The Orbit

Question 1

What are these signs of orbital disease?

Answer 1

Eyelid & periocular edema

Chemosis

Epibulbar injection

Question 2

What is this sign of orbital disease?

Answer 2

Proptosis

Question 3

What is orbital pulsation and what is it a clue too?

Answer 3

Cavernous sinus fistula, defect in orbital roof transmitted via CSF

It is a clue to orbital pathology

Example: Pulsating mires (normal usually)

Question 4

What is this sign of orbital disease?

Answer 4

Dystopia (R inferior)

Question 5

What is this sign of orbital disease?

Answer 5

Ophthalmoplegia (R hypotropia)

Question 6

What are some clues to orbital pathology?

Answer 6

Orbital pulsation

Bruit

Choroidal folds

Disc Edema

Optic Atrophy

Question 7

What is Ocular Auscultation?

Answer 7

Listen to eye for high pitched sounds or compare eyes to each other.

Question 8

Answer 8

Preseptal Cellulitis

Question 9

What is the presentation of preseptal cellulitis?

Answer 9

Red, edematous lids, tender

No proptosis, chemosis, vision change, pupillary involvement, fever or EOM restriction

Question 10

What are the most common bacteria/viruses that cause preseptal cellulitis?

Answer 10

Bacteria: staph aureus, strep pyrogenes

Children: H influenza

Question 11

What are some common causes of preseptal cellulitis?

Answer 11

Laceration, insect bite

Infection spread from hordeolum, dacryocystitis, sinusitis, conjunctivitis or URI

Question 12

What is the treatment for preseptal cellulitis?

Answer 12

Daily Follow Up

Afebrile: Oral antibiotic for 10 days

Augmentin, Cefalcor, Bactrim

Question 13

How should you treat a patient <5yo with moderate to severe preseptal cellulitis that is febrile and showing no improvement?

Answer 13

Send them to the hospital for IV antibiotics.

Question 14

What is orbital cellulitis?

Answer 14

A life threatening infection of soft tissue behind the orbital septum

Children > Adults

Proptosis, Pain (EOM restriction), fever, malaise

Must be hospitalized immediately

Question 15

What are some differentials to lid swelling?

Answer 15

Conjunctivitis

Dacryoadenitis

Dacryocystitis

Chalazion or hordeolum

Preseptal cellulitis

Orbital cellulitis

Tumor

Question 16

Answer 16

Chalazion

Question 17

Answer 17

Dacryoadenitis

Question 18

What is the most common form of dacryoadenitis?

Answer 18

Inflammatory dacryoadenitis

Question 19

What percent of dacryoadenitis lesions are idiopathic and how does it present?

Answer 19

50% of lesions

Acute or subacute with pain, erythema, dry eye, swelling

Unilateral 80% of the time

Question 20

What is the least common form of dacryoadenitis?

Answer 20

Neoplastic

Question 21

What are the common disease associated with inflammatory autoimmune dacryoadenitis?

Answer 21

Sarcoid

Sjogren’s

Wegener

Question 22

How is autoimmune dacryoadenitis different from idiopathic?

Answer 22

Painless swelling which is often bilateral

Question 23

What is the gold standard of diagnosis for non-infectious disease?

Answer 23

Biopsy

Question 24

Answer 24

Subconjunctival “salmon patch” extension from lymphocytic infiltration of the lacrimal gland

Question 25

What is a risk that can run when lymphocytic infiltration of the lacrimal gland?

Answer 25

Can go from a benign hyperplasia to malignant lymphoma

Question 26

What at the common infectious agents for infectious dacryoadenitis?

Answer 26

Typically Viral: Epstein Barr, mumps, adenovirus, Hzoster, Hsimplex, rhinovirus Rarely Bacterial: Staph, MRSA, strep, Haemophilus, Gonorrhea

Question 27

How does infectious dacryadenitis present?

Answer 27

**Pain, erythema, edema lateral upper lid "s" curve** Children and your adults typically

Question 28

How is viral infectious dacyroadenitis different from bacterial?

Answer 28

Viral = Bilateral 40%, Fever 25% Bacterial = Unilateral, Afebrile

Question 29

How should you treat infectious dacryoadenitis?

Answer 29

Follow daily Oral antibiotics Hospitalize if moderate to severe

Question 30

What are some differentials if antibiotics are not working for infectious dacryoadenitis?

Answer 30

Viral (cold compresses & analgesic) Idiopathic Orbital Inflammatory Disease (IOID) Tumor

Question 31

What is Idiopathic Orbital Inflammatory Disease?

Answer 31

Orbital Pseudotumor, nonspecific orbital inflammatory dz Afebrile Orbital CT scan, blood tests Improves dramatically w/ oral steroids

Question 32

What percent of hyperthyroidism patients have Grave's Ophthalmopathy?

Answer 32

25-50% Females 5:1 Majority have increased orbital fat &/or EOM volume

Question 33

What is a primary risk factor for GO in Grave's?

Answer 33

Smoking

Question 34

Answer 34

Thyroid Ophthalmopathy

Question 35

What is Dalrymple's sign?

Answer 35

Lid retraction

Question 36

What is Von Graefe's sign?

Answer 36

Lid lag

Question 37

What are the chief complaints of a thyroid ophthalmopathy patient?

Answer 37

Dry, gritty Blur Tearing Diplopia Pressure sensation behind eye Other vision loss if optic nerve involved

Question 38

How do you manage thyroid ophthalmopathy?

Answer 38

Lubrication Topical anti-inflammatory agents Sleep w/ head elevated to reduce periorbital edema Tape eyelifs shut during sleep

Question 39

How do you manage Grave's disease?

Answer 39

Endocrinologist Treat exposure keratitis Orbital decompression

Question 40

What is an alternative to orbital decompression?

Answer 40

Monoclonal antibodies to target B and T cel activation