Facial Asymmetries of Orbit and Pseudo Orbit Flashcards
pseudo orbital dz: condition with a sign associated with orbital dz
inflammation of one of the upper lids (ie internal hordeolum)
unequal palpebral apertures not associated with exophthalmos (2)
- inflammation of one of the upper lids (internal hordeolum)
- microphthalmia
- closure or winking of an eye because it is irritated,
- blepharospasm (an extreme case of the above)
- levator dehiscence
unequal palpebral apertures NOT associated with exophthalmos
weakening of the connection between the levator and the tarsal plate in the upper lid, often observed among the elderly
levator dehiscence
• over contraction of the muscles of facial expression in a contralateral facial nerve palsy
• retraction of the contralateral lid
• misdirected facial nerve fibers, after CN7 damage (can lead to a rare and peculiar form of facial
asymmetry known as jaw-winking, in which an eye closes in response to opening and closing the mouth
unequal palpebral apertures not associated with exophthalmos
• ocular trauma or any surgery in or around an eye,
• also: enophthalmos, in which the palpebral apertures
are actually of different sizes but due to malposition of the globe.
•physiological pseudoptosis (physiological asymmetry
more than normal but not associated with pathology).
unequal palpebral apertures not associated with exophthalmos
! Dorsal midbrain syndrome
! Thyroid-related orbitopathy
! Aberrant regeneration syndromes
! Pseudo lid retraction e.g., contralateral ptosis
lid retraction
- Lid retraction
- Palsy of up gaze
- “Retraction nystagmus” on attempted upgaze
- Tectal pupils
sluggish, mydriatic, near resp>lite resp
dorsal midbrain syndrome
what are the 2 categories of unequal palpebral apertures associated with orbital dz
- not associated with thyroid dz
2. associated with thyroid dz
! orbital mass ! venous stasis ! EOM paralysis (external ophthalmoplegia) ! orbital cellulitis ! orbital pseudotumor ! surgery ! other (unusual)
exophthalmos with equal or unequal palpebral apertures not thyroid related
orbital contents into a sinus, e.g., in blow-out fracture, sinus surgery
enophthalmos with equal or unequal palpebral apertures
what can happen when v pressure is too high (mass lesion)
venous stasis
what does it mean if all eye muscles are paretic at the same time
external ophthalmoplegia
exophthalmos with equal or unequal caucasian palpebral apertures
> 20 mm
exophthalmos with equal or unequal african palpebral apertures
> 24 mm
exophthalmos with equal or unequal palpebral apertures will have an asymmetry of what?
2.0 mm or more
what type of pathology accounts for 90% of exophthalmos
thyroid related
what can be used to find abnormalities even when pt is euthyroid?
modern blood tests
! TRO ! Thyroid ocular disease ! Grave's disease / Grave's orbitopathy ! Grave's ophthalmopathy ! Dysthroid orbitopathy ! Dysthroid myopathy ! Dysthyroid ophthalmopathy
thyroid related orbitopathy synonyms
name 3 TRO symptoms
- binocular diplopia
- ocular irritation
- my eyes look funny
! exophthalmos ! stare, lid retraction ! inferior punctate staining ! abnormal eye movements ! sector injection ! elevated IOP / optic neuropathy ! lid edema
TRO signs
what are 3 TRO lab tests
- TSH
- elevated T4 (not T3)
- thyroid stimulating antibody (if in doubt)
! educate the patient ! exophthalmometry ! measure palpebral aperture ! check for corneal staining, TBUT ! muscle field ! Take IOP & document ONH ! communicate with endocrinologist
TRO specific procedures
! Adnexa ! Lids ! Bulbar conjunctiva ! Cornea ! Eyeball ! Extraocular muscles ! IOP ! Optic nerve
TRO checklist tissues
! Puffiness ( adnexa) ! Edema, retraction, stare (lids) ! Sector injection (conj) ! Exposure keratitis, staining (cornea) ! Exophthalmos (eyeball) ! Incomitancy, enlargement (EOMs) ! Elevation or elevated on up gaze (IOP) ! Compression, glaucoma (optic nerve)
TRO checklist signs
during progression what are 3 TRO interventions?
tarsorrhaphy
orbital decompression systemic steroids
monocular occlusion
when progression has stopped, what are 2 TRO interventions?
! lid reconstruction for cosmesis
! alleviate diplopia
what are the 4 steps of TRO management
- co-manage the endocrine disorder
- protect the CORNEA (lubricant, tape lids at night)
- protect the ON
- help the patient cope with diplopia, cosmesis
what are 3 cases when prescribing prism?
- acquired strabismus
- spread of comitancy
- there is incomitancy
what are diagnositc tools for Rxing prism in acquired strabismus? (5)
- CT
- maddox rod
- double maddox rod vergences
- ARFT
- hess lancaster screen
where do we put the direction of base when Rxing prism in acquired strabismus?
move image to where eye points (apex toward direction of deviation)
how much prism do we have an acquired strabismus pt?
measure the deviation
trial & error: prism bars, TF
How:
usually must surface, decenter if poss two pairs of glasses
