Orbital disease Flashcards
What occurs with soft tissue involvement?
Includes lid and periorbital oedema, ptosis and conjunctival swelling due to inflammation or vascular abnormalities
What is proptosis (exophthalmos)?
Abnormal protrusion of the globe externally, the protrustion can be intra/extraconal Pseudoproptosis may occur with high myopia or contralateral enophthalmos
Causes: thyroid eye disease, tumours, inflammation, infection
What is enopthalmos?
condition in which the globe is recessed within the orbit
Small globe- nanopthalmos, micropthalmos or phthisis bulbi
Structural abnormalities e.g. blow out fracture
Atrophy of the orbital contents- irradiation or scleroderma
What is ophthalmoplegia?
restriction or disability of the ocular muscles
Tumour
Restrictive myopathy- thyroid eye disease (TED) or myositis
Ocular motor nerve lesions
Trauma- longstanding blow out fracture
What are dynamic properties fo the eye?
Increased venous pressure- thyroid eye disease or vascular problems
Pulsation- AV communication (+/- bruit) or defect in orbital floor (CSF pulsation & no bruit)
Bruits may be heard with the bell of a stethoscope, it is a sign of carotid-cavernous fistula
What are fungus changes that occur?
Optic disc changes, disc swelling, atrophy, opticociliary shunts
Choroidal folds
Retinal vascular changes
What are the common ocular manifestations of thyroid eye disease?
Eyelid retraction periorbital oedema Exophthalmos (proptosis) (1/3) (permanent in 70% of cases) Diplopia (5-10%) Lid lag when following from superior to inferior position Eyelid erythema Conjunctival injection Chemosis Swelling of the caruncle Eyelid oedema Optic neuropathy (5%)(perform CT, assess VA, colour vision, papillary reactions, visual fields, fundoscopy) Restrictive myopathy
What occurs with restrictive myopathy?
up to 50% of patients will have a permanent diplopia
oedema is the cause in active stages and fibrosis in later stages
the muscles affected in order of frequency are inferior rectus, media rectus, superior rectus and finally lateral rectus
What are the signs in orbital cellulitis?
infection located behind the orbital septum, usually secondary to ethmoiditis severe malaise, fever Severe orbital oedema Redness Ptosis Painful ophthalmoplegia Optic nerve dysfunction, if advanced
What are the complications of orbital cellulitis?
Optic neuropathy and abscess formation, in severe cases this can lead to infection of the cranial cavity (raised IOP, retinal vasculature occlusion)
What is idiopathic orbital inflammatory disease (IOID)?
A non-neoplastic, non-infectious orbital lesion and can involve any soft tissue component, presentation is typically between 20-50 years and with an abrupt painful
onset
Usually unilateral with proptosis, chemosis, periorbital swelling and ophthalmoplegia- this is a diagnosis of exclusion
What are the vascular orbital disorders?
Orbital venous anomalies (varices): Isolated orbital varices Combined orbital & external varices Carotid-cavernous fistula: Direct/Indirect
What are orbital venous varies?
Usually unilateral and may bleed or become thrombosed These patients will demonstrate intermittent proptosis accentuated by the Valsalva manoeuvre
What is a direct carotid-cavernous fistula?
Abnormal communications between the carotid artery and cavernous sinus
This is a high velocity flow shunt, causes include head trauma or spontaneous rupture
Pulsatile proptosis with bruit and thrill- abolished by ipsilateral carotid compression there is retinal venous congestion and haemorrhage
Ptosis
Chemosis
Conjunctival injection
Ophthalmoplegia
Raised IOP
What is an indirect carotid-cavernous fistula?
Abnormal indirect communications between meningeal branches of the internal carotids and the cavernous sinus, these are mostly congenital malformationor spontaneous rupture Dilated episcleral vessels Raised IOP Occasional ophthalmoplegia Mild proptosis
What are encephaloceles?
Herniation of intracranial contents through the congenital skull defect
Meningocele contains only dura and a meningoencephalocele contains dura and brain tissue- transmission of CSF will cause a pulsatile proptosis without a bruit
What re the types of orbital tumours?
Vascular tumours- capillary or cavernous haemangioma
Lacrimal gland tumours- pleomorphic adenoma
Neural tumours-noptic nerve glioma or optic never sheath meningioma
Miscellanous tumours- metastases or invasion from sinuses
What are cavernous haemangiomas?
the most common adult orbital benign tumour- found just behind the globe
They are most common in women 40-60
treatment is surgical excision
What are capillary haemangiomas?
The most common orbital tumour in children with 30% present a birth and 100% present by 6 months of age- these tumours may enlarge on coughing or straining These are associated with systemic conditions (high output cardiac failure, Maffuci syndrome etc) Growth is during the 1st year and 70% have resolved by age 7
Treated with steroid injections, systemic steroids and local resection if possible
What are pleomorphic lacrimal gland adenomas?
Present in the 4th to 5th decades and are painless and slow growing
These tumours are well encapsulated so can be surgically removed
What are lacrimal gland carcinomas?
Present in the 4th to 6th decades and have a very poor prognosis
Painful and grow rapidly Diagnosis is by biopsy and treatment is radical surgery and radiotherapy
What are optic nerve gliomas?
Typically affect young girls and are associated with NF-1 Present at end of 1st decade with gradual visual loss
Slow growing lesions can be observed, but excision is necessary if affecting vision or cosmesis
What are optic nerve sheath meningiomas?
Typically affects middle aged women and causes gradual visual loss to due optic nerve compression
treatment depends on the tumour, but excision and radiotherapy may be necessary
Where do metastatic tumours to the orbit commonly spread from?
Breast Bronchus Prostate Skin melanoma GI tract Kidney
What is the treatment for orbital cellulitis?
Systemic antibiotics and monitoring of optic nerve function Indications for surgery: Resistance to antibiotics Orbital or subperiosteal abscess Optic neuropathy
What is the treatment for idiopathic orbital inflammatory disease?
has a varying outcome from mild to severe
Early spontaneous remission without sequelae- no treatment
Prolonged intermittent activity with eventual remissions, treatment options steroid therapy, radiotherapy and cytotoxic usage
Severe prolonged activity causing a ‘frozen orbit’
