A patient presenting with orbital disease requires a thorough and often multidisciplinary approach to determine the cause of the illness. It is an area of ophthalmology in which the patient may have manifestations of a systemic disease that threaten not only their vision but also their life. Treating the patient requires an in-depth approach involving clinical examination, laboratory testing, imaging, and appropriate medical and surgical treatment.

Traditionally, an approach to orbital disease incorporated the six P’s:

Although this provides a basic framework for evaluating orbital disease, a more thoughtful approach to the orbit can help lead to the appropriate investigation and diagnosis. Each disease affecting the orbit, whether caused by infectious, inflammatory, neoplastic, vascular, congenital, or traumatic etiologies, presents in a unique way. The wide spectrum of orbital disease can be narrowed by considering some key underlying principles and a thorough knowledge of orbital anatomy.

The initial view of a patient can be quite helpful as you start your investigation. Some questions that can be asked are the following: Is the patient in distress or bent over in pain? Does the patient have periorbital edema? Does the patient have eyelid retraction? Some obvious signs of the disease process can be seen immediately and help formulate a working diagnosis.