Day 1 (2): Basic Clinical Evaluation of Orbital Diseases

Question 1

What are the 6 basic P’s of orbital disease evaluation?

Answer 1

1. Pain
2. Proptosis
3. Periorbital changes
4. Progression
5. Palpation
6. Pulsation

Question 2

Pain: what to ask in the history?

Answer 2

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?

Question 3

Common differentials for orbital pain?

Answer 3

1. Hemorrhage
2. Inflammatory (infectious vs non-infectious)
3. Malignancy

Question 4

Differentials for orbital inflammation?

Answer 4

1. 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

2. 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)

Question 5

Infection and inflammation confined to the eyelids and periorbital structures anterior to the orbital septum (anterior lamella)?

Answer 5

Preseptal Cellulitis

Question 6

Infection and inflammation that has spread posterior to the orbital septum?

Answer 6

Orbital Cellulitis

Question 7

Anterior reflection of the periosteal thickening (arcus marginalis) at the orbital rim?

Answer 7

Orbital Septum
- barrier to prevent spread of bacterial infection posteriorly into orbit

Question 8

Provides a route of entry for infection and neoplasms from the sinuses/nasal cavity into the orbit?

Answer 8

Ethmoidal Foramina

Question 9

Treatment options for orbital cellulitis w/ or w/o subperiosteal abscess?

Answer 9

Medical: Cloxacillin 250 mg QID x 2 weeks

Surgical: Incision and Drainage

Question 10

Hallmark of orbital disease?

Answer 10

Proptosis

Question 11

Proptosis vs Exophthalmos?

Answer 11

Exophthalmos: anterior displacement of globe secondary to thyroid eye disease

Proptosis: from all other causes

Question 12

2 prerequisites to be considered a TRUE proptosis

Answer 12

1. ANTERIOR DISPLACEMENT of the globe
2. INCREASE IN VOLUME of orbital contents

• Considered a form of anterior decompression of the orbit
• if BOTH not satisfied: PSEUDOPROPTOSIS

Question 13

When to suspect proptosis?

Answer 13

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

Question 14

Differentials for pseudoproptosis

Answer 14

1. Lid fissure asymmetry
2. Ipsilateral Macrophthalmos
3. Contralateral Enophthalmos

Question 15

Differentials for Lid Fissure Asymmetry?

Answer 15

NO anterior displacement of globe and NO increase in orbital content volume

1. IPSILATERAL Lid Retraction
   - d/t TED: lymphocytic infiltration of LPS
2. CONTRALATERAL Blepharoptosis
   - d/t Horner’s Syndrome: denervation of the Muller’s muscle causing drooping of the upper lids

Question 16

What is the triad of Horner’s Syndrome or Oculosympathetic Paresis?

Answer 16

• Due to a lesion along the oculosympathetic pathway
• IPSILATERAL:

1. Miosis: iris dilator; parasympathetic signals to the iris sphincter predominate leading to pupillary constriction = anisocoria + dilation lag
2. Anhidrosis: inability to sweat
3. 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

Question 17

Differentials for Ipsilateral Macrophthalmos

Answer 17

Macrophthalmos: increased globe size

(+) Increase in orbital content volume BUT NO anterior displacement

1. Long axial length: high myopia
2. Buphthalmos: congenital glaucoma

Question 18

Differentiate MACROphthalmos, MICROphthalmos, EXOphthalmos and ENOphthalmos and Proptosis.

Answer 18

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

Question 19

Differentials for Contralateral Enophthalmos.

Answer 19

Posterior displacement of contralateral eye

1. Orbital Fractures: orbital floor blow-out fractures
2. Contralateral Microphthalmos: phthisis bulbi
3. Globe Retraction: schirrhous breast carcinoma
4. Orbital Fat Atrophy

Question 20

Most common tumor that metastasizes to the orbit?

Answer 20

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

Question 21

Differentials for TRUE Proptosis

Answer 21

V: Vascular: AV fistulas

E: Endocrine: thyroid-related eye disease

I: Inflammatory: orbital inflammatory disease

N: Neoplastic: orbital tumors

Question 22

Orbital tumors can be classified into the following based on source:

Answer 22

1. Primary tumors: arising from orbit itself
2. Secondary tumors: direct extension or metastatic
3. Systemic disease with orbital manifestation

Question 23

Differentials of primary orbital tumors.

Answer 23

1. Choristoma: benign overgrowth of normal tissue foreign to the orbit (NORMAL tissue, ABnormal location)
2. Hamartoma: benign overgrowth of normal tissue that’s normally found in the orbit (NORMAL tissue, NORMAL location
3. Mesenchymal: fibrous tissue, muscle
4. Neural: nerve tissue
5. Lymphoid and Inflammatory: lymphoid tissue
6. Epithelial: glandular

Question 24

Most common mesenchymal orbital tumor in adults

Answer 24

Dermatofibroma

Question 25

Differentials of secondary orbital tumors.

Answer 25

1. Direct extension from: - Sinus - Cranium - Globe 2. Metastasis from distant site - Brain - Kidneys - Lungs - Breast

Question 26

Most common primary site of tumors metastasizing in the orbit in CHILDREN?

Answer 26

KIDNEYS (Wilm's Tumor) BRAIN (Neuroblastoma)

Question 27

Most common primary site of tumors metastasizing in the orbit in ADULTS?

Answer 27

LUNGS BREASTS

Question 28

Differentials for systemic diseases with orbital manifestations.

Answer 28

1. Hematopoeitic: Leukemia 2. Histiocytosis: Langerhans cell histiocytosis 3. Phacomatosis/Neurocutaneous Syndrome: neurofibromatosis

Question 29

Parts of the Orbital Examination

Answer 29

1. Gross Examination: eyelids, periorbital areas, conjunctiva 2. Routine Eye Examination: - Visual Acuity (UCVA and BCVA) - Motility exam - Intraocular Pressure determination - Fundoscopy/Ophthalmoscopy 3. Eye reflexes: pupil reflex and corneal reflex 4. Palpation: (+/-) pulsation, (+/-) resiliency, tumor characteristics if anteriorly-located 5. Auscultation: (+/-) bruits 6. Systemic Exam

Question 30

How do you qualify and quantify proptosis?

Answer 30

1. Direction 2. Measurement/Severity 3. Dynamics

Question 31

Qualify DIRECTION of proptosis.

Answer 31

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

Question 32

How is proptosis quantified

Answer 32

1. 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. 2. Exophthalmometer: measure from lateral orbital rim to the corneal apex - Hertel's: most used - Luedde's

Question 33

What is the average normal measurement from the lateral orbital rim to corneal apex among Filipinos?

Answer 33

13.5 mm [10-20 mm or 1-2 cm] Consensus: Normal: less than or equal to 21 mm Proptosed: more than 21 mm

Question 34

How to characterize progression of orbital diseases?

Answer 34

Duration: Gaano na katagal? 1. Acute: days or weeks - infectious - non-infectious inflammatory - hemorrhage - malignant neoplasms 2. 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)

Question 35

Value of palpation of orbital masses

Answer 35

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

Question 36

How to check for pulsations in the orbit?

Answer 36

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

Question 37

What are the clinical findings associated with neurofibromatosis?

Answer 37

1. Sphenoid bone dysplasia: pulsating proptosis 2. Plexiform Neurofibroma: pathognomonic of NF-1; MC peripheral nerve sheath tumor of the orbit 3. ON Glioma 4. Axillary freckling 5. Cafe-au-lait spots 6. Fibroma molluscum

Question 38

Why is the proptosis secondary to sphenoid bone dysplasia pulsating?

Answer 38

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

Question 39

CT findings in sphenoid bone dysplasia

Answer 39

(-) Noticeable sphenoid bone (+) Antero-inferior displacement of orbital contents and globe (+) Progressive herniation of temporal lobe into orbital cavity

Question 40

Delay in the movement of the upper eyelids inferiorly with downgaze

Answer 40

Von Graefe's Sign: dynamic sign Lig Lag: static sign; difference in palpebral fissure size in primary gaze vs downgaze

Question 41

Periorbital changes as clues to orbital disease diagnosis

Answer 41

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