Download 2.orbit diseases -cl eval

Common Clinical
Presentations and Clinical
Evaluation in Orbital
Diseases
Dr. Ayesha Abdullah
20.08.2015
LEARNING OBJECTIVES
By the end of this lecture the students would be
able to;
1. Categorize orbital diseases
2. Correlate the common symptoms & signs of
orbital diseases with the underlying
structural and functional disorder
3. Outline the protocol for the clinical
evaluation of a patient with orbital disorder
CLASSIFICATION OF ORBITAL DISEASES
1. Congenital anomalies
2. Infections; orbital cellulitis
3. Inflammations; thyroid ophthalmopathy,
Tumours; primary , secondary, benign,
malignant
4. Vascular malformations; Carotid-Cavernous
Fistula (CCF), orbital varices
5. Traumatic disorders; blow-out fracture
CLASSIFICATION OF ORBITAL DISEASES
1. Congenital anomalies
2. Infections; orbital cellulitis
3. Inflammations; thyroid ophthalmopathy/
Thyroid Eye Disease (TED),
4. Tumours; primary , secondary, benign,
malignant
5. Vascular malformations; Carotid-Cavernous
Fistula (CCF), orbital varices
6. Traumatic disorders; blow-out fracture
Congenital Abnormalities
Inflammations
Tumours / neoplastic disorder
Vascular malformations
Caraticocavernous Fistula
COMMON SYMPTOMS & SIGNS OF
ORBITAL DISEASES
• Symptoms
– Pain; orbital/ periorbital/ with ocular
movements
– Visual disturbances, loss/ blurring/
– Diplopia/ squint
– Swelling of the eyelids/ periorbital area/
mass
– Protrusion of the eyeball
• Signs
• Related to the eyeball
– Proptosis; forward displacement of the
eyeball
– Dystopia; horizontal/vertical displacement
of the eyeball in the coronal plane which
may/ may not coexist with the forward
displacement
– Enophthalmos ; recession of the globe into
the orbit
– Nanophthalmos ; a very small eyeball
– Anophthalmos: No eyeball- empty socket
Proptosis & dystopia
Vertical
dystopia
Proptosis
Horizontal
dystopia
Proptosis, diplopia, enophthalmos
• Conjunctival & lid signs; swelling of the lid,
conjunctival chemosis, injection ( redness)
• Ocular motility disturbances; restrictive or
muscle entrapment disorders, neurological
disorders- strabismus
• Corneal signs; secondary to exposure of the
cornea
• Posterior segment signs; venous dilatation &
tortuosity , vascular occlusions, optic disc
(OD) swelling, optic atrophy, choroidal folds
Conjunctival, lid & ocular motility signs
• Other signs; bruit (carotid-cavernous
fistula/CCF), pulsations (CCF, orbital
roof defects), palpable mass
• Sight threatening signs are exposure
keratopathy, pupillary abnormalities
( RAPD) & optic disc or vascular
changes in the retina
Causes of proptosis
• Common causes of proptosis in adults
– Thyroid eye disease
– Tumours
• Common causes of proptosis in children
– Orbital cellulitis
– Tumours
– Congenital malformations of the orbital
bones
Clinical evaluation of orbital disorders
• History
• Examination
– Assessment of visual functions; Visual
acuity & colour vision
– Examination of the anterior segment
– Examination of the pupils
– Examination of the posterior segment
– Examination of the Extra Ocular Muscles
– Intraocular pressure measurements
• Special tests
– Exophthalmometry ( measuring globe
protrusion & displacement – proptosis,
dystopia)
– Local palpation
– Bruit & pulsations
– Checking for cranial nerve dysfunctions (II,
III, IV, V, VI, VII,VIII)
Clinical test; measuring proptosis
Exophthalmometer
• IMAGING
– Ultrasonography (US)
– CT scan
– MRI
– Plain radiographs ( Caldwell & Waters
view)- mostly taken over by CT & MRI
Our case
A16 year old female patient presented with
forward protrusion of the right eye for the last one
year, it was developed gradually with an
associated visual loss……
Questions?
• What could have been the cause of the
protruding globe?
• Which structures could have been
involved?
• What do you need to ascertain that?
• Why the visual loss?
• What would be the effect of this
protrusion on the eye?
• What would happen to this patient?
What is
this?
Summary
•
•
•
•
Orbital disease are not common but can have sight
threatening & at times life threatening sequelae
Common categories of orbital disorders include;
Congenital anomalies, infections, inflammations,
tumours, traumatic disorders
Commonest presentation is with proptosis, sight
threatening signs include corneal exposure
keratopathy, RAPD, optic disc changes
The commonest causes of proptosis in adults
include TED & tumours while in children the
commonest causes are orbital cellulitis, congenital
disorders & tumours/ neoplastic disorders.