Ciliary ganglion is an inflammatory lesion of the ciliary vegetative ganglion, the leading manifestation of which is ocular vegetative pain, accompanied by lacrimation, conjunctival hyperemia, serous rhinitis and photophobia. The disease can be complicated by the development of keratitis, iridocyclitis, conjunctivitis. The typical clinic and soreness of the trigger points of the orbit allows diagnosing ciliary ganglion; in difficult cases, diagnostic administration of lidocaine or novocaine into the ciliary ganglion area. The therapeutic algorithm includes the use of analgesic eye drops, anti-inflammatory and symptomatic agents, physiotherapeutic methods and reflexotherapy.
General information
The ciliary vegetative ganglion is located behind the eyeball in the fatty tissue of the eye socket next to the trunk of the optic nerve. Its diameter is about 2 mm. The ciliary node consists of parasympathetic neurons receiving innervation from the preganglionic fibers of the oculomotor nerve branch. Sensitive fibers of the nosocomial nerve and sympathetic fibers from the internal carotid plexus pass through the ganglion. Short ciliary nerves emerge from the ciliary node, which have both parasympathetic fibers, which are processes of ganglion neurons, and sensitive and sympathetic fibers passing through it.
The ciliary nerves go to the back surface of the eyeball and pass through its albumen; innervate the muscles of the pupil and the shell of the eye, including the cornea. Interestingly, the pupil sphincter and the ciliary muscle receive innervation only by parasympathetic fibers, and the pupil dilator — only by sympathetic ones. In this regard, with violations of autonomic innervation with a predominance of the parasympathetic system, there is a narrowing of the pupil (miosis), with greater excitation of sympathetic fibers — pupil dilation (mydriasis).
Along with neuralgia of the submandibular and sublingual nodes, ganglionitis of the pterygoid node and neuralgia of the ear node, practical neurology refers ciliary ganglion to vegetative ganglionitis of the facial region.
Causes
Etiological factors causing ciliary ganglion can be infectious and inflammatory diseases of the eye (bacterial keratitis, chronic conjunctivitis, corneal ulcer, endophthalmitis) and chronic infectious foci of ENT organs (chronic purulent otitis, sinusitis, tonsillitis). In some cases, the cause of ganglionitis of the ciliary node are distant infectious foci: osteomyelitis, pleural empyema, pyelonephritis, purulent cholecystitis, cervical lymphadenitis, chronic cystitis, etc.; common infectious diseases: rheumatism, tuberculosis, diphtheria, syphilis, sepsis; endogenous intoxication in chronic kidney disease, cirrhosis of the liver, oncopathology, hyperthyroidism, diabetes); toxic effects of industrial hazards and household poisons, medicines, alcohol.
Sometimes ciliary ganglion develops as a postoperative complication of surgical interventions on the eyeball or in the cavity of the orbit. Compression of the ciliary ganglion by an increasing tumor of the orbit is possible.
The development of ganglionitis of the ciliary node is predisposed to: vegetative-vascular dystonia, hypertension and arterial hypotension, hypovitaminosis, cold effects on the face and head, vibration, stressful situations.
Symptoms
The leading symptom characterizing ciliary ganglion is vegetative pain in and behind the eyeball. It has an intense burning character inherent in all vegetalgias, and occurs in the form of a painful paroxysm, the duration of which varies from 30 minutes to several hours. In some cases, ciliary ganglion is observed, in which the pain paroxysm lasts more than a week. According to the description of the patients themselves, during an attack of vegetalgia, they have a feeling of “squeezing the eyeball out of the socket.” The pain radiates to the temple and forehead, less often to the hard palate and the root of the nose. Reflex irradiation is observed quite rarely, it leads to the spread of pain to the back of the head, neck and shoulder on the side of the disease.
The pronounced vegetative coloration of paroxysms accompanying ciliary ganglion is typical. During the attack period, there is redness of the conjunctiva of the eyeball, lacrimation, rhinorrhea, photophobia. It is possible to activate a herpes infection with rashes on the skin of the nose and forehead, which disappear after a couple of weeks. Ophthalmological diseases may occur — keratitis, conjunctivitis, iridocyclitis.
Paroxysm of vegetalgia, as a rule, occurs in the evening or at night. The acute period is accompanied by a series of daily attacks, then a long intercrime stage is possible. Usually ciliary ganglion is characterized by the typical vegetalgia seasonality of exacerbations — spring, autumn.
Diagnostics
Objectively, in patients with ciliary ganglion, there is a sharp pain when pressing on the inner corner of the eye, the projection points of the exit of the supraorbital nerve (the border of the medial and middle 1/3 of the supraorbital margin) and the nasolacrimal nerve (the medial point of the orbit). Depending on the predominance of excitation of parasympathetic or sympathetic fibers, patients have Gorner syndrome or Pti syndrome. The first includes a triad of signs: myosis, drooping of the upper eyelid and enophthalmos, the second — mydriasis, exophthalmos and dilation of the eye slit.
A neurologist can diagnose ganglionitis of the ciliary node. However, an ophthalmologist’s consultation is required to examine the condition of the eyeball. The latter checks visual acuity, perimetry and examination of eye structures (ophthalmoscopy, biomicroscopy, diaphanoscopy). Ophthalmological examination is aimed both at identifying the pathology that caused ciliary ganglion and at diagnosing changes in the eyeball resulting from ganglionitis.
In a difficult diagnostic situation, a blockade of the ciliary ganglion is performed — retrobulbar injection into the area of the node of the lidocaine or novocaine. Relief of pain indicates the correctness of the diagnosis.
The search for a causal infectious focus may require consultation with an otolaryngologist, dentist, urologist, gastroenterologist, surgeon; appointment of additional examinations — urine analysis, blood test, radiography of the sinuses, rhinoscopy, pharyngoscopy, otoscopy, kidney ultrasound, liver ultrasound, gynecological examination, etc.
Treatment
The primary task of treatment is the relief of pain paroxysms. For this purpose, instillation of 0.25% dicaine solution into the eye is prescribed, preferably in combination with 0.1% epinephrine solution. Eye drops are used for the first 5-7 days of the disease. Nonsteroidal anti—inflammatory drugs (diclofenac, ibuprofen, piroxicam) are recommended, in case of intense vegetalgia – a complex powder containing bendazole, nicotinic acid, vit. C, thiamine, diphenyltropine and glutamic acid.
In parallel, depending on the clinical symptoms accompanying ciliary ganglion, symptomatic agents (sedatives, hypnotics, ganglioblockers, holinoblockers) are prescribed. In the presence of a herpetic rash, antiviral agents (amantadine, acyclovir) and interferon inducers (amixin, cycloferon) are recommended. Intramuscular injection of vit is advisable. B12 and vit. B1. Patients with chronic cerebral ischemia are additionally prescribed vascular and metabolic therapy: pentoxifylline, vinpocetine, meldonium, piracetam.
Combined therapy of ganglionitis of the ciliary node includes the use of physiotherapy. The most proven are diadinamotherapy, endonasal electrophoresis with novocaine, ultraphonophoresis of novocaine on the brow area, magnetotherapy. Reflexotherapy is successfully used in patients with poor tolerance of pharmaceuticals.