Retrobulbar lesions, shallow orbit Direction of proptosis may indicate pathology - lesions in muscle cone (cavernous hemangioma and ON tumors) -> axial proptosis - extraconal lesions -> eccentric proptosis

Orbital Dx Flashcards by Sarah Duong

Pulsatile proptosis

Defect in orbital roof; CSF

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Which part of the orbital floor is affected in a blowout fracture?

Posteromedial portion of maxillary bone

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Maxillary carcinoma invades the orbit via the ___ and displaces the globe upwards.

Maxillary sinus (orbital floor forms roof of maxillary sinus)

Enophthalmos and eye movement problems

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Orbital cellulitis is frequently secondary to

Ethmoidal sinusitis

If pt has a stye, treat quickly before it spreads into orbit.

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Tolosa-Hunt

Inflammation of SOF and apex

Ophthalmoplegia, venous outflow obstruction - Ddx: angle closure attack

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Clinical signs of orbital disease

Soft tissue involvement
Proptosis
Enophthalmos
Ophthalmoplegia
Pulsation
Bruit
Fundus changes: optic disc swelling, optic atrophy, opticociliary collaterals, choroidal folds

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Causes of soft tissue involvement

Thyroid eye disease, orbital inflammatory disease, obstruction to venous drainage

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Signs of soft tissue involvement

Lid and periorbital edema, skin discoloration, ptosis, chemosis

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Causes of proptosis

Retrobulbar lesions, shallow orbit

Direction of proptosis may indicate pathology

lesions in muscle cone (cavernous hemangioma and ON tumors) -> axial proptosis
extraconal lesions -> eccentric proptosis

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Proptosis characteristics

Greater than 20mm - Ddx: high myopic eye (normal, not proptotic)
Difference of 2mm btw the two eyes - more important

Also note palpebral apertures and any lagophthalmos

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Pseudoproptosis

Facial asymmetry
Severe ipsilateral enlargement of glob (high myopia or buphthalmos)
- buphthalmos - concern w/ congenital glx
Ipsilateral lid retraction
Contralateral enophthalmos - blowout fracture or congenital (phthisis bulbi); other eye appears to be proptotic

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Causes of enophthalmos

Atrophy of orbital contents
Sclerosis orbital lesions: metastatic scirrhous carcinoma and chronic sclerosis goes inflam orbital dx
Pseudoenophthalmos- microophthalmos or phthisis bulbi

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Ophthalmoplegia causes

Orbital mass
Restrictive myopathy (thyroid eye disease)
Ocular motor nerve involvement asso w/ lesions in cavernous sinus, orbital fissures or posterior orbit (carotid-cavernous fistula), Tolosa-Hunt, malignant lacrimal gland tumors
Tethering of EOM of fascia in blowout fracture - ex: IR trapped secondary to blowout fracture - eyeball can’t move up

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Which tests are used to determine if a lesion is restrictive or paretic? And how does it work?

Forced duction test
Positive FDT - eye cannot move (restricted)
Negative FDT - eye can move (nerve problem)

Differential IOP test
6mmHg or more in direction of restricted lesion

Saccades show reduced velocities in paretic lesions

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Dynamic clues to etiology of lesion

Increasing venous pressure w/ head position, Valsalva maneuver, jugular compression can induce/exacerbate proptosis in pts w/

orbital venous anomalies
infants w/ orbital capillary hemangiomas

Pulsation - arteriovenous communication (bruit dep on size) or defect in orbital roof (no asso bruit - CSF)
* best seen during applanation tonometry
Bruit = carotid-cavernous fistula; sound lessened or abolished by gently compressing ipsilaeral carotid artery in neck; decr VA/RAPD/+CV

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Initial feature of compressive optic neuropathy

Optic disc swelling
* may precede optic atrophy (severe compressive optic neuropathy)

Caused by thyroid eye dx and optic nerve tumors

Opticociliary collaterals

Enlarged peripapillary capillaries which divert blood from central retinal venous circ to peripapillary choroidal circ when there is an obstruction

May be asso w/ orbital or optic nerve tumors which compress intraorbital ON and impairs blood flow thru CRV

optic nerve sheath meningioma
optic nerve glioma
CRVO
idiopathic intracranial HTN and glx

Choroidal folds

Orbital lesions (tumors, thyroid eye dx, inflam conditions)

Usually asymptomatic, no vision loss

More common w/ greater amounts of proptosis and ant located tumors; sometimes can precede proptosis

Swollen ONH always causes vision loss. True or false

False - maybe, maybe not

Pale ONH (= optic atrophy) causes RAPD, color vision defect, decreased vision. True or false?

True

Choroidal folds w/ vision loss (although usually asymptomatic)

Central

Something behind the eye is pushing it forward

What causes preseptal cellulitis?

Skin trauma
Local infection (stye, dacryocystitis, sinisitis)
Remote infection of upper respiratory tract or middle ear by haematogenous spread

Signs of preseptal cellulitis

Unilateral tender and red lid w/ periorbital edema

NO PROPTOSIS/CHEMOSIS, NO EFFECT ON OPTIC NERVE FXN

Preseptal cellulitis tx

Oral antibiotics: Augmentin 500mg tid x 10 days, cephalosporin 500mg x10 days days

Rarely IV antibx s

Bacterial orbital cellulitis is more common in children. True or false?

True

Pathogenesis of orbital cellulitis

``` Sinus-related Pre-septal cellulitis Local spread (dental/ear infections) Hematogenous Post-trauma Post-surgical (retinal, lacrimal, orbital) ```

Diagnosis of orbital cellulitis

Fever Decreased VA, RAPD, color defect Unilateral tender warm and red periorbital and lid edema Proptosis - often obscured by lid swelling (usually lateral and downwards) Painful ophthalmoplegia ON dysfunction

Complications of orbital cellulitis

Exposure keratopathy, incr IOP, CRVO/CRAO, intracranial complications (meningitis, brain abscess, cavernous sinus thrombosis)

IOID can result inflammation of soft tissues such as myositis, dacryoadenitis (THINK SARCOIDOSIS), optic perineuritis, or scleritis. True or false?

True *pain w/ any of these, think orbital disease. Then r/o orbital cellulitis w/ biopsy first.

IOID in adults is unilateral and bilateral in children. True of false?

True

Treatment for IOID is antibx eyedrops. True or false?

False - eyedrops will not help; steroid IV or oral

IOID is asso w/ proptosis, ophthalmoplegia, ON dysfunction. True or false?

True

Treatment for IOID

Steroids - make sure pt doesn’t have any other underlying dx first Antimetabolites Biological NO ANTIBX - NOT AN INFECTION

Dacryoadenitis

Lacrimal gland involvement in 25% of pts w/ IOID Usually occurs in isolation and resolves spontaneously w/o tx Rarely caused by bacteria

Tolosa-Hunt

Nonspecific granulomatoius inflammation of cavernous sinus, SOF, and/or orbital apex Idiopathic Dx of exclusion

Carotid cavernous sinus fistula

Arterial blood flows anteriorly into ophthalmic beings - venous and arterial stasis, incr EVP, decr arterial blood flow to cranial nerves w/in cavernous sinus Classified based on etiology (spontaneous and traumatic), hemodynamics (high and low flow), and anatomy (direct and indirect)

Signs of CCF

Severe bulbar redness, ptosis, pulsatile proptosis (Ddx: defect in orbital roof), bruit, ophthalmoplegia, ON dysfunction, radial bvs coming from around sclera

Anophthalmic socket:

Enucleation - removal of globe but leaves EOMs intact Evisceration - removal of globe but leaves sclera and EOMs intact Exenteration - removal of glob and soft tissues (everything out)