22/09, 6:37 PM

( Proptosis )

- Proptosis due To increse Intraorbital Pressure

( Axial or Non Axial )

- Axial Proptosis is Due to Intaconal Lesions .

- Non-Axial : Due To Extraconal

- Proptosis : Any Organ Including The Eye .

- Exophtalmos : Due To Graves Disease .

- PseudoProptosis : In Eyelid Retraction , High

Myopia ( Axial ) & Contralateral Enophthalmos .
22/09, 6:37 PM

Eyelid Retraction : Normal Eyelied = Upper Covers

2mm of Cornea , Lower reaching The Limbis .

$ Clinical Picture :

1 - History : P

Pain , Progression , Truma , Past Medical ( CA ,

DM , Thyroid )

2- Examination :
22/09, 6:37 PM

A - Proptosis Or PseudoProptosis ?

- Hertel Exopthalmometer :

- Normally : 15-17 mm
- Proptosis : >20mm Or >2mm Difference
Between The 2 Eyes .
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- Ruler Test
- Nafzigers Method : ‫ﺗﺠﻲ ﻣﻦ ورى اﻟﻤﺮﻳﺾ‬

Globe ‫ واﻟـ‬Frontal Bridge ‫ واﻟـ‬Eyebrow ‫اﻟﻄﺒﻴﻌﻲ ﻳﻜﻮن اﻟـ‬

. ‫ﻣﺘﻮازﻳﻴﻦ‬

B- Pulsation :

- Tonometer or Stethescop
- Bruit ( Caroid Cavernous Fistula )
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C- Palpation :

- Consistency ( Tuomr ) , Temperature

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D - Periorbital Changes :

Note : Corkscrew Conjunctival Blood vessels Sign

of ( Carotid Cavernous Fistula Is Associated With
6th Nerve Palsy ).

E- Other Test :

Vesion ‫اﻟﻤﻬﻢ أﺣﺎﻓﻆ ﻋﲆ اﻟـ‬

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- Corneal Examination

- Follow Up By Optic Nerve Function : VA,Color ,

Contrast , RAPD , VF ( Compressive Optic
neuropathy ), Early Central Scotoma ( Detected
By VF )

- Ocular Motility : Paralytic Or Restrective

- Forced Duction : Determin Paralytic Or

Restrective .

- Braleys Sign :

‫ وﺑﻌﺪﻳﻦ ﺗﻘﻴﺴﻪ ﻓﻲ‬Primary Position ‫ ﻓﻲ اﻟـ‬IOP ‫ﺗﻘﻴﺲ اﻟـ‬

6> ‫ ﻟﻮ‬Restrective ‫ ﻳﻌﻨﻲ‬6< ‫ ﻟﻮ اﻟﻔﺮق‬، Limitation ‫إﺗﺠﺎه اﻟـ‬
. Paralytic ‫ﻳﻌﻨﻲ‬

F - Orbital Imaging :

‫ﻣﻬﻢ ﺟﺪاً وﻻزم ﺗﻌﻤﻠﻪ ﺣﺘﻰ ﻟﻮ ﻣﺘﺄﻛﺪ ﻣﻦ اﻟﺘﺸﺨﻴﺺ‬

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B-Scan : Limited Uses , For EOM

- CT : Bone Hyper & Soft Tissue Hypo

Beter For Fracture + Hemorrhage + Tissue Close

To Bone

- MRI : Bone Hypo & Soft Tissue Hyper

Better for Soft Tissue + Globe + Muscles + Brain +

Cavernous Sinus

vitreous ‫ زي اﻟـ‬Hypo ‫ ﻓﻲ اﻟﺮﻧﻴﻦ‬Fliud ‫ ﻳﻄﻠﻊ ﺷﻜﻞ اﻟـ‬T1 ‫اﻟـ‬

. Hyper ‫ ﺗﻄﻠﻊ‬Fluid ‫واﻷﺷﻴﺎء اﻟﻠﻲ ﻣﺎ ﻓﻴﻬﺎ‬

. T1 ‫ ﻋﻜﺲ اﻟـ‬T2 ‫اﻟـ‬

World War 2 : Water White In 2

- T1 : In Orbital Myositis ( Muscle has Low Water

Content )
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- T2 : In Thyroid To See EOM , Superior Opthalmic

Vein ( Carotid Cavernous Fistula )

In Ophthalmology CT Almost Enough

$ Causes Of Proptosis :

- Is it Bilateral Or Unilateral ?

- Most common In Both Is Thyroid Eye Disease

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( Thyroid Eye Disease )

- Auto-immune

‫ ﺿﺪ اﻟـ‬antibodies ‫ أﻧﻮاع ﻣﻦ اﻟـ‬3 ‫أﻛﺘﺸﻔﻮا أﻧﻪ ﻳﻄﻠﻊ واﺣﺪ ﻣﻦ‬

Thyroid Gland

، thyroid stimulating immunoglobulin ‫اﻟﻨﻮع اﻷول ﻫﻮ‬

T3 ‫ وﺗﺰﻳﺪ أﻓﺮاز‬stimulation ‫ وﺗﻌﻤﻞ‬Thyroid Gland ‫ﻳﺮوح ﻟﻠـ‬
Graves disease ‫ وﻧﺴﻤﻴﻬﺎ‬Hyperthyrodism ‫ ﻓﺘﻌﻤﻞ‬T4 ‫و‬
. Occuler Manifestation ‫ﻟﻮ ﺣﺼﻞ‬

Orbit ‫ ﻓﻲ اﻟـ‬Fibroblast ‫اﻟﻤﺸﻜﻠﺔ أﻧﻪ أﻳﻀﺎً ﻳﺘﻔﺎﻋﻞ ﻣﻊ اﻟـ‬

Actaviation ‫وﻳﻌﻤﻞ ﻟﻬﺎ‬

‫ ﻳﺮوح ﻟﻠـ‬thyroid peroxidase antibodies ‫اﻟﻨﻮع اﻟﺜﺎﻧﻲ ﻫﻮ‬

‫ وﻳﻘﻠﻞ أﻓﺮاز‬Coloid ‫ ﻟﻠـ‬Destriction ‫ وﻳﻌﻤﻞ‬Thyroid Gland
ً‫ و اﻟﻤﺸﻜﻠﺔ أﻧﻪ أﻳﻀﺎ‬Hypothyrodism ‫ وﻳﻌﻤﻞ‬T4 ‫ و اﻟـ‬T3 ‫اﻟـ‬
‫ وﺗﻌﻤﻞ ﻟﻬﺎ‬Orbit ‫ ﻓﻲ اﻟـ‬Fibroblast ‫ﻳﺘﻔﺎﻋﻞ ﻣﻊ اﻟـ‬
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Actaviation

‫ ﻓﻲ‬Fibroblast ‫ ﺗﺮوح ﻟﻠـ‬immunoglobulin ‫اﻟﻨﻮع اﻟﺜﺎﻟﺚ ﻫﻮ‬

. Thyroid Gland ‫ ﺑﺪون ﻣﺎ ﺗﺄﺛﺮ ﻋﲆ اﻟـ‬Orbit ‫اﻟـ‬

‫ أو‬Hyper ‫ ﻣﺎﻟﻬﺎ ﻋﻼﻗﺔ ﺑـ‬Ocular manifestation ‫اﻟـ‬

Euothyrodism ‫ أو‬HypoThyrodism

EOM ‫ ﻓﻲ اﻟـ‬Fibroblast ‫ ﻟﻠـ‬Actaviation ‫اﻟﻔﻜﺮة أﻧﻪ ﻳﻌﻤﻞ‬

Deposation ‫ وﻳﻌﻤﻞ‬، ‫ وﻳﻜﺒﺮ ﺣﺠﻤﻬﺎ‬Fibrosis ‫وﻳﺤﺼﻞ ﻓﻴﻬﺎ‬
‫ ﻳﺴﺤﺐ‬Hydrophilic ‫ وﻫﻮ‬Glycosaminoglycans ‫ﻟﻠـ‬
Orbit ‫ داﺧﻞ اﻟـ‬Edema ‫اﻟﺴﻮاﺋﻞ ﻣﻦ اﻟﺪم ﻟﻠﻌﻀﻼت وﻳﻌﻤﻞ‬
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‫ ﻓﻲ اﻟـ‬Fat Deposetion ‫ أﻳﻀﺎً ﻳﻌﻤﻞ‬، Proptosis ‫ﻓﻴﺤﺼﻞ اﻟـ‬

. Orbit

- 90% Of Thyroid Eye Disease associated With

Hyperthyrodism , 10% With Euthyroid and
Hypothyroid ( Hashimoto )

$ Risk Factors :

- Smoking , Stress , More in Women's .

$ Phases Thyroid Eye Disease :

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Quiescent Phases ‫ﻧﺘﺪﺧﻞ ﻟﻠﻌﻼج اذا وﺻﻠﺖ اﻟﻤﺮﻳﺾ ﻟﻠـ‬

initial Phase ‫ وأﺣﻴﺎﻧﺎً ﻧﺘﺪﺧﻞ ﻟﻠﻌﻼج ﻓﻲ اﻟـ‬، ‫وﻣﺎ ﺗﺤﺴﻦ ﻛﺜﻴﺮ‬
‫ أو‬Exposure Keratopathy ‫ ﻣﺜﻞ‬Complications ‫ﻟﻮ ﻋﺎﻣﻞ‬
. Compressive Optic Neuropathy ‫دﺧﻞ ﻓﻲ‬

$ Clinical Picture :

A- Soft Tissue Involvement : First

‫ ﻳﺄﺛﺮ ﻋﲆ‬Soft Tissue ‫ ﻟﻠـ‬inflammatory Reaction ‫ﻳﺼﻴﺮ‬

‫ وﻏﺎﻟﺒﺎً ﺗﻌﺪي ﺑﺪون ﺗﺸﺨﻴﺺ‬Cornea ‫ واﻟـ‬Conj
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Focal Hypermia Outline Recti Insertion ‫اﻻ اذا ﺣﺼﻞ‬

limbus ‫ ﺑﻴﻨﻬﺎ وﺑﻴﻦ اﻟـ‬Clear Zone ‫وﻓﻴﻪ‬

B - Lid Retraction 90% : Second

‫ ﻳﺒﺪأ ﻳﻈﻬﺮ‬، Levator ‫ ﻫﻲ اﻟـ‬Fibrosis ‫أول ﻋﻀﻠﺔ ﻳﺼﻴﺮ ﻓﻴﻬﺎ‬

T4 ‫ و‬T3 ‫ ﺣﺘﻰ ﻗﺒﻞ ﻣﺎ ﻳﺰﻳﺪ‬Hyperthrodism ‫ﻗﺒﻞ أﻋﺮاض اﻟـ‬
. ‫ ﺷﻬﺮ‬12 - 6 ‫ ﺑـ‬Tyroid Gland ‫وﺣﺘﻰ ﻗﺒﻞ ﻣﺎ ﺗﺘﻬﺎﺟﻢ اﻟـ‬

Lid Retraction ‫ﺗﺮﺗﻴﺐ اﻟﻌﻼﻣﺎت اﻟﻠﻲ ﺗﺼﻴﺮ ﻟﻠـ‬

Lid Retraction In Primary ‫ وﻫﻲ‬Dalrymple Sign ‫اﻟـ‬

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‫‪position .‬‬

‫اﻟـ ‪ Kochers Sign‬ﻳﺒﺤﻠﻖ واﻟﺴﺒﺐ أن اﻟـ ‪Lower Eyelied‬‬

‫أﻳﻀﺎ ﺻﺎر ﻓﻴﻬﺎ ‪. Fibrosis‬‬

‫اﻟـ ‪ Von Graefes Sign‬ﻳﺼﻴﺮ ‪ Lid Lag‬ﻟﻤﺎ اﻟﻤﺮﻳﺾ ﻳﻄﺎﻟﻊ‬

‫ﺗﺤﺖ وﻧﺴﻤﻴﻬﺎ ‪. Scleral Show‬‬

‫ﺑﻌﺪﻳﻦ ﺗﺒﺪأ ﺗﺘﺄﺛﺮ اﻟـ ‪ ، EOM‬وأول ﻋﻀﻠﺔ اﻟـ ‪ IR‬وﻣﺎ ﺗﺒﻴﻦ ﻣﻌﻨﺎ ‪،‬‬
‫وﻟﻜﻦ ﺑﻌﺪﻫﺎ اﻟـ ‪ MR‬وﺗﺒﻴﻦ ﻓﻲ اﻟـ ‪ Moebius Sign‬وﻫﻮ ‪Lack‬‬
‫‪. Of Convergence‬‬

‫ﺑﻌﺪﻳﻦ ﻳﺼﻴﺮ ‪ Fibrosis‬ﻓﻲ اﻟـ ‪ Orbicularis‬وﺗﺒﻴﻦ ﻓﻲ اﻟـ‬

‫‪ Steallwag Sign‬وﻫﻮ ‪incomplete & Infrequent‬‬
‫‪ ) Blinking‬ﻳﺒﺤﻠﻖ وﻣﺎ ﻳﺮﻣﺶ ﺑﺎﻟﺸﻜﻞ اﻟﻄﺒﻴﻌﻲ ‪ 15‬ﻣﺮة ﻓﻲ‬
‫اﻟﺪﻗﻴﻘﺔ (‬
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‫ وﻟﻜﻦ‬، ‫ ﺷﻬﺮ‬12-6 ‫ ﺧﻼل‬Lid Retraction ‫اﻟﻤﻔﺮوض ﻳﺘﺤﺴﻦ اﻟـ‬

. ‫ ﻧﻌﺎﻟﺞ ﻣﺒﺎﺷﺮة‬Complication ‫ﻟﻮ ﻓﻴﻪ‬

$ Managment Of Lid Retraction :

A- Upper Eyelid

1- First Line : Mullerotomy ( Cut The Insertion ) =

Lower the Lid by 2 mm , If we Need >2 ?

2- Mullerotomy + Levator Tenotomy :

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‫اﻟـ ‪ Levator Tenotomy‬ﺗﻌﻤﻞ ‪ Partial Incision‬ﻣﻦ اﻟﺠﻨﺐ‬

‫ﻋﺸﺎن ﺗﺼﻴﺮ أﻃﻮل ﻳﻨﺰل اﻟـ ‪ Eyelid‬ﺑﻤﻘﺪار ‪ 3mm‬ﻟﻮ ﺗﺤﺘﺎج‬
‫‪ 4mm‬ﺗﺤﻂ ‪Spacer‬‬

‫ﻟﻮ أﺣﺘﺠﺖ أﻛﺜﺮ ﻣﻦ ‪ 4mm‬؟‬

‫‪3- Levator Z Myotomy :‬‬

‫ﺟﻤﻴﻊ اﻟﻌﻤﻠﻴﺎت اﻟﺴﺎﺑﻘﺔ ‪ Permenant‬ﻧﺴﻮﻳﻬﺎ اذا ﻓﻴﻪ‬

‫‪ Complication‬أو ﺑﻌﺪ ﻣﺎ ﺗﺘﻌﺪى اﻟـ ‪Quiescent Phase‬‬
‫ﺑﺪون ﺗﺤﺴﻦ ‪.‬‬
22/09, 6:37 PM

4- Lateral Tarsorrhaphy
5- Botox inj in Levator : 3 Month

B- Lower Eyelid :

‫ ﻧﺮﺟﻌﻬﺎ ﻟﻮرى‬Lower Lid Rectatores ‫ ﻟﻠـ‬Recession ‫ﻧﻌﻤﻞ‬

. Spacer ‫وﻣﻤﻜﻦ ﻧﺤﻂ‬

C- Exophthalmous 70% : Axial Proptosis

22/09, 6:37 PM

$ Management Of Exophthalmous :

- Systemic Steroid : 60mg To 80mg Day for 3 Days

to 2 Weeks , If No improvment Give Iv
Methylprednislon 500mg in 200cm NS in 30 Min
( Decrease Proptosis in 24 H ) , If No Improvment ?

-Irradiation : Destriction of fibroblast &

Glycosaminoglycans , If No Improvment ?

- Orbital decompression :

Nasal ‫ ﻳﻔﺘﺢ ﻟﻚ ﻋﲆ اﻟـ‬Medial Wall ‫ﺗﺸﻴﻞ ﺟﺰء ﻣﻦ اﻟـ‬

‫أﻳﻀﺎ‬
ً ‫ وﺗﺸﻴﻞ‬، Orbital Fat ‫ وﺗﻌﻄﻲ ﻣﺴﺎﺣﺔ ﻛﺒﻴﺮة ﻟﻠـ‬Sinisus
‫ وﻟﻮ ﻣﺶ ﻛﻔﺎﻳﺔ ؟ ﺗﺸﻴﻞ ﺟﺰء ﻣﻦ اﻟـ‬, Lateral Wall ‫ﺟﺰء ﻣﻦ اﻟـ‬
‫ و ﺟﺰء‬Roof ‫ وﻟﻮ ﻣﺎ ﺗﺤﺴﻦ ؟ آﺧﺮ ﺷﻲء ﺗﺸﻴﻞ ﺟﺰء ﻣﻦ اﻟـ‬، Floor
. Orbital Apex ‫ﻣﻦ اﻟـ‬

D- Restrictive Myopathy 30-50% :

- Must Do MRI T2 : Bellies Enlargment Sparing

Tendon
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- Restriction To The Antagonist muscle : IR Fires

To Be Affected Causing SR Restrection .

- Diplobia

$ Managment Of Restrictive Myopathy :

- First Prism

- Surgery :
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‫ واﻟـ‬، ‫ وﻣﺎﻓﻲ ﺗﺤﺴﻦ‬Quiescent Phases ‫ﺷﺮوﻃﻬﺎ اﻧﻪ دﺧﻞ اﻟـ‬

. Primary Posation ‫ ﻓﻲ اﻟـ‬diplopia ‫ واﻟـ‬، ‫ ﺛﺎﺑﺘﺔ‬Angle

Diplopia ‫ و‬Proptosis ‫ و‬Lid Retraction ‫ﻟﻮ اﻟﻤﺮﻳﺾ ﻋﻨﺪه‬

‫ وﻣﺎ ﺗﺤﺴﻦ ؟‬Quiescent Phases ‫ودﺧﻞ اﻟـ‬

. DSL ‫ﺑﺎﻟﺘﺮﺗﻴﺐ ﻧﻌﻤﻞ اﻟـ‬

Compresive Optic ‫ ﻋﺸﺎن اﻟـ‬Decompression ‫اﻟـ‬

Lid ‫ وﺑﻌﺪﻳﻦ اﻟـ‬Squint Surgey ‫ وﺑﻌﺪﻳﻦ اﻟـ‬neuropathy
Surgey

E- Cimpressive Optic Neuropathy 5% :

Optic Nerve ‫اﻟﻌﻀﻼت ﺗﻀﻐﻂ ﻋﲆ اﻟـ‬

‫ وأﺳﺮع‬Color Vision ‫ و اﻟـ‬Central Vision ‫أول ﺷﻲء ﻳﺘﺄﺛﺮ اﻟـ‬
VF ‫ﺷﻲء ﻳﻜﺸﻔﻬﺎ‬
22/09, 6:37 PM

$ Managment Of Compressive Optic

Neuropathy :

- Give IV Methyl Predinslone , If No Improvment in

24h ? Do Orbital decompression .

F- Choroidal Folds ( Rare ) :

Due to Fibrosis Of Scleral Inner Surface

. horizontal ‫ وﻣﺎﺷﻴﻪ‬Retinal Folds ‫ﻧﻤﻴﺰﻫﺎ أﻧﻬﺎ أﻋﺮض ﻣﻦ اﻟـ‬

22/09, 6:37 PM
04/10, 10:05 PM

( Preseptal Cellulitis & Orbital Cellulitis )

Bony orbita ‫ وراﻳﺢ ﻟﻠـ‬Trsus ‫ ﻳﻄﻠﻊ ﻣﻦ اﻟـ‬Septm ‫اﻟـ‬

. Margine

- Preseptal Cellulitis : Anterior To Septm

‫ و ﻳﺤﺼﻞ‬muscles ‫ ﻳﻜﺒﺮ ﺣﺠﻢ اﻟـ‬Orbital Cellulitis ‫ﻓﻲ اﻟـ‬

‫ و‬Vision ‫ ﻳﻜﺒﺮ وﺗﺘﺄث اﻟـ‬Optic Nerve Sheth ‫ واﻟـ‬diplopia
04/10, 10:05 PM

cavernous ‫ وﻣﻤﻜﻦ ﻳﻨﺘﺸﺮ ﻟﻠـ‬، Proptosis ‫أﻳﻀﺎً ﻳﺤﺼﻞ‬

. sinus

‫ واﻟـ‬Orbit ‫ ﻟﻠـ‬drainage ‫ ﻳﺤﺼﻞ ﻓﻴﻪ اﻟـ‬cavernous sinus‫اﻟـ‬

‫ وﻗﻠﻴﻞ‬Superior Opthalmic Vein ‫ ﻋﻦ ﻃﺮﻳﻖ اﻟـ‬Eyelied
‫ ﻟﺬاﻟﻚ اﻟـ‬Valve ‫ وﻣﺸﻜﻠﺘﻬﺎ ﻣﺎ ﻓﻴﻬﺎ‬Inferior Opthalmic Vein
. ‫ ﻳﻌﺪي ﺑﺴﺮﻋﺔ‬Infection

2 Cavernous Sinus
$ Pathogen Routes :
04/10, 10:05 PM

Note : Spread Like From Stye , Chalazion ,

Hordeolum , Dacroyocystitis .

Most Commot Spread is Ethmoditis

$ Etiology :

- Most Common is Bacteria

- In Immunocopromised Must Suspect Fungi
( Mucormyosis )
04/10, 10:05 PM

$ Dignosis :
04/10, 10:05 PM

Note : Cavernous Sinus Thrombosis : Same As

Orbital Cellulitis + Symptoms Of Increas ICP
( Sever Headach + Nausea + Vomating )

‫ ﻣﻤﻜﻦ ﻳﻨﺘﻘﻞ ﻋﺒﺮﻫﺎ اﻟـ‬IntrCavernous Connection ‫ﻓﻴﻪ‬

Retrograde ‫ اﻟﺜﺎﻧﻲ وﻳﺼﻴﺮ‬Cavernous ‫ ﻟﻠـ‬Infection
. Bilateral Orbital Cellulitis ‫ﻟﻠﻌﻴﻦ اﻟﺜﺎﻧﻴﺔ وﻳﺼﻴﺮ‬

$ Classification : Chandlers
04/10, 10:05 PM

$ Tests :

. Orbital Cellulitis ‫ﻧﻌﻤﻠﻬﺎ اذا ﺷﻜﻴﺖ ﻓﻲ اﻟـ‬

- CBC : Leukocytosis
- CT Scan : If You Can't See The Globe
- Cultures : Blood If Febrile

$ Treatment :

- If Pt Febrile Or <2 Y Treat As Orbital Cellulitis .

04/10, 10:05 PM

- Orbital Cellulitis : IV Antibiotics For 3 or 4 Days ,

Then Shift To Oral if there's Improvment .

( Nonspecific Orbital Inflammation , Idiopathic

Orbital inflammation , Orbital inflammatory
Syndrome )

- IOID ( Idiopathic Orbital inflammatory Disease )

Most Common Cause Of Painful Orbital Mass

‫ أﺣﻴﺎﻧًﺎ ﻳﺄﺛﺮ ﻋﲆ ﻋﲆ اﻟـ‬، Intraorbital inflammation ‫ﻳﺤﺼﻞ‬

Lacrimal Gland ‫ وأﺣﻴﺎﻧﺎ ﻳﺄﺛﺮ ﺑﺲ ﻋﲆ اﻟـ‬Orbital Tissue
. ‫ وﻣﺎ ﻳﻌﺮﻓﻮن اﻟﺴﺒﺐ‬EOM ‫ﺑﺲ أو‬

Orbital Cellulitis ‫ﺗﺸﺨﺼﻪ اذا أﺳﺘﺒﻌﺪت ﻛﻞ أﺳﺒﺎب اﻟـ‬

04/10, 10:05 PM

‫ﺣﺴﺐ اﻟﻤﻜﺎن اﻟﻠﻲ ﻳﺄﺛﺮ ﻋﻠﻴﻪ ﺗﻜﻮن ﻟﻪ ﺗﺴﻤﻴﻪ ﻣﺨﺘﻠﻔﺔ‬

- Tolosa-Hunt Syndrom : Superior Orbital fissure ,

Orbital Apex ,And cavernous sinus

$ clinical picture :

- Adult , Unilateral , No Hx Of Truma .

04/10, 10:05 PM

$ Imaging :
04/10, 10:05 PM

Note : The Extention To Lareral Rectus From

Lacrimal Gland , Most Common MR Then SR , LR ,
IR .

Note : Unlike Thyroid Eye Disese , The Tendon Is

Affected .
04/10, 10:05 PM

Note : inflammation Of Optic Nerve Sheeth

( Tramline Sign )

‫ ﻣﺎﺷﻲ ﺑﺸﻜﻞ ﻃﺒﻴﻌﻲ واﻟﻐﺸﺎء‬Center ‫ ﻓﻲ اﻟـ‬Optic Nerve ‫اﻟـ‬

04/10, 10:05 PM

‫ ﻳﺴﻤﻮﻧﻬﺎ ﺧﻂ اﻟﻤﻴﺘﺮو ) ﻓﻲ اﻟﻨﺺ ﺧﻔﻴﻒ‬، Inflamed ‫اﻟﻠﻲ ﺣﻮﻟﻪ‬

‫ ﻣﻦ اﻟـ‬Optic Nerve ‫ ﻳﺄﺛﺮ ﻋﲆ اﻟـ‬، ( ‫واﻟﺠﺎﻧﺒﻴﻦ ﻋﺮﻳﻀﺔ‬
. Compression

Note : In Orbital Apex and Cavernous Sinus

Affection Must Do MRI .

Note : Widening Of Orbital Forman + cavernous

sinus Affection ( If Idiopathic = Tolosa-Hunt
04/10, 10:05 PM

Syndrom )

Mucormyoisis ‫ﻳﺸﺒﻪ‬

$ Biopsy :

- Don't Start Steriod Before Biopsy

Biopsy : Non Specific Inflammatory Cells

$ Managment Of Idiopathic Orbital inflammatory

04/10, 10:05 PM

Disease :

- NSAID For 3 Weeks If No Improvment Take Biopsy

And Start Sterioid .

- Radiation if No Improvment With Seroids .

- Antimetabolites : Methotrxate

- Tumor Necrosis Factor Inhiptors : Infliximab

( Less Side Effect And More Effective Then
Steroids ) But Expensive .
04/10, 10:05 PM

( Carotid Cavernous Fistula )

- Not Common But Easy To Dignois .

‫ ﻋﺎﻣﻠﺔ‬Dural Sheeth ‫ ﻋﺒﺎرة ﻋﻦ‬cavernous sinus ‫اﻟـ‬

Intracavernous Connection ‫ ﺻﻐﻴﺮة وﺑﻴﻨﻬﻢ‬Sinsus
Intracavernous ‫ اﻷﺛﻨﻴﻦ ﻳﻮﺟﺪ‬cavernous sinus ‫وﺑﻴﻦ اﻟـ‬
. Connection

‫ واﻟـ‬Medial Wall ‫ وﺟﺰء ﻣﻦ اﻟـ‬Sphnoid ‫ ﻳﻮﺟﺪ اﻟـ‬Floor ‫اﻟـ‬

Laterl ‫ واﻟـ‬Frontal Lobe ‫ واﻟـ‬Optic Chasma ‫ ﻳﻮﺟﺪ‬Roof
‫ وﻣﻦ ﻗﺪام اﻟـ‬Dural Sheeth of Temporal Bone ‫ ﻳﻮﺟﺪ‬Wal
. SOF ‫ واﻟـ‬Orbital Apex

، ‫ ﻣﻨﻪ‬Branch ‫ ﻧﻔﺴﻪ أو‬Intrnal Carotid ‫ ﺑﻴﻦ‬Fistula ‫ﺗﺤﺼﻞ‬

‫ ﻷﻧﻬﺎ ﺗﺘﻐﺬى‬Globe ‫ ﻟﻠـ‬Ischemia ‫ ﻓﺘﺼﻴﺮ‬، Sinus ‫اﻟﺪم ﻳﻤﲆ اﻟـ‬
‫ ﻷن اﻟـ‬Venous congestion ‫ وﻳﺼﻴﺮ‬, Internal carotid ‫ﺑـ‬
‫ وﻳﻌﻤﻞ اﻟـ‬، Eyelied ‫ واﻟـ‬Glob ‫ ﻣﻠﻴﺎن ﻓﻤﺎ ﻳﻘﺪر ﻳﺼﺮف اﻟـ‬Sinus
. Bruit ‫ و‬Pulsatile Proptosis ‫ وﻫﻲ‬Signs Of Fistula
04/10, 10:05 PM

$ Types :

A- Main ICA ( Direct ) : High Flow : Signs Of

Ischemia & Fistula
Note : B,C,D ( Low Flow , No Signs Of Ischemia Or
Fistula , Just Sings Of Venous Congestion .
04/10, 10:05 PM

C- Meningeal Branches of ECA

‫ وﻻزﻗﻪ ﻓﻴﻪ ﻣﻦ ﺗﺤﺖ‬cavernous sinus ‫ﻣﺎﺷﻴﺔ ﺗﺤﺖ اﻟـ‬

Fistula ‫وﺣﺼﻞ ﺑﻴﻨﻬﺎ وﺑﻴﻨﻪ‬

D- Meningeal Branches Of ICA & ECA

$ Direct Carotid Cavernous Fistula( Type A)

- Rare
- Spontaneously : 30% Post manpose
- Truma : Most Common Even Old Truma
04/10, 10:05 PM

$ Clinical Presentation Of CCF :

- Classic Triad : Pulsatile Proptosis , Chemosis &

Orbital Bruit .
04/10, 10:05 PM

Iris ‫ ﻓﻲ اﻟـ‬Vasodilatation ‫ ﻳﺤﺼﻞ‬Ischemia ‫ﺑﺴﺒﺐ اﻟـ‬

Cells ‫ و‬Flare ‫ وﺗﻌﻤﻞ‬vessels

. symptom ‫ ﺣﻖ ﻛﻞ‬Pathophysiology ‫أﻓﻬﻢ اﻟـ‬

$ CT & MRI :
04/10, 10:05 PM
‫‪04/10, 10:05 PM‬‬

‫اذا ﻣﺎ ﺑﻴﻦ ﻓﻲ اﻟـ ‪ CT‬أو اﻟـ ‪ MRI‬ﻧﻌﻤﻞ ‪ CTA‬أو ‪MRA‬‬

‫‪Magnitic Resoning Angio‬‬

‫‪$ Treatment :‬‬

‫أﺣﻨﺎ ﻧﻌﺎﻟﺞ اﻟﻤﺸﺎﻛﻞ اﻟﻠﻲ ﻓﻲ اﻟﻌﻴﻦ ‪ ،‬أﻣﺎ اﻟـ ‪ Fistula‬ﻳﻌﺎﻟﺠﻬﺎ‬

‫ﺟﺮاح اﻟﻤﺦ واﻷﻋﺼﺎب ‪.‬‬
04/10, 10:05 PM

$ Indirect Carotid Cavernous Fistula :

- Classic Triad : Corkscrew Blood Vessels +

Glaucoma + 6th Nerve Palsy .
- No Signs Of Ischemia
Glaucoma ‫ ﻏﺎﻟﺒﺎً ﺑﺘﺸﺨﺼﻪ ﺑﺴﺒﺐ اﻟـ‬، ‫ﻛﻞ اﻷﻋﺮاض ﺗﺠﻲ ﻣﺘﺄﺧﺮ‬
04/10, 10:05 PM

Note : Proptosis But Not Pulsatile .

24/09, 11:07 PM

( Lacrimal Gland Tumors )

- Very Rare , 1 in Milion

SuperioTemporal Orbit ‫ ﻓﻲ اﻟـ‬Mass ‫ﺗﺤﺼﻞ‬

$ Classification :

Non-Epithelial : 75% Most Common

‫‪24/09, 11:07 PM‬‬

‫‪$ Pleomorphic Adenoma ( Benign ) :‬‬

‫ﻓﻲ اﻟـ ‪ CT‬ﺗﺸﻮﻓﻬﺎ ‪ Solid‬وﻗﻄﻌﺔ وﺣﺪة وداﺋﺮﻳﺔ وﻣﺎ ﺗﺤﺼﻞ ﻓﻴﻬﺎ‬

‫‪24/09, 11:07 PM‬‬

‫وﺗﻐﻴﺮ ﺷﻜﻠﻪ ‪ Bone‬ﺗﻀﻐﻂ ﻋﲆ اﻟـ ‪ Mass‬اﻟـ ‪Bone Errosion ,‬‬

‫‪ Adenoid‬وﻫﺬي اﻟﺨﺎﺻﻴﺔ ﺗﻔﺮﻗﻬﺎ ﻋﻦ اﻟـ ‪ Errosion‬ﺑﺲ ﺑﺪون‬
‫‪Cyctic CA .‬‬

‫اﻟـ ‪ Biopsy‬ﻣﻤﻨﻮع ‪ ،‬ﻷن ﻓﻴﻪ أﺣﺘﻤﺎل ﻳﺘﺤﻮل اﻟﻮرم ﻟـ‪Malignant‬‬

‫وﻟﻮ ﺧﺰﻗﺘﻬﺎ ﺑﻴﻨﺘﺸﺮ ‪.‬‬

‫‪$ Treatment :‬‬

24/09, 11:07 PM

‫ﻓﻲ ﻛﻞ اﻷﺣﻮال ﻻزم ﺗﺸﻴﻠﻬﺎ‬

$ Adenoid Cystic CA :

‫ وﻣﻤﻜﻦ ﻳﺤﺼﻞ‬Rapid Progressive Proptosis ‫ﻣﺆﻟﻤﺔ و‬

. Lacrimal Nerve ‫ ﻓﻲ اﻟﻤﻨﺎﻃﻖ اﻟﻠﻲ ﻳﻐﺬﻳﻬﺎ اﻟـ‬Hypothesia
‫‪24/09, 11:07 PM‬‬

‫اﻻﺷﻬﺮ ﻫﻮ اﻟـ ‪ Cribiform‬اﻟﺠﺒﻨﺔ اﻟﺴﻮﻳﺴﺮﻳﺔ‬

24/09, 11:07 PM

$ Tretment :

Biobsy ‫ﺑﻌﺪ ﻣﺎ ﺗﺴﺘﺄﺻﻠﻬﺎ ﺗﻌﻤﻞ‬

$ Orbital Lymphoma : >50

. Salmon Mass ‫ ﺗﺴﻤﺊ اﻟـ‬Conj ‫ﺗﺸﺨﺼﻬﺎ ﻣﻦ اﻟـ‬

Lacrimal Gland ‫وﻣﻤﻜﻦ ﺗﺠﻲ ﻓﻲ اﻟـ‬

Firm
‫‪24/09, 11:07 PM‬‬

‫ﻓﻲ اﻟـ ‪ CT‬ﺗﺠﻤﻊ ﻣﺎ ﺑﻴﻦ ﺧﺼﺎﺋﺺ اﻟـ ‪ Benign‬واﻟـ ‪. malignant‬‬

‫ﺗﻌﻤﻞ ‪ Remodling‬ﻓﻲ اﻟـ ‪ Bone‬ﺗﻠﺘﻒ ﺣﻮل اﻟـ ‪ Glob‬ﺑﺲ‬
‫ﺗﻜﻮن ‪. ill Defined‬‬
24/09, 11:07 PM
04/10, 10:08 PM

( Cavernous Sinus Syndrome )

‫ ﻟﺬاﻟﻚ ﻻزم‬، ‫ ﻳﺴﺒﺒﻪ أﻛﺜﺮ ﻣﻦ ﻣﺮض‬presentation ‫ﻋﺒﺎرة ﻋﻦ‬

. ‫ﺗﻌﺮف اﻟﺴﺒﺐ‬

. Cavernous Sinus ‫ﻳﻀﺮب ﻛﻞ ﺷﻲء ﻳﻌﺪي ﻓﻲ اﻟـ‬

- CN3 & CN4 & CN6

‫ ﻷﻧﻪ ﻳﻀﻐﻂ ﻋﲆ اﻟـ‬Loss Corneal Sensation ‫ﻳﻌﻤﻞ‬

Maxilary ‫ واﻟـ‬Opthalmic

. horner syndrome ‫ وﻳﺴﺒﺐ‬ICA ‫ﻳﻀﻐﻂ ﻋﲆ اﻟـ‬

. ‫ﻣﺶ ﻻزم ﻛﻞ اﻷﻋﺮاض ﺗﺤﺼﻞ‬

04/10, 10:08 PM

. ‫ ﻟﻮ اﻟﺴﺒﺐ ﻏﻴﺮ ﻣﻌﺮوف‬Tolosa-Hunt S ‫اﻟـ‬

$ Clinical Presentation :
04/10, 10:08 PM

. ‫ﻓﻴﻪ أﻋﺮاض ﻣﻌﻴﻨﺔ ﻟﻮ ﺟﺎت ﻻزم ﺗﻔﻜﺮ ﺑﺴﺒﺐ ﺧﻄﻴﺮ‬

‫ ﻣﻤﻜﻦ ﺗﻜﻮن‬Rigors ‫ واﻟـ‬Tachycardia ‫ و‬Fever ‫اﻟـ‬

. cavernous Sinus thrombosis

‫ ؟‬Cavernous Sinus Syndrome ‫ﻛﻴﻒ ﻧﺸﺨﺺ‬

‫ﺗﺤﺼﻞ ﻓﻲ ﻧﻔﺲ اﻟﻌﻴﻦ‬

6th Nerve Palsy + Horner Syndrome
cavernous sinus ‫ﻷن ﻫﺬوﻻ اﻹﺛﻨﻴﻦ ﻣﺎ ﻳﻠﺘﻘﻮن أﺑﺪاً اﻻ ﻓﻲ اﻟـ‬
04/10, 10:08 PM

. Parkinson Sign ‫وﻧﺴﻤﻴﻬﺎ‬

‫ وﻫﻮ ﻋﺒﺎرة ﻋﻦ‬Orbital Apex Syndrom ‫ﻓﻲ ﻣﺮض ﻧﺴﻴﻤﻪ‬

Optic Nerve ‫ و ﻣﻌﻪ‬Cavernous Sinus Syndrome
. dysfunction

( Mucormycosis )
‫‪04/10, 10:08 PM‬‬

‫ﻟﻴﺲ ﻧﻮع واﺣﺪ وﻟﻜﻦ ﻋﺎﺋﻠﺔ ﻣﻦ اﻟـ ‪ Molds‬ﺗﺴﻤﻰ‬

‫‪. Mucormycetes‬‬

‫ﻳﺼﻴﺐ ﺿﻌﻴﻒ اﻟﻤﻨﺎﻋﺔ واﻟﻠﻲ ﻋﻨﺪﻫﻢ ‪ Acidosis‬ﻷﻧﻪ ﻳﺄﺧﺮ‬

‫‪ Aggregation‬ﻟﻠـ ‪ Granulocytes‬واﻟـ ‪ Fibroblast‬ﻓﻤﺎ ﻳﺘﻢ‬
‫ﺣﺼﺎر اﻟـ ‪. Infection‬‬

‫اﻟﻤﺸﻜﻠﺔ ﻓﻴﻪ أﻧﻬﺎ ‪ ، rapidly progressive‬ﺗﺪﺧﻞ ﻟﻠـ ‪Blood‬‬

‫‪ Vessels‬ﻓﺘﻌﻤﻞ ‪ Ischemia‬و ‪ Necrosis‬و ‪ Infarction‬ﻟـ‬
‫‪ Tissue‬اﻟﻠﻲ ﻳﻐﺬﻳﻪ ‪ ،‬وﻟﻤﺎ ﻳﻤﻮت اﻟـ ‪ Tissue‬ﻳﺴﺘﻌﻤﺮه اﻟﻔﻄﺮ‬
‫وﻳﺘﻐﺬئ ﻋﻠﻴﻪ وﺗﻨﺘﻘﻞ ﻟـ ‪ Blood vessels‬آﺧﺮ ‪ ،‬ﻟﺬاﻟﻚ ﺗﻨﺘﺸﺮ‬
‫ﺑﺴﺮﻋﺔ ‪.‬‬
‫‪04/10, 10:08 PM‬‬

‫ﻳﺴﺒﺐ ﺳﻮاد ﻓﻲ اﻟـ ‪ Tissue‬ﻧﺴﻤﻴﻪ ‪Black Eschar‬‬

‫اﻟﻔﻄﺮ ﻫﺬا ﻣﻮﺟﻮد ﺣﻮاﻟﻴﻨﺎ ﺑﺸﻜﻞ ﻳﻮﻣﻲ ‪.‬‬

‫أﺷﻬﺮ ﻃﺮﻳﻘﺔ ﻳﻬﺎﺟﻤﻨﺎ ﻋﻦ ﻃﺮﻳﻖ ‪ , Inhalation‬ﺗﻨﺘﻘﻞ ﻣﻦ اﻟـ‬

‫‪ Nasal sinus‬وﺑﻌﺪﻳﻦ ﻟﻠـ ‪ Orbit‬وﺑﻌﺪﻳﻦ ﻟﻠـ ‪ , Brain‬وﻣﻤﻜﻦ‬
‫ﻳﻌﺪي ﻣﺒﺎﺷﺮة ﻣﻦ اﻟـ ‪ Nasal‬ﻟﻠـ ‪. Brain‬‬

‫وﻣﻤﻦ ﻳﺮوح ﻟﻠـ ‪ Lung‬أو ﻋﻦ ﻃﺮﻳﻖ ‪ Oral Cavity‬وﻳﺮوح ﻟﻠـ‬

‫‪. GIT‬‬

‫أﻏﻠﺐ اﻟﺤﺎﻻت ﻳﻜﻮن ﻋﻦ ﻃﺮﻳﻖ اﻟـ ‪ Ethmoid‬أو اﻟـ ‪Maxillary‬‬

‫وﻳﻮﺻﻞ ﻟﻠـ ‪. Orbit‬‬

‫ﻟﻜﻦ أﺣﻴﺎﻧًﺎ ﻳﺠﻲ ﻋﺒﺮ اﻟـ ‪ NasoLacrimal Duct‬ﺑﺸﻜﻞ‬

‫‪ Retrograde‬ﻣﻦ اﻟـ ‪ inferior Meatus‬وﻣﻦ اﻟـ ‪Lacrimal‬‬
‫‪ Sac‬ﻳﻘﺘﺤﻢ اﻟـ ‪. Orbit‬‬

‫ﻣﺸﻜﻠﺘﻪ أول ﻣﺎ ﻳﻮﺻﻞ اﻟـ ‪ Orbit‬ﻳﺮوح ﻟﻠـ ‪ Apex‬ﻓﻴﺴﺒﺐ اﻟـ‬

04/10, 10:08 PM

Orbital Apex Syndrom ‫ واﻟـ‬Cavernous Sinus

Syndrome ‫ واﻟـ‬Horner Syndrom ‫ واﻟـ‬Optic Nerve
dysfunction ‫ و اﻟـ‬Sensory Loss ‫ ﻓﻲ اﻟـ‬V1 ‫ و اﻟـ‬V2 ، ‫و‬
Proptosis ‫ و‬Chemosis .

$ Treatment :

‫ و‬IV Amphotericin ‫ ﻋﺒﻲ اﻟﻤﺮﻳﺾ ﺑـ‬، ً‫ﺑﻤﺎ أﻧﻪ ﻋﻨﻴﻒ ﺟﺪا‬

‫ ﺑﺸﻜﻞ‬Infarction ‫ ﺻﺎر ﻓﻴﻪ‬Tissue ‫ وﺷﻴﻞ أي‬Retrobulbar
. ‫ﻳﻮﻣﻲ‬
‫‪04/10, 10:08 PM‬‬

‫ﻓﻴﻪ ﻧﻮﻋﻴﻦ ﻣﻦ اﻟـ ‪ ، Amphotericin‬ﻳﺴﻤﻰ ‪ Liposomal‬آﻣﻦ‬

‫وﻗﻠﻴﻞ اﻟﻤﻀﺎﻋﻔﺎت و ﻓﻌﺎﻟﻴﺘﻪ أﻋﲆ وﻟﻜﻨﻪ ﻏﺎﻟﻲ ‪.‬‬

‫اﻟﺜﺎﻧﻲ ﻫﻮ ‪ Non Liposomal‬رﺧﻴﺺ وﻟﻜﻦ ﻳﻌﻤﻞ ‪Renal‬‬

‫‪ dysfunction‬وﻓﻌﺎﻟﻴﺘﻪ أﺿﻌﻒ ‪ ،‬ﻟﺬاﻟﻚ ﻣﺎ ﺗﻘﺪر ﺗﻌﻄﻲ ﻛﻤﻴﺎت‬
‫ﻛﺒﻴﺮة ‪.‬‬

‫ﻟﻮ ﺣﺼﻞ ‪ Damage‬ﻟﻠـ ‪ Optic Nerve‬ﺗﻌﻤﻞ ‪Exentration‬‬

‫ﻋﺸﺎن ﺗﺤﻤﻲ اﻟـ ‪. Brain‬‬
23/09, 8:45 PM

( Orbital Floor Fractures )

- Most common is Floor Then Medial Wall

- lamina papyracea thicknes : 0.2-0.4 mm ( Third

Most Common )

- Infraorbital Canal Roof thicknes : 0.23 mm ( Most

Common )

Maxillary : 0.37 mm Second Most Common

23/09, 8:45 PM

( Medial Part Of Floor )

‫ ﻟﻤﺎذا ﻟﻴﺴﺖ اﻷﻛﺜﺮ ؟‬lamina papyracea ‫اﻟـ‬

Air ‫ وﻫﻲ ﻋﺪد اﻟـ‬Truma ‫ﻷن ﻓﻴﻬﺎ ﺧﺼﺎﺋﺺ ﺗﺨﻠﻴﻬﺎ ﺗﻘﺎوم اﻟـ‬
. Maxillary ‫ ﺑﻌﻜﺲ اﻟـ‬، ‫ ﻓﻴﻬﺎ ﻗﻠﻴﻞ‬spaces

$ Orbital Floor Fractures :

23/09, 8:45 PM

Lower Orbital ‫ ﻓﻲ اﻟـ‬fracture ‫ ﺗﺤﺼﻞ‬Direct ‫ﻓﻲ اﻟـ‬

. Floor ‫ وﻳﻤﺘﺪ ﻟﻠـ‬Margin

‫ ﻓﻲ‬fracture ‫ أﻧﻚ ﻣﺎ ﺗﺤﺼﻞ‬Direct ‫ ﺗﻔﺮق ﻋﻦ اﻟـ‬Indirect ‫اﻟـ‬

. Orbit ‫ ﺑﺴﺒﺐ اﻟﻀﻐﻂ اﻟﺸﺪﻳﺪ داﺧﻞ اﻟـ‬، Orbital Margine ‫اﻟـ‬

$ Physical Examination :
23/09, 8:45 PM

Note : Enopthalmos In Floor & Medial Wall

fracture .

Note : Most common Sign Is Infraorbital

Anesthesia
23/09, 8:45 PM

Note : Infraorbital Nerve supply Side Of The Nose

& Lower Lid & Upper Lip .

Note : Diplopia due to direct cut of nerve or

edema , or muscle cut or edema .

$ CT : Coronal With Thin Cuts ( 1- 1.5mm )

‫ واﻟﺸﻲ‬، ‫ ﻣﻦ أوﻟﻪ ﻵﺧﺮه‬Floor ‫ ﻳﺠﻴﺐ ﻛﻞ اﻟـ‬Cornonal ‫ﻷن اﻟـ‬

‫ ﺗﺄﺛﺮ ﻋﲆ‬artifacts ‫اﻟﺜﺎﻧﻲ ﻟﻮ اﻟﻤﺮﻳﺾ ﻣﺮﻛﺐ ﺳﻦ ﻣﻌﺪﻧﻲ ﺑﺘﻌﻤﻞ‬
Floor ‫رؤﻳﺔ اﻟـ‬
23/09, 8:45 PM

Note : Most common Intraped muscle is Inferior

Rectus .
23/09, 8:45 PM

Schmitic CT

$ Treatment :

‫أﺗﺪﺧﻞ وأﻋﺎﻟﺞ أو ﻻ ؟‬

- Oral Steroid 1mg /Kg For 1 Week .

Optic Nerve ‫ ﻋﺸﺎن ﻣﺎ ﺗﻌﻤﻞ ﺗﻀﻐﻂ ﻋﲆ اﻟـ‬Edema ‫ﻟﻮ ﻓﻴﻪ‬

. muscle ‫واﻟـ‬

- Surgery : After 2 Weeks

‫‪23/09, 8:45 PM‬‬

‫ﻟﻮ ﻣﺎﻓﻴﻪ ‪ Improvment‬ﺧﻼل أﺳﺒﻮﻋﻴﻦ أﺗﺪﺧﻞ ﻓﻲ ﻫﺬي‬

‫اﻟﺤﺎﻻت ‪ ،‬ﻟﻮ ﻓﻴﻪ ‪ Improvment‬وﻟﻮ ﺑﺴﻴﻂ أﻧﺘﻈﺮ ‪.‬‬

‫ﻟﻴﺶ ﻧﺘﺪﺧﻞ ﺑﻌﺪ أﺳﺒﻮﻋﻴﻦ ﻓﻲ اﻟـ ‪ Diolopia‬؟ ﻷن ﻟﻮ اﻟﺴﺒﺐ‬

‫‪ Edema‬ﻛﺎن ﺗﺤﺴﻦ وﻟﻮ ﻧﺴﺒﻴﺎً ﺧﻼل أﺳﺒﻮﻋﻴﻦ ﻋﲆ اﻟـ‬
‫‪. Steroid‬‬

‫‪Note : Complete Regenration Of muscle Fibers‬‬

‫‪Complete in 2 Monthes .‬‬
23/09, 8:45 PM

Note : Large Fracture = > Half of The Floor .

Note : Symptomatic Fracture Even in Small , in <18

Y . Why ?

‫ و‬ischemia ‫ وﻳﻌﻤﻞ‬Trap Door ‫ﻷﻧﻪ ﻏﺎﻟﺒﺎً ﻋﲆ ﻫﻴﺌﺔ‬

Occluo ‫ وأﻳﻀﺎً ﻷن اﻟـ‬، ‫ اﻟﻤﺨﻨﻮق‬Tissue ‫ ﻟﻠـ‬Infarction
. ‫ ﻗﻮي ﺟﺪاً ﻓﻲ اﻷﻃﻔﺎل‬cardiac Reflex

Note : Occluo cardiac Reflex

( Tachcardia ,Tachepnia , Hypotention , Vasovegal
Attack , Sweeting )