Facial Asym-orbit and pseudo-orbit_Dr. Kurtz

Question 1

What are the sign/symptoms of the Dorsal midbrain syndrome?

Answer 1

1. Lid retraction
2. Palsy of upgaze with both eyes affected
3. Retraction nystagmus on attempted upgaze
4. Tectal pupils (sluggish, mydriatic, near response > light response)

Question 2

What disorder would you think if you see tectal pupils?

Answer 2

Dorsal midbrain syndrome that’s secondary to pineal gland tumor

Question 3

What are the signs of a tectal pupil?

Answer 3

sluggish, large pupils and near response > light response

Question 4

T/F Tectal pupils is not one of the near-light dissociation syndromes.

Answer 4

False

Question 5

What is the most common disease that causes unequal palpebral apertures?

Answer 5

Thyroid disease (90%) and other disease (10%)

Question 6

What are the causes of exophthalmos with equal or unequal palpebral apertures not associated with Thyroid disease?

Answer 6

It is typically metastatic.

1. Orbital mass
2. Venous statsis (bloos is staying in orbit and taking up space)
3. EOM paralysis (external ophthalmoplegia ->all EOMs are paretic at the same time = globe slides forward)
4. Orbital cellulitis (inflammation in orbit)
5. Orbital pseudotumor (pressure in orbit but not caused by a mass)
6. Orbital surgery/trauma
7. Other (unusual)

Question 7

What are the Thyroid Related Orbitopathy (TRO)?

Answer 7

1. binocular diplopia
2. ocular irritation
3. “my eye looks funny”

Question 8

What are the signs for TRO?

Answer 8

Exophthalmos
stare, lid retraction
inferior punctate staining
abnormal eye movements
sector injection
elevated IOP/optic neuropathy
lid edema

Question 9

Which specialist would you talk to when you suspect your pt has Thyroid Related Orbitopathy?

Answer 9

Communicate with endocrinologist

Question 10

What kind of tests would you do if you suspect your pt has TRO?

Answer 10

1. educate pt
2. exophthalmometry
3. measure palpebral aperture
4. check corneal staining, TBUT
5. muscle field (EOM)
6. Take IOP & document ONH
7. talk to endocrinologist

Question 11

What are the treatments for TRO?

Answer 11

Tarsorrhaphy
orbital decompression
systemic steroid
monocular occlusion

Question 12

What would you think about if you see pt with retracted lid (exposing upper scleral) but it’s not due to exophthalmos?

Answer 12

Think

1. Dorsal midbrain syndrome that’s secondary to pineal gland tumor. Refer ASAP. Urgent.
2. Thyroid-related orbitopathy (more common than dorsal midbrain)
3. Aberrant regeneration syndromes
4. Pseudo lid retraction (ex. contralateral ptosis)