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

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

1
Q

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

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

Pain: what to ask in the history?

A

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?

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3
Q

Common differentials for orbital pain?

A
  1. Hemorrhage
  2. Inflammatory (infectious vs non-infectious)
  3. Malignancy
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4
Q

Differentials for orbital inflammation?

A
  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
  1. 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)
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5
Q

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

A

Preseptal Cellulitis

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6
Q

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

A

Orbital Cellulitis

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7
Q

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

A

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

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8
Q

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

A

Ethmoidal Foramina

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9
Q

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

A

Medical: Cloxacillin 250 mg QID x 2 weeks

Surgical: Incision and Drainage

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10
Q

Hallmark of orbital disease?

A

Proptosis

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11
Q

Proptosis vs Exophthalmos?

A

Exophthalmos: anterior displacement of globe secondary to thyroid eye disease

Proptosis: from all other causes

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12
Q

2 prerequisites to be considered a TRUE proptosis

A
  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
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13
Q

When to suspect proptosis?

A

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

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14
Q

Differentials for pseudoproptosis

A
  1. Lid fissure asymmetry
  2. Ipsilateral Macrophthalmos
  3. Contralateral Enophthalmos
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15
Q

Differentials for Lid Fissure Asymmetry?

A

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
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16
Q

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

A
  • 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

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17
Q

Differentials for Ipsilateral Macrophthalmos

A

Macrophthalmos: increased globe size

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

  1. Long axial length: high myopia
  2. Buphthalmos: congenital glaucoma
18
Q

Differentiate MACROphthalmos, MICROphthalmos, EXOphthalmos and ENOphthalmos and Proptosis.

A

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

19
Q

Differentials for Contralateral Enophthalmos.

A

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
20
Q

Most common tumor that metastasizes to the orbit?

A

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
21
Q

Differentials for TRUE Proptosis

A

V: Vascular: AV fistulas

E: Endocrine: thyroid-related eye disease

I: Inflammatory: orbital inflammatory disease

N: Neoplastic: orbital tumors

22
Q

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

A
  1. Primary tumors: arising from orbit itself
  2. Secondary tumors: direct extension or metastatic
  3. Systemic disease with orbital manifestation
23
Q

Differentials of primary orbital tumors.

A
  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
24
Q

Most common mesenchymal orbital tumor in adults

A

Dermatofibroma

25
Q

Differentials of secondary orbital tumors.

A
  1. Direct extension from:
  • Sinus
  • Cranium
  • Globe
  1. Metastasis from distant site
  • Brain
  • Kidneys
  • Lungs
  • Breast
26
Q

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

A

KIDNEYS (Wilm’s Tumor)

BRAIN (Neuroblastoma)

27
Q

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

A

LUNGS

BREASTS

28
Q

Differentials for systemic diseases with orbital manifestations.

A
  1. Hematopoeitic: Leukemia
  2. Histiocytosis: Langerhans cell histiocytosis
  3. Phacomatosis/Neurocutaneous Syndrome: neurofibromatosis
29
Q

Parts of the Orbital Examination

A
  1. Gross Examination: eyelids, periorbital areas, conjunctiva
  2. Routine Eye Examination:
  • Visual Acuity (UCVA and BCVA)
  • Motility exam
  • Intraocular Pressure determination
  • Fundoscopy/Ophthalmoscopy
  1. Eye reflexes: pupil reflex and corneal reflex
  2. Palpation: (+/-) pulsation, (+/-) resiliency, tumor characteristics if anteriorly-located
  3. Auscultation: (+/-) bruits
  4. Systemic Exam
30
Q

How do you qualify and quantify proptosis?

A
  1. Direction
  2. Measurement/Severity
  3. Dynamics
31
Q

Qualify DIRECTION of proptosis.

A

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

32
Q

How is proptosis quantified

A
  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
33
Q

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

A

13.5 mm [10-20 mm or 1-2 cm]

Consensus:

Normal: less than or equal to 21 mm
Proptosed: more than 21 mm

34
Q

How to characterize progression of orbital diseases?

A

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)

35
Q

Value of palpation of orbital masses

A

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

36
Q

How to check for pulsations in the orbit?

A

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

37
Q

What are the clinical findings associated with neurofibromatosis?

A
  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
38
Q

Why is the proptosis secondary to sphenoid bone dysplasia pulsating?

A

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
39
Q

CT findings in sphenoid bone dysplasia

A

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

40
Q

Delay in the movement of the upper eyelids inferiorly with downgaze

A

Von Graefe’s Sign: dynamic sign

Lig Lag: static sign; difference in palpebral fissure size in primary gaze vs downgaze

41
Q

Periorbital changes as clues to orbital disease diagnosis

A

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

Ophthalmology (44 decks)

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