Orbital Disease (Cale) Flashcards
thinnest wall in the orbit
medial
ophthalmoplegia
restriction of EOM
how can you test for ophthalmoplegia
forced ductions
clues to pathology
orbital pulsation (cavernous sinus fistula, defect in orbital roof transmitted via CSF), Bruit (carotid-cavernous fistula, carotid stenosis in CVA, A-V malformations, choroidal folds, disc edema, optic atrophy
Orbital septum
dense fibrous sheath acting as barrier between orbit and eyelid. Orignates from periosteum of superior and inferior orbital rims. Inserts into levator aponeurosis just above superior tarsal border and inferior lid retractors just below inferior tarsal border
Preseptal cellulitis
red, edematous lids, tender. No proptosis, chemosis, vision change, pupillary involvement, fever or EOM restriction. Staph aureous, strep pyogenes most common. Children H influenza
Causes for preseptal cellulits
laceration, insect bite. Infection spread from hordeolum, dacryocystitis, sinusitis, conjunctivitis or URI or middle ear
Management preseptal cellulitis
treatment (daily followup)
-afebrile, mild: oral antibiotic for 10 days. for child can use augmentin, cefaclor, bactrim. for adult can use augmentin, cefaclor, bactrim or moxifloxacin. Moderate to severe, febrile (no improvement)- hospital admission for IV antibiotics
orbital cellulitis
life-threatening infection of soft tissue behind orbital septum, children> adult. Spnemoniae, S. aureus, S pyogenes, H influenzae. Proptosis, pain, fever, malaise
complications of orbital cellulitis
meningitis, brain abscess, cavernous sinus thrombosis
orbital cellulitis emergency case
hospital admission, IV ceftazidime (vancomycin) and oral metronidazole (anaerobes)
differential Dx of acutely inflammed orbit
orbital cellulitis, fungal infection (mucormycosis), dacryocystitis, dacryoadenitis, vascular, neoplasm, thyroid eye disease, idopathic orbital inflammatory dz, myositis, collagen vascular dz or autoimmune, scleritis, conjunctivitis
Lacrimal gland disease
dacryoadenitits
dacryoadenitis
inflammatory w/ or w/o autoimmune dz, neoplastic (least common), biopsy is gold standard of diagnosis
inflammatory lacrimal gland disease
idiopathyc dacryoadenitits. autoimmune comorbidity frequent. acute or subacute with pain, erythema, dry eye,s welling, unilateral (80%)
autoimmunity- primary target of immune system in autoimmune disorders: sarcoid sjogren’s, wegener, IgG4-related older pt, painless swelling often bilateral
neoplastic
unilateral palpable mass, dystopia, proptosis, low incidence of pain, redness, lympocytic infiltration (elderly), pleomorphic adenoma (young mild), carcinoma (mid-aged with high mortality)
lymphocytic infiltration of lacrimal gland
can run from benign hyperplasia to malignant lymphoma (subconjunctival “salmon patch” extension
Infectious Dacryoadenitis
pain, erythema, edema lateral upper lid’s curve (kids), viral typically, bacterial rare
how to treat infectious dacryoadenitis
if mild and uncertain etiology follow daily with oral antibiotics, in kids with augmentin 20-40mg/kg/day, in adults augmentin 250-500mg po q8h.
If moderate to severe-hospitilize
viral infectious dacryoadenitis
most common epstein-barr virus, mumps, adenovirus, Hzoster, Hsimplex, rhinovirus, bilateral 40%, fever 25%
bacterial infectious dacryoadenitis
staph, MRSA, strep, haemophilus, neisseria, gonorrhea. Unilateral typically, afebrile
differential not responsive to antibiotics
viral (cold compresses, analgesic), idopathic orbital inflammatory disease (CT scan, blood tests, improves with oral steroid), tumor (non-painful, orbital CT scan, biopsy)
grave’s ophthalmopathy in hyperthyroidism
clinical eye involvement more common in females. majority have increase in orbital fat (younger) or EOM volume (older). Smoking is primary risk factor for GO in Graves. Manifestations largely due to expanding orbital content in unyielding bony orbit
grave’s autoimmunity etiology
attack of TSH receptor by TSH receptor auto-antibodies. Abnormal circulating T3-T4 levels (TSH cause release of these)
clinical signs of thyroid ophthalmopathy
lid retraction (dalrymple’s sign), lid lag (von graefe sign), proptosis (measure with exophthalmometer), hyperemia over lateral/medial recti, exposure keratitis, periorbital swelling, chemosis, fat prolapse, EOM restriction and diplopia, optic nerve compression, superior limbic keratoconjunctivitis
chief complaints for thyroid ophthalmopathy
dry, gritty, blur, tearing, diplopia, pressure sensation behind the eye, other vision loss if optic nerve involved
Management of eye in mild disease
lubrication of SLK, exposure dryness, topical antiinflammatory agents (Steroid, NSAID, cyclosporin), sleep with head elevated to reduce periorbital edema, tape eyelids shut during sleep
management Grave’s
endocrinologist (corticosteroids concurrently), treat exposure keratitis, orbital decompression, new approaches designed to avoid the need for orbital decompression (monoclona antibodies to target B and T cell activation and adipogenesis)
idopathic orbital inflammatory disease
non-infective, non-neoplastic space-occupying lesions. Unilateral (Can be bilateral in kids), F=M middle age to older. Periorbital red, swelling, pain, proptosis, ophthalmoplegia, optic nerve involvement, spontaneous remission, intermittent possible, protracted
treatment IOID
observation if mild, biopsy to rule out neoplasia, NSAID often effective (Ibuprofen), Oral steroids only after confirmed dx, radiotherapy if no improvement, antimetabolites if no improvement
Orbital myositis
idiopathic inflammation of one or more EOMs in absence of thyroid orbitopoathy, often spontaneous resolution 3-6wk, etiology unknown
Orbital myositis epidemiology
F>M young adult, 50% bilateral, acute (single episode lasting), chronic (persistent episode lasting), recurrent result in more chronic disease, fibrosis
orbital myositis signs
pain exacerbated by eye movement, diplopia (restricted EOM), injection over involved muscle, lid edema, ptosis, fibrosed muscle enlargement
- NSAID (Ibuprofen)
- oral steroids if persisting
Tolosa-Hunt Syndrome
Dx of exclusion, rare, idiopathic, granulomatous inflammation of cavernous sinus, superior orbital fissure, orbital apex, remissions and recurrences, proptosis, mild, oculomotor nerve palsies usually with pupil involvement, sensory loss V1, V2 of trigemina
tolosa hunt syndrome treatment
steroid
cavernous sinus Fistula
elevated venous sinus and episcleral venous pressure (signs of orbital arterial and venous stasis), hemorrhagic chemosis, pulsatile proptosis, whoosing noise in head, bruit, increase IOP, vision loss and neuro impact immediate or delayed (Optic nerve and nerves VI, III, IV, V), most not life threatening
Cavernous Sinus thrombosis
clotting within sinus, high mortality, rapid onset: HA, malaise, nausea/vomiting, proptosis, chemosis, reduced VA, CN III-VI involved
what does cavernous sinus thrombosis result from
infection (sinusitis), preseptal and orbital cellulitis, otitis
epiphora
defective drainage
-anatomical: malposition of puncta (ectropion)
-obstruction/stenosis
-lacrimal pump failure (horner’s muscle, lower lid laxity)
hypersecretion secondary to inflammation
tests for epiphora
fluorescein disappearance test, johns dye, probing and irrigation, dacryocystography, nuclearl lacrimal scintigraphy
dacryocystitis
pain and epiphora
dacryocystitis treatment
warm compresses, oral antibiotics follow daily- kids give augmentin or cefaclor, adults give cephalexin or augmentin. can also give topical antibiotics in addition (trimethoprim/polymixin B (Polytrim) qid). probing is contraindicated. Consider CT scan if atypical. Incision and drainage carries risk of developing lacrimal fistula. DCR required after infection resolved
chronic canaliculitis
swelling and mucopurulent
congenital conditions
nasolacrimal duct obstruction or dacryocele
nasolacrimal duct obstruction
common, usually spontaneous resolution. Massage over canaliculus, lid hygiene, erythromycin ung if bacterial conj, probe after 12 months resolved
dacryocele
collection of amnionic fluid (noninflammatory) or mucus in lacrimal sac, due to imperforate hasner valve
inflammatory disease
chalazion idiopathic orbital ID Orbital myositis tolosa-hunt syndrome dacryoadenitis
infectious disease
dacryoadenitis preseptal cellulitis orbital cellulitis dacrocystitis chronic canaliculitis
autoimmune disease
graves thyroid ophthalmopathy
congenital conditions
nasolacrimal duct obstruction
dacryocele
