Dacryoadenitis, Orbital Pseudotumor, and TED Flashcards
dacryoadenitis
acute or chronic inflammation of the lacrimal gland
dacryoadenitis etiology/associations
- idiopathic (idiopathic orbital inflammatory syndrome)
- bacterial infection; most common bacteria include Staph, Strep, Neisseria gonorrheae, syphilis, TB
- viral infection; most common viral infections include mumps, infectious mononucleosis, influenza, varicella zoster
- autoimmune, inflammatory systemic disease; most common diseases include sarcoidosis, RA, SLE, Sjogren’s syndrome, GPA, IgG4-related disease
dacryoadenitis demographics
depends on etiology
dacryoadenitis laterality
- depends on etiology
- systemic disease and idiopathic are typically bilateral
- bacterial is typically unilateral
- viral can be unilateral or bilateral
dacryoadenitis symptoms
- temporal upper eyelid swelling, redness, and tenderness/pain
- droopy eyelid
- tearing
- if infectious, fever
- if bacterial, discharge
- if chronic, dry eye
dacryoadenitis signs
- temporal upper eyelid edema, erythema, and tenderness/pain
- S-shaped eyelid
- lacrimal gland edema and hyperemia, lacrimal gland may be palpable
- globe displacement inferiorly and medially
- inflammation may extend to conjunctiva; seen as conjunctival injection and chemosis
- if infectious, fever
- if bacterial, purulent discharge
- if viral, tender and/or swollen preauricular lymph nodes
- if chronic, signs of aqueous-deficient dry eye
dacryoadenitis complications
orbital cellulitis
dacryoadenitis management
- orbital CT scan or MRI; confirm the diagnosis and rule out other processes such as orbital cellulitis or tumor
- treat empirically as a bacterial infection with oral antibiotics for 24 hours with careful reassessment; if no response to treatment, consider another etiology
- bacterial: mild or moderate- oral antibiotic; severe: hospitalize and treat as orbital cellulitis
- viral: cold compresses and analgesic for palliative therapy; if zoster, oral antiviral
- non-infectious: oral steroids; order lab work based on most likely etiologies; if systemic etiology, refer out for systemic treatment
dacryoadenitis pearls: non-infectious etiologies
- typically ____ with ____ signs and symptoms
- ____ common than infectious
- ____ is the most common non-infectious etiology
chronic;
milder;
more;
sarcoid
dacryoadenitis pearls: infectious etiologies
- typically _____ with _____ signs and symptoms
- ____ is the most common infectious etiology
- ____ infection is rare
- ____ common than non-infectious etiologies
acute; more severe; viral; bacterial; less
idiopathic orbital inflammatory syndrome
- also called IOIS or orbital pseudotumor
- acute inflammation of soft tissues in the orbit to varying degrees: fat, connective tissue, muscle (myositis), lacrimal gland (dacryoadenitis), inflammation may extend to the globe- Tenon’s capsule (tenonitis), sclera (scleritis), uvea (uveitis)
idiopathic orbital inflammatory syndrome etiology
idiopathic
idiopathic orbital inflammatory syndrome demographics
no predilection
idiopathic orbital inflammatory syndrome laterality
typically unilateral in adults and bilateral in children
idiopathic orbital inflammatory syndrome symptoms
- eyelid swelling, redness, and pain
- red eye(s)
- bulging/displaced eye
- double vision
- pain on eye movement
idiopathic orbital inflammatory syndrome signs
- eyelid edema, erythema, and tenderness/pain
- conjunctival chemosis and injection
- proptosis
- globe displacement
- if EOMs involved, signs of myositis (restricted EOM and pain with eye movement)
- if lacrimal gland is inflamed, signs of dacryoadenitis
- if sclera/Tenon’s capsule involved, signs of posterior scleritis
- if uvea involved, signs of uveitis
idiopathic orbital inflammatory syndrome complications
compression on the globe and/or optic nerve
idiopathic orbital inflammatory syndrome management
- orbital CT scan or MRI: confirm the diagnosis and rule out other processes such as orbital cellulitis or tumor
- oral steroid 1-1.2 mg/kg/day as initial dose; patients typically show improvement within 48 hours
- IV steroid for severe cases
- orbital radiotherapy if no response to steroid or disease recurs as steroid is tapered
idiopathic orbital inflammatory syndrome pearls:
- ____ is the hallmark of IOS, but is only present in 65% of patients
- diagnosis of exclusion
an explosive, painful onset
thyroid orbitopathy
- also called thyroid eye disease (TED) and/or thyroid ophthalmopathy
- autoimmune, inflammation of orbital tissue in patients with thyroid disease
thyroid orbitopathy etiology/associations
- stimulation of orbital fibroblasts
- orbital fibroblasts upregulate the synthesis of GAGs that deposit in orbital tissues leading to congestion and edema
- orbital fibroblasts differentiate into adipocytes which then proliferate and deposit in and around the orbit
- orbital fibroblasts differentiate into myofibroblasts which then proliferate and lead to muscle enlargement
- 90% of cases are associated with Graves’ disease; may also be associated with hyperthyroidism, hypothyroidism, Hashimoto’s disease
thyroid orbitopathy demographics
- women»_space; men; women more commonly have Graves’ disease
- typically occurs during the ages of 40 years and 60 years
thyroid orbitopathy laterality
bilateral > unilateral
thyroid orbitopathy symptoms
- dry eye: FBS (foreign body sensation), redness, tearing, intermittent blurred vision
- elevation of the upper eyelid
- bulging eyes
- eyelid swelling
- double vision
- pain on eye movement
thyroid orbitopathy signs
- upper eyelid retraction
- Dalrymple’s sign
- lagophthalmos
- temporal flare
- exophthalmos
- periorbital edema and erythema
- conjunctival injection and chemosis; more pronounced at the site of the rectus muscle insertion
- exposure keratopathy
- superior limbic keratoconjunctivitis
- Von Graefe’s sign
- eyelid lag
- restricted EOM with possible pain on eye movement; inferior and medial rectus muscles most commonly affected, leading to hypotropia and esotropia, respectively
Dalrymple’s sign
widening of the palpebral fissure with superior scleral show
lagophthalmos
inability to close the eyes completely
temporal flare
elevation of the temporal upper eyelid compared to its normal anatomical location
exophthalmos
same as proptosis, globe protrudes anteriorly in relation to the lids
exposure keratopathy
corneal damage that occurs from prolonged exposure to the outside environment; due to lagophthalmos and/or exophthalmos
superior limbic keratoconjunctivitis
inflammation of the superior limbus, cornea, bulbar and tarsal conjunctiva
Von Graefe’s sign
delayed descent of upper eyelid DURING downgaze; dynamic finding
eyelid lag
upper eyelid is higher than normal when the eye is IN downgaze; static finding
thyroid orbitopathy complications
- compression on the globe and/or optic nerve
- compressive optic neuropathy occurs in ~5% of cases
thyroid orbitopathy management: for mild cases
- topical lubrication
- Restasis or Xiidra
- eyelid taping or patching phs in addition to topical lubrication
- cold compresses qam and head elevation qhs for periorbital/orbital edema
- sodium restriction to reduce water retention and periorbital/orbital edema
- selenium supplementation 100 ug bid
- prism for diplopia
thyroid orbitopathy management: for moderate to severe cases of compressive optic neuropathy
- oral or IV steroids
- orbital radiotherapy
- orbital decompression surgery: following orbital decompression surgery, strab surgery (for diplopia) and eyelid lid surgery (for eyelid retraction) may be performed
thyroid orbitopathy management:
_____ if severe congestive orbitopathy or optic neuropathy or atypical cases (i.e., unilateral proptosis or bilateral proptosis without upper eyelid retratcion)
orbital CT or MRI
thyroid orbitopathy management:
- monitor exophthalmos with _____; normal limits are ____ in whites, ____ in blacks, and within ____ between the 2 eyes
- discuss _____; increases severity of disease; 7x more likely to develop TED
- _____ for treatment of systemic disease
exophthalmometry; 12-20 mm; 12-24 mm; 2 mm; smoking cessation; refer to PCP/endocrinologist
thyroid orbitopathy clinical pearls:
- most common cause of _____
- ____ is the most common presenting sign of TED; up to ____% of patients are affected; it is due to ____
- _____ is the second most common sign associated with TED
orbital disease in adults; upper eyelid retraction; 90; increased sympathetic tone acting on Muller's muscle, contraction of the levator palpebrae superioris, proptosis, and/or scarring between the lacrimal gland and the levator palpebrae; exophthalmos
thyroid orbitopathy: new treatment option
- Tepezza
- FDA approved Jan 2020
- monoclonal antibody injection therapy for TED
- MOA: insulin-like growth factor-1 (IGF-1R) antagonist, prevents orbital fibroblast stimulation
- showing great promise and will probably become more common in the next few years
thyroid orbitopathy is divided into _____ phases
active and stable
thyroid orbitopathy: active phase
- i.e., clinically progressive
- typically lasts between 1-3 years
- symptoms wax and wane
- 5-10% risk of recurrence
thyroid orbitopathy: stable phase
- aka quiescent phase
- spontaneous resolution of active phase
majority of patients with TED have ____ disease and require primarily ____ as a means of symptom management
mild to moderate;
supportive care
thyroid orbitopathy:
- as a general guideline, surgery is not advised until ____
- exceptions include: _____
- ____% of patients with TED undergo some type of surgical intervention
a euthyroid state is maintained and the TED has been in the stable phase for at least 6-9 months;
vision loss from compressive optic neuropathy or exposure keratopathy, in which cases urgent surgical intervention is warranted;
~20
thyroid orbitopathy:
- TED does not necessarily follow the associated thyroid dysfunction and may occur _____
- concomitant ____ may occur in a minority of patients
months to years before or after thyroid dysfunction;
myasthenia gravis
