Orbital diseases of the dog and cat: A case based discussion (Proceedings)

Orbital disease can be a challenge to diagnose and treat appropriately. Only the more common acquired and pathologic orbital conditions will be discussed within the scope of this lecture.

Changes in globe position characterize orbital disease, and are readily identified in most cases as facial asymmetries. Clinical examination is the most important single diagnostic technique. Direct orbital palpation and globe retropulsion can also be performed for diagnostic purposes. Since dogs and cats lack bony ventral orbital structures, an oral exam, usually under sedation, is considered part of a complete orbital exam. Signs of pain on orbital and/or oral examination are clinically relevant and should be noted. Although radiography is occasionally helpful, more advanced orbital imaging techniques like ultrasound, computed tomography (CT), and Magnetic Resonance Imaging (MRI) are more useful in most cases. The information obtained from imaging helps guide sample collection, such as for cytology, culture and sensitivity, and histopathology.

Exophthalmia, or anterior displacement of the globe, is the most common orbital condition and must be differentiated from buphthalmia, or globe enlargement. Enophthalmia, or inward sinking in of the globe, occurs less commonly as a pathologic entity, and must be differentiated from a phthisical or shrunken globe, as well as from exophthalmia of the contralateral globe. Strabismus (globe deviation) and globe displacement represent related, but slightly different, abnormalities of globe position, and may be associated with exophthalmia.

Exophthalmic globes may grossly bulge or simply be relatively resistant to manual retropulsion when compared to the contralateral eye. Indentation of the caudal globe may be identified by ophthalmoscopy. Intraocular pressure elevation may or may not occur due to compression of the globe by surrounding tissues. Secondary keratitis due to increased exposure is common. Fortunately for diagnostic reasons, exophthalmia is almost always unilateral in nature. The more common differentials for acquired exophthalmia in dogs include orbital cellulitis/abscess, orbital neoplasia, salivary cyst/mucocele, hematoma, and extraocular muscle myositis. The latter condition is a rare condition seen only in dogs, while the former conditions apply to cats as well. Extraocular muscle (EOM) myositis is also the exception in that it is bilateral in nature, unlike most cases of exophthalmia. It is an autoimmune condition in which both eyes grossly protrude, and is typically seen in Golden Retrievers. Orbital imaging will reveal dramatic enlargement of the major extraocular muscles. There is some risk associated with the biopsy of these small muscles, but results may be diagnostic. Treatment via systemic immunosupression is usually at least initially successful, if the disease is caught in its acute stages, before muscle fibrosis and atrophy occur. The combination of good history-taking and general physical exam with indications of trauma, should provide an index of suspicion for orbital hematoma, which can be supported by ultrasound, treated presumptively, and further diagnostics be pursued only if nonresponsive to time and treatment.

Diagnostic efforts in most cases of unilateral exophthalmia in the dog and cat should be aimed at differentiating orbital inflammatory disease (infectious cellulitis, abscess, cellulitis secondary to salivary mucocele) from orbital neoplasia. Orbital inflammatory disease most commonly occurs in young febrile animals, for which jaw excursion and globe retropulsion elicits pain; while the opposite is true of small animal patients with orbital neoplasia- they are usually older, afebrile, and painless. Inflammatory disease is typically acute in nature, whereas neoplasia tends to be gradually progressive. These are not hard and fast rules, and should be interpreted with caution. Following an initial clinical exam, including an oral exam, imaging is usually indicated. Orbital ultrasound can often help to differentiate inflammatory from neoplastic disease. Cystic structures, such as seen with true orbital abscess, are readily identified in this manner. Unfortunately a more generalized inflammatory process, cellulitis, is a more common manifestation of septic retrobulbar infection than organized abscess. Sometimes orbital foreign bodies may be identified within the retrobulbar space as well, in association with the inflamed soft tissues. Advantages of ultrasound include relatively low expense compared to CT and MRI, lack of need for general anesthesia, and its usefulness in guiding biopsy and aspiration. Its major disadvantages are lack of specificity and inability to provide a clear idea of extent and origin of neoplastic lesions. MR imaging is ideal for most orbital lesions, although CT may be preferred if bony involvement is suspected. In a study of 25 patients with orbital disease, 22/25 were correctly diagnosed with MRI alone, in the absence of confirmatory diagnostic tests, whereas radiography was useful only for advanced neoplasms extending out of the orbit, and ultrasound gave both false positive and negative results (Dennis R).

Ultimately, orbital neoplasia requires histopathologic confirmation, although locational information can provide clues. Orbital neoplasms occur ventromedially most commonly, which reflects secondary invasion from the nasal cavity or sinuses (Mason et al). Considering normal anatomy, dorsolateral location may suggest lacrimal gland origin, anterior ventromedial location may suggest third eyelid gland origin, and a ventral lesion could suggest salivary gland origin. These sorts of masses result in globe deviation or displacement, which can be seen clinically. Masses within the orbital cone, on the other hand, result in a direct anterior displacement of the globe, without alteration in globe position or third eyelid elevation, and are commonly associated with blindness. An optic nerve tumor would be expected to have this presentation. Regardless of location, biopsy (preferably) or fine needle aspirate of the mass is required for diagnostic purposes. Unfortunately, the vast majority (>90%) of orbital neoplasms in dogs and cats are malignant, and diagnosed at an advanced stage. Extent, anatomic origin, evidence of metastatic spread, and histopathologic diagnosis, are important factors affecting prognosis. As for most neoplasia, referral to an oncologist for staging and the most up-to-date treatment options is ideal.

Orbital abscess/cellulitis is usually most readily sampled through an oral approach, and this allows a gravity-aided drainage for therapeutic purposes as well. A blade or needle may be inserted into the soft tissues behind the last upper molar tooth to obtain samples for cytology and culture, and the surgical wound widened through insertion and subsequent opening of hemostatic forceps. With a true abscess, grossly visible "pus" is seen, and its drainage, combined with appropriate medical therapy, results in rapid resolution in most cases. Diffuse bacterial cellulitis does not result in visible extrusion of fluid, but the open wound combined with medications still results in a high rate of rapid and permanent resolution. A viscous fluid may be obtained in the case of zygomatic salivary mucocele or cyst. While performing the drainage procedure, the teeth should be examined and dental radiographs performed if tooth root origin suspected. Culture results help guide antibiotic therapy, although broad-spectrum empirical choices should be made initially. Simultaneous systemic anti-inflammatory therapy is usually indicated to help more rapidly reduce periorbital swelling, which is likely to be further exacerbated by the sampling process. Temporary tarrsorrhaphy can be performed to protect the globe from exposure until retrobulbar inflammation is reduced and the globe returns to its normal position. Recurrence suggests resistant infection, retained foreign material, or localized etiology (for example: tooth or sinus disease) requiring further diagnostic effort.

Enophthamia is much less common than exophthalmia. Enophthalmia with secondary third eyelid elevation has been associated with ocular pain, such as occurs with corneal ulceration. Miosis, ptosis, and enophthalmia with third eyelid elevation are neurologic signs associated with the sympathetic denervation characteristic of Horner's syndrome. Acute unilateral presentation may indicate traumatic origin, such as occurs from orbital bone fracture or iatrogenic trauma from dental cleanings. Age or trauma-related orbital soft tissue atrophy may result in progressive enophthalmia. In the earlier stages, the problem is primarily cosmetic, but later secondary entropion and vision-impairing third eyelid elevation can occur. Neoplasia within the anterior orbit can also result in enophthalmia.

Case discussion is used to illustrate the above principles of diagnosis of orbital diseases in the dog and cat.