extending from intracranial meningioma. Women usually invade one side, mostly benign and occasionally malignant. If it is malignant, it grows slowly. If it is malignant, it grows quickly. Because tumors often originate from the optic sheath at the orbital apex, there are visual impairment and eye movement limitation in the early stage. From sphenoid ridge, unilateral exophthalmos, early papillae edema, visual field, ophthalmoplegia and olfactory disturbance may occur. X-ray film shows that the optic foramen at the orbital apex and anterior clinoid process can be enlarged with hyperosteogeny. CT scan showed thickening of optic canal. Magnetic resonance imaging (MRI) is superior to CT in the diagnosis of optic canal and intracranial dissemination of high-density masses whose orbital apex expands around the optic nerve or cone-shaped high-density shadows reach the orbital apex or see cranio-orbital communication.

(5) neurilemmoma

Schwann cell proliferation in nerve sheath is common in adults, and most of them are benign, mostly from muscle cone or upper orbit, which leads to eyeball protruding forward or shifting downward. Those with motor nerves are early dyskinesia, and those with spontaneous pain and tenderness at the orbital apex are early vision loss and optic atrophy, which should be differentiated from hemangioma. Ultrasonic exploration is helpful to diagnose the sonogram, which is characterized by less echo, strong sound transmission and no deformation of the probe, and is helpful to distinguish neurilemmoma.

(vi) Optic glioma

It is common in children. Before 10, 75% of women had painless unilateral exophthalmos. The course is slow. There is visual impairment in front of the process, and papilla edema or optic atrophy can be seen. If the tumor spreads to the chiasma, it will affect the contralateral visual field. Because the optic nerve thickens and hardens, it will also affect eye movement. Both B-ultrasound and CT scan can show spindle enlargement of optic nerve, and magnetic resonance imaging can show diffusion in optic canal.

(vii) Orbital sarcoma

Malignant tumors originating from mesoderm leaves are called sarcomas, 65% of which occur before the age of 20, and the incidence rate rises again after the age of 40. Sarcoma originated from musculoskeletal fascia or was transferred by it. The most common malignant tumor in childhood is rhabdomyosarcoma, which has pain first, then rapid and highly prominent eyeball, edema of eyelid bulbar conjunctiva, and tenderness in the early stage, that is, eye movement disorder is easy to destroy bone wall, sinus and skull, with high malignancy. B-ultrasound showed hypoechoic or anechoic lesions in orbit with unclear boundary. CT scan and magnetic resonance imaging showed that the tumor shape was as follows

(viii) Orbital cancer

Clinical manifestations and imaging examination are helpful to diagnose the primary tumor of metastatic cancer, especially breast cancer and lung cancer. Elderly people with a history of cancer with unilateral exophthalmos and diplopia should be carefully examined to exclude metastatic cancer.

Three kinds of endocrine exophthalmos

Thyroid toxic exophthalmos

It is a disease which is composed of exophthalmos, diffuse goiter and hyperthyroidism, and it is more common in middle-aged women. Another clinical manifestation is that there are only eye signs and no previous history of hyperthyroidism. Thyroid function test is normal or low. The ocular manifestations of GraVes' disease are eyelid edema, atrophy and delayed conjunctival congestion. The eyeball protrudes forward, the convergence movement is poor, and the blink reflex is reduced. Imaging examination showed symmetrical swelling of extraocular muscles, especially coronal CT scan. The determination of serum T3T4TSH, T3 inhibition test and TRH test are all helpful for the diagnosis of exophthalmos.

(2) thyrotropin exophthalmos

Also known as malignant exophthalmos or infiltrative exophthalmos, most of them are middle-aged men. Binocular diseases often occur in hypothyroidism or hyperthyroidism, and become hypothyroidism after drug or surgical treatment, resulting in weakened pituitary feedback inhibition. Hyperthyroidism patients can also have increased secretion of thyrotropin, and hyperthyroidism patients can also have increased thyrotropin. Bed pain, conjunctival edema, conjunctival protrusion, blepharoptosis, corneal exposure, eyeball fixation.

Prevention of exophthalmos:

There are many reasons for exophthalmos, and the treatment principles are different. Patients with exophthalmos should go to the ophthalmology department of the hospital in time to find out the types and specific causes of exophthalmos and treat them, especially those caused by trauma. If left untreated, the eyeball will further protrude, causing exposure keratitis and damaging vision, especially the eyeball protrusion caused by malignant tumor, which can cause distant metastasis and endanger life.