Day 1 (2): Basic Clinical Evaluation of Orbital Diseases Flashcards
What are the 6 basic P’s of orbital disease evaluation?
- Pain
- Proptosis
- Periorbital changes
- Progression
- Palpation
- Pulsation
Pain: what to ask in the history?
Onset: kailan nagsimula?
Duration: gaano na katagal?
Course: may mga pagbabago bang napansin?
Timing: laging andyan o kusang nawawala at bumabalik?
Alleviating/Precipitating factors: may mga nagawa bang nakabawas o nakapalala sa sakit?
Associated symptoms: mapula? namamaga? lagnat? walang gana kumain?
Clues: history of URTI or sipon/ubo/masakit na lalamunan?
Common differentials for orbital pain?
- Hemorrhage
- Inflammatory (infectious vs non-infectious)
- Malignancy
Differentials for orbital inflammation?
- Infectious (usually bacterial)
- Preseptal cellulitis: anterior to orbital septum
- Orbital cellulitis w/ or w/o abscess formation: posterior to septum
- Dacryocystitis: inflammation of the lacrimal sac or NLD
- Non-Infectious (specific or non-specific)
- From a Systemic Inflammatory Disease: TED
- Neoplastic
- Malformation
- Traumatic
- Non-specific/Idiopathic: dacryoadenitis, myositis, optic neuritis, diffuse idiopathic orbital inflammation (IOI)
Infection and inflammation confined to the eyelids and periorbital structures anterior to the orbital septum (anterior lamella)?
Preseptal Cellulitis
Infection and inflammation that has spread posterior to the orbital septum?
Orbital Cellulitis
Anterior reflection of the periosteal thickening (arcus marginalis) at the orbital rim?
Orbital Septum
- barrier to prevent spread of bacterial infection posteriorly into orbit
Provides a route of entry for infection and neoplasms from the sinuses/nasal cavity into the orbit?
Ethmoidal Foramina
Treatment options for orbital cellulitis w/ or w/o subperiosteal abscess?
Medical: Cloxacillin 250 mg QID x 2 weeks
Surgical: Incision and Drainage
Hallmark of orbital disease?
Proptosis
Proptosis vs Exophthalmos?
Exophthalmos: anterior displacement of globe secondary to thyroid eye disease
Proptosis: from all other causes
2 prerequisites to be considered a TRUE proptosis
- ANTERIOR DISPLACEMENT of the globe
- INCREASE IN VOLUME of orbital contents
- Considered a form of anterior decompression of the orbit
- if BOTH not satisfied: PSEUDOPROPTOSIS
When to suspect proptosis?
Normal: the imaginary line extending from the upper to the lower orbital rim SHOULD be tangential to the corneal apex when viewed laterally
Proptosis: corneal apex is more anterior to the imaginary line
Differentials for pseudoproptosis
- Lid fissure asymmetry
- Ipsilateral Macrophthalmos
- Contralateral Enophthalmos
Differentials for Lid Fissure Asymmetry?
NO anterior displacement of globe and NO increase in orbital content volume
- IPSILATERAL Lid Retraction
- d/t TED: lymphocytic infiltration of LPS - CONTRALATERAL Blepharoptosis
- d/t Horner’s Syndrome: denervation of the Muller’s muscle causing drooping of the upper lids
What is the triad of Horner’s Syndrome or Oculosympathetic Paresis?
- Due to a lesion along the oculosympathetic pathway
- IPSILATERAL:
- Miosis: iris dilator; parasympathetic signals to the iris sphincter predominate leading to pupillary constriction = anisocoria + dilation lag
- Anhidrosis: inability to sweat
- Ptosis: superior tarsal muscle/Muller’s muscle (partial/mild: < 2mm) + Reverse ptosis of lower lid = decreased lid fissure
*Reverse Ptosis: lack of normal opening of lower lid from the contraction of the inferior tarsal muscle
Differentials for Ipsilateral Macrophthalmos
Macrophthalmos: increased globe size
(+) Increase in orbital content volume BUT NO anterior displacement
- Long axial length: high myopia
- Buphthalmos: congenital glaucoma
Differentiate MACROphthalmos, MICROphthalmos, EXOphthalmos and ENOphthalmos and Proptosis.
MACROphthalmos: large eyeball
MICROphthalmos: small eyeball
EXOphthalmos: anterior displacement of eyeball from TED
ENOphthalmos: posterior displacement of eyeball (sunken)
Proptosis: anterior displacement from other causes
Differentials for Contralateral Enophthalmos.
Posterior displacement of contralateral eye
- Orbital Fractures: orbital floor blow-out fractures
- Contralateral Microphthalmos: phthisis bulbi
- Globe Retraction: schirrhous breast carcinoma
- Orbital Fat Atrophy
Most common tumor that metastasizes to the orbit?
Scirrhous/Fibrosing Breast Carcinoma
- long latency period between dx of breast CA and detection of orbital metastasis (4-6 years)
- enophthalmos may occur even if primary lesion is occult
Differentials for TRUE Proptosis
V: Vascular: AV fistulas
E: Endocrine: thyroid-related eye disease
I: Inflammatory: orbital inflammatory disease
N: Neoplastic: orbital tumors
Orbital tumors can be classified into the following based on source:
- Primary tumors: arising from orbit itself
- Secondary tumors: direct extension or metastatic
- Systemic disease with orbital manifestation
Differentials of primary orbital tumors.
- Choristoma: benign overgrowth of normal tissue foreign to the orbit (NORMAL tissue, ABnormal location)
- Hamartoma: benign overgrowth of normal tissue that’s normally found in the orbit (NORMAL tissue, NORMAL location
- Mesenchymal: fibrous tissue, muscle
- Neural: nerve tissue
- Lymphoid and Inflammatory: lymphoid tissue
- Epithelial: glandular
Most common mesenchymal orbital tumor in adults
Dermatofibroma
Differentials of secondary orbital tumors.
- Direct extension from:
- Sinus
- Cranium
- Globe
- Metastasis from distant site
- Brain
- Kidneys
- Lungs
- Breast
Most common primary site of tumors metastasizing in the orbit in CHILDREN?
KIDNEYS (Wilm’s Tumor)
BRAIN (Neuroblastoma)
Most common primary site of tumors metastasizing in the orbit in ADULTS?
LUNGS
BREASTS
Differentials for systemic diseases with orbital manifestations.
- Hematopoeitic: Leukemia
- Histiocytosis: Langerhans cell histiocytosis
- Phacomatosis/Neurocutaneous Syndrome: neurofibromatosis
Parts of the Orbital Examination
- Gross Examination: eyelids, periorbital areas, conjunctiva
- Routine Eye Examination:
- Visual Acuity (UCVA and BCVA)
- Motility exam
- Intraocular Pressure determination
- Fundoscopy/Ophthalmoscopy
- Eye reflexes: pupil reflex and corneal reflex
- Palpation: (+/-) pulsation, (+/-) resiliency, tumor characteristics if anteriorly-located
- Auscultation: (+/-) bruits
- Systemic Exam
How do you qualify and quantify proptosis?
- Direction
- Measurement/Severity
- Dynamics
Qualify DIRECTION of proptosis.
Rule : globe is displaced away from the location of the mass
Axial Displacement: displaced anteriorly
- retrobulbar within the muscle cone (from vessels, nerve, muscle or intraconal fat)
- cavernous hemangioma, ON meningioma/glioma
Non-Axial Displacement: displaced in other directions
- outside the muscle cone
E.g.
Superior displacement = mass in the orbital floor
- maxillary sinus tumor
Inferomedial displacement = mass in the superolateral wall
- lacrimal gland tumor, dermoid cyst
Inferolateral displacement = mass in the superomedial wall
- frontoethmoidal mucocoele, subperiosteal abscess adjacent to ethmoidal sinus, nasopharyngeal CA
How is proptosis quantified
- Grossly by standing behind the pt with the pt seated, facing in front with the head tilted at a 45 degree angle while the MD lifts both upper lids to compare both globes.
- Exophthalmometer: measure from lateral orbital rim to the corneal apex
- Hertel’s: most used
- Luedde’s
What is the average normal measurement from the lateral orbital rim to corneal apex among Filipinos?
13.5 mm [10-20 mm or 1-2 cm]
Consensus:
Normal: less than or equal to 21 mm
Proptosed: more than 21 mm
How to characterize progression of orbital diseases?
Duration: Gaano na katagal?
- Acute: days or weeks
- infectious
- non-infectious inflammatory
- hemorrhage
- malignant neoplasms - Chronic: months to years
- benign neoplasms
Rapidity of growth: Malaki ba ang pagbabago nung nagsimula at ngayon? Gaano kabilis?
Stationary: no change
Slowly progressive: benign
Rapidly progressive: malignant
Regressing: benign (hemangioma, lymphangioma)
Value of palpation of orbital masses
If mass is palpable: describe
- approximate dimensions (L x W)
- solid/cystic/soft
- movable/non-movable
- well-circumscribed/poorly-circumscribed
- location in the orbit: clue to the diagnosis
If mass is non-palpable:
- retrobulbar/within muscle cone: (+) resistance to retrodisplacement
- outside the muscle cone: (+/-) resistance
Resilience: tanggap lang ng tanggap
(+) Resilience = NO resistance
(-) Resilience = (+) resistance, rigid, (+) SOL behind globe
How to check for pulsations in the orbit?
AV Fistulas
(+) Thrill: rhythmic pulsations made by flowing blood on PALPATION
(+) Bruit: audible flow of blood over enlarged vessels on AUSCULTATION over the superior orbital rim using the bell
What are the clinical findings associated with neurofibromatosis?
- Sphenoid bone dysplasia: pulsating proptosis
- Plexiform Neurofibroma: pathognomonic of NF-1; MC peripheral nerve sheath tumor of the orbit
- ON Glioma
- Axillary freckling
- Cafe-au-lait spots
- Fibroma molluscum
Why is the proptosis secondary to sphenoid bone dysplasia pulsating?
Normal: arterial pulsations in the cranium are transmitted to the CSF fluid and to the orbital tissues over a small area surrounding the ON at the orbital apex (BONE = rigid and a poor conductor of vibrations)
Sphenoid bone dysplasia
- absence of a large part of the roof (lesser wing) and the lateral wall (greater wing) cause pulsations to be directly transmitted over a larger area of the orbital tissues
- communication between middle cranial fossa contents and orbit
- pulsations coincide with PR/HR
CT findings in sphenoid bone dysplasia
(-) Noticeable sphenoid bone
(+) Antero-inferior displacement of orbital contents and globe
(+) Progressive herniation of temporal lobe into orbital cavity
Delay in the movement of the upper eyelids inferiorly with downgaze
Von Graefe’s Sign: dynamic sign
Lig Lag: static sign; difference in palpebral fissure size in primary gaze vs downgaze
Periorbital changes as clues to orbital disease diagnosis
Salmon-colored conjunctival mass: Lymphoma
Eyelid retraction and lid lag: TED
Congestion over EOM insertion: TED
Corkscrewing of conjunctival vessels: AVF
S-shaped eyelid: NF
Prominent temple: Sphenoid wing meningioma
Vascular anomaly over lid skin: Hemangioma/varix/lymphangioma
