Orbital Disease Flashcards
1
Q
Orbital Pathophysiology is due to…?
A
- Inflammation – as result of inflammatory disease e.g. thyroid eye disease or due to infection e.g. orbital cellulitis
- Compression – tumours
- Both
- Inflammation causes swelling & swelling can cause compression
- Rare
- Orbit difficult to examine as can’t see on SL
2
Q
What are the clinical features with orbital pathology?
A
- Proptosis – bulging of eyes
- ↓VA
- Pain
- Diplopia
3
Q
What clinical evaluation would you carry out with orbital disease?
A
- Complete ophthalmic examination
- Careful medical & ophthalmic history, including time course of disease, past trauma, ocular surgery, & systemic illnesses
- Assessment of VA & VFs, anterior & posterior segment evaluation, & external & periorbital inspection – take time, stand back & look at pxs face
4
Q
Which hospital investigations would be carried out with orbital disease?
A
- Imaging – CT scan, MRI scan, Ultrasound
o CT scan: good for bony abnormalities
o MRI scan: goof for soft tissues - Systemic investigations e.g. blood test including thyroid function test or inflammatory markers – depending on clinical suspicion
5
Q
What are the general characteristics of orbital inflammation?
A
- Painful proptosis
- Red eye, chemosis
- Myositis -> inflammation of EOM -> limitation of movement
- Occurs anywhere in orbit, specifically around lacrimal gland
- Diagnosis:
-Orbital CT scan – ultrasound
-Biopsy - Treatment:
-Immunosuppression such as steroids – systemic steroids are required – eyedrops are not sufficient
6
Q
What is Thyroid Orbitopathy (AKA Graves’ Disease)?
A
- Thyroid orbitopathy 50% is most common orbital lesion
- Immunological disorder that affects orbital muscles & fat
- Middle-aged adults (30-50 years) are affected most frequently
- Disease is seen in women more commonly than in men, ration 3-4 : 1
- It is always bilateral process but is often asymmetrical
- Multiple muscles are involved simultaneously, most commonly inferior & medial rectus
7
Q
What are the symptoms & signs of Thyroid Orbitopathy?
A
- Dry eyes - common
- Conjunctival injection (redness) & swelling – common – general pain & discomfort
- Lid retraction – fairly common – can give impression of proptosis but more often than not there is no proptosis
- Exophthalmos – proptosis – reasonably common – can only check by standing behind the patient and looking down
- Diplopia – rare & indicates significant thyroid eye disease
- Corneal exposure – uncommon – significant proptosis or lid retraction & inability to close the eye properly
- Rarely optic nerve compression
8
Q
What is the treatment and prognosis of Thyroid Orbitopathy?
A
- Depends on if active or inactive, or if mild, moderate or severe
- Mild:
o Topical lubrication & steroids - More severe:
o Oral immuno-suppression
o Low dose radiotherapy - Soft tissue & bony decompression – if thyroid and orbit are inflamed – need to create more space in the orbit
- Improving cosmesis:
o Upper lid lowering
o Lower lid elevation - Squint surgery – if muscles are involved
- Important to wait for disease stabilisation & resolution of inflammation can take up to 12 years – in majority of cases, after a year or 2 condition becomes stabilised and can perform surgery for residual abnormalities
- Ask if patient smokes – known to worsen prognosis of thyroid eye disease
- Selenium supplementation – bought in supermarkets – mild to moderate thyroid eye disease – seems to have a protective effect if used for 6 months
9
Q
What type of referral does active thyroid disease require?
A
URGENT attention & referral
10
Q
What is orbital cellulitis and what causes it?
A
- Infection inside the orbit
- Major causes of orbital cellulitis:
-Sinusitis (58%)
-Lid or face infection (28%)
-FB (11%)
-Haematogenous (blood) (4%)
11
Q
What are the orbital symptoms of orbital cellulitis?
A
- Pain
- Lid oedema & erythema (redness of skin caused by infection)
- Chemosis
- Axial proptosis – if diffuse disease occurs
- Abaxial displacement – if an abscess forms
- ↓ ocular motility – common
- IOP may be elevated
- Rapid loss of vision from optic nerve compression, optic neuritis & vasculitis may ensue
- Severe, untreated cases:
o Posterior extension – may develop
o Cavernous sinus thrombosis – may develop
o Subdural empyema – may develop
o Intracranial abscess – fatal condition – may develop
12
Q
What are the warning signs of orbital cellulitis?
A
- Dilated pupil
- Marked ophthalmoplegia – inability of eye to move
- Loss of vision
- Afferent pupillary defect
- Papilledema
- Perivasculitis – v red looking eyelids
- Violaceous lids
13
Q
What systemic symptoms may accompany orbital cellulitis?
A
Fever
Feeling v unwell
14
Q
Treatment for orbital cellulitis?
A
- Refer immediately to hospital – do not waste time as can progress fast in children
- In children: systemic antibiotics, sinus drainage needed in only 50% of cases
- In adults: draiage of sinuses & abscess may be needed in 90% of cases
15
Q
Describe Diffuse Idiopathic Orbital Inflammation (Pseudotumor) & the symptoms of it?
A
- Symptoms:
-Abrupt pain
-Conj injection
-Chemosis
-Lid oedema
-Exophthalmos – proptosis
-Diplopia
-Motility restriction - Palpable mass detected in 50% cases
- No systemic manifestations
- Sclerosing vs non-sclerosing
- Systemic corticosteroids typically result in a dramatic improvement
- Prognosis is generally excellent
- Unlikely to see in primary care
