Lecture 3 - Orbital Myositis to Cysts

Question 1

Idiopathic, non-specific inflammatory disorder of one or more of the EOM’s, a subtype of IOID, due to chronic inflammatory cellular infiltrate in muscle fibers

Answer 1

Orbital Myositis

Question 2

Female with history of Rheumatoid arthritis, During examination of a patient complaining of eye pain, you find that EOMs increase the pain and cause diplopia, and RMR, RSR and RLR are resctricted. There is also lid edema, ptosis, and chemosis, and mild proptosis. a CT scan shows fusiform enlargement of the RMR but no sign of tendon involvement. Diagnose and treat.

Answer 2

1. Orbital Myositis
2. NSAID if mild, systemic steroids show dramatic imrpovement, Radiotherapy is effective in limiting recurrences that can occur with systemic steroids. Prednisolone for 3 months, 60 mg/day

Chronic if more than 2 months or recurrent attacks
Can be caused by Graves disease, but painless and systemic manifestation

Question 3

Which nerves are near the cavernous sinus? -4

Answer 3

CN III - Oculomotor
CN IV- Trochlear
CN V1- Ophthalmic
CN V2- Maxillary

Question 4

Abnormal communication between Internal Carotid Artery and Cavernous Sinus. ICA blood flows anteriorly in to the venous channels within the cavernous sinus, leading to increased episcleral and Superior Ophthalmic Vein pressure, and decreased arterial blood flow to the cranial nerves within the CS- caused by trauma or spontaneous

Answer 4

Direct Carotid Cavernous Fistula

Question 5

Floyd “Money” Mayweather comes in to your office after a big fight with complaint of sudden onset vision loss. Upon inspection, you find corkscrew conjunctival vessels, pusatile proptosis with bruit and thrill, chemosis, affected eye that cant turn outward, increased IOPs, swollen optic disc, and intraretinal hemorrhages. Diagnose and Treat.

Answer 5

1. Direct Carotid Cavernous Fistula

2. Cannulation or intraorbital puncture of superior orbital vein for drainage of Superior Ophthalmic Vein

Question 6

Abnormal communication between ICA and cavernous sinus, Intacarvernous portion of the internal carotid artery remains intact. Fistula occurs etween the cavernous sinus and the branches of the ICA, ECA, or both, meningeal branches anastomose with sinus channels in the cavernous sinus. Slow blood flow into sinus channels causes more subtle clinical features than a direct fistula - often misdiagnosed or overlooked.

Answer 6

Indirect Carotid Cavernous Fistula

Question 7

Mike Tyson comes into your office with mild epibulbar injection, exaggerated ocular pulsation, increased IOP, mild proptosis with soft bruit, inability to turn eye outward, and moderate venous dilation in fundus. Diagnose and treat.

Answer 7

1. Indirect Carotid Cavernous Fistula
2. endovascular embolization for recanalization, cannulation or intraorbital puncture of superior orbital vein for drainage. ICCF can sometimes have spontaneous resolution

Question 8

Also known as choristoma - benign mal-development of normal tissue not normally found at the specific tissue site, arise from ectoderm and may contain epithelium structures like keratin, hair, teeth.

Answer 8

Dermoid Cyst - superficial or deep

Question 9

Superficial keratin- filled mass, usually in the Supratemporal rim

Answer 9

Epidermoid cyst

Question 10

Solid mass of fatty material and hair below the bulbar conjunctival surface

Answer 10

Dermolipoma

Question 11

A patient complains about a firm, round, smooth, painless subcutaneous mass she has had on the supratemporal portion of her left eye since birth. The edges are easily palpable so it isnt deep or extensive. Diagnose and Treat.

Answer 11

1. Superficial Dermoid Cyst
2. Excision, do not rupture the lesion because it will release keratin and cause a severe foreign body inflammatory response

Question 12

A 22 y/o patient with proptosis shows you a CT scan he got after developing a mass protruding from bone near the eyebrow. the CT shows a well circumscribed cystic lesion extending intracranially as it is associated with a bony defect in this case. Diagnose and Treat.

Answer 12

1. Deep Dermoid Cyst
2. Excision, if it leaks contents into adjacent tissue it will cause painful FB reaction and fibrosis, may reoccur and cause persistent low-grade inflammation if not excised completely

Question 13

Cystic lesion involving the orbit that develops when the drainage of normal paranasal sinus secretions is obstructed by allergy, infection, trauma, tumor, or congenital narrowing. If expands, will erode walls of sinuses. Becomes orbital when they invade from frontal or ethmoid sinus, sometimes maxillary sinus.

Answer 13

Sinus Mucocele

Question 14

Patient with newly developed proptosis, diplopia, and epiphora, there was not pain as there was no secondary infection. CT revealed soft tissue mass in the ethmoid sinus with thinning of the sinus walls. Diagnose and Treat.

Answer 14

1. Sinus Mucocele

2. Complete removal of mucocele to re establish sinus drainage