Download AMatterofMillimetersFinal

3/28/2016
A MATTER OF
MILLIMETERS
PATIENT INFORMATION
• 57 WM
• POH
• (+) trauma OS
• PMH
• Hyponatremia
• Hyperglycemia
• Chronic low back pain
ALANNA O’KEEFE – MARCH 29 TH , 2016
PATIENT INFORMATION
EXAM INFORMATION
• CC – “my eye sticks out”, “friends were worried”
• BCVA: 20/20 OU
• (-) pain, diplopia, pulsatile exophthalmos, bruit
• Refraction
• No thyroid problems
• (+) occasional FBS, redness
• OD: -4.75 -1.25 x 040
• OS: -2.75 -2.25 X 150
• EOMS: Limitation OS
• VF: clear OU
• Exophthalmometry
• Base: 100 mm
• OD: 14 mm
• OS: 21 mm
http://www.jcytol.org/showbackIssue.asp?issn=0970-9371;year=2008;volume=25;issue=2
1
3/28/2016
EXAM INFORMATION
PLAN
• Observation
• Exophthalmos
• Incomplete lid closure OS
• CT
• IOP
• CTA
• 16 mmHg OU
• AMD
• Lens
• 1+ NS
• Optic Nerve
• OD: .15
• OS: .25
• Vitreous
• Asteroid hyalosis OD
• Preservision and Amsler grid
• Cataracts
• Monitor yearly
• CMA with Presbyopia
• SRx
•Macula
• Soft coalesced drusen OU
CLINICAL MANIFESTATIONS
EXOPHTHALMOS OVERVIEW
• Exophthalmos
• Proptosis
• Bruit
• Exophthalmos
• Chemosis
• Specific
• Arterialized corkscrew conjunctival vessels
• Thyroid-Associated Ophthalmopathy
• Diplopia
• Glaucoma
2
3/28/2016
MEASUREMENT
HERTEL EXOPHTHALMOMETER
• Exophthalmometry
• Hertel exophthalmometer
• Base measurement
• Used for future measurements
• Exophthalmos measurement
• Accuracy
• Patient fixation
• Positioning
• Worm’s-eye view
https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDA
x8jfULsh0VAdAsNSU!/?ActiveNumber=1&ActivePopup=1&StepPos=510&contentUrl=%2Fsrg%2Fpopup%2Fadditional_material%2F92%2F
X70-examination.enl.jsp&popupStyle=diagnosis&printPopup=true&soloState=true
ALTERNATIVES
ALTERNATIVES
• Luedde Exophthalmometer
• Naugle exophthalmometer
• Distance from corneal apex to orbital rim
• Relative difference between each eye
• Transparent ruler
• Above and below superior and inferior orbital rims
• Forehead
• Cheek bones
• Indications
• Asymmetry of lateral orbital rims
• Congenital
• Orbital fracture
• Previous surgery
• Lateral orbitotomy
http://archive.constantcontact.com/fs014/1107938791324/archive/1110930109840.html
3
3/28/2016
NAUGLE EXOPHTHALMOMETER
NORMATIVE VALUES
• Agree to disagree
• Multiple sources with varying ranges.
• Normal Range : 11mm – 24mm
•
Ethnicity
•
• Asian: 18 mm
• Caucasian: 20 mm
• African American: 24 mm
Sex
•
• More prominent in men.
Asymmetry
•
• Greater than 2mm abnormal
Age
•
Increase as we age
https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDA
x8jfULsh0VAdAsNSU!/?ActiveNumber=1&ActivePopup=1&StepPos=511&contentUrl=%2Fsrg%2Fpopup%2Fadditional_material%2F92%2F
X70-examination.enl.jsp&popupStyle=diagnosis&printPopup=true&soloState=true
DIFFERENTIAL DIAGNOSES
HISTORY OF PRESENT ILLNESS
• Tumor
• Onset/Course
• Vascular Abnormality
• Days to weeks
• Inflammatory
• Months to years
• Trauma
• Thyroid-Associated Ophthalmopathy
• Pseudoproptosis
• Enlarged globe
• Asymmetrical orbital size
• Asymmetric palpebral fissures
• EOM weakness/paralysis
• Old photographs
• Symptoms
• Pain, diplopia, changes in vision
• Systemic Disease
• Thyroid
• Cancer
• Ear, Nose, or Throat abnormalities
• Prior injury
• Contralateral enophthalmos
4
3/28/2016
ESSENTIAL EXAM ELEMENTS - SIGNS
ESSENTIAL EXAM ELEMENTS – SIGNS
• Globe Displacement
• Axial displacement
• Red Flags
• Nonaxial displacement
• Bilateral
• Eye pain or diplopia on EOMs
• Unilateral
• Severe headache
• Loss of vision or visual field
• Periorbital Changes
http://www.eyecancer.com/conditions/21/lymphoma-of-theconjunctiva
• Fever
• Pulsating proptosis
http://www.kellogg.umich.edu/theeyeshaveit/redeye/arteriovenous-fistula.html
pdfs.journals.lww.com
SPECIAL TESTING
BLOODWORK
• Exophthalmometry
• Thyroid Function Testing
• Eyelids
• Thyroid-Stimulating Hormone (TSH)
• Palpation
• Ultrasensitive
• Orbit, Thyroid, Regional lymph nodes
• Pulse or thrill
• Presumptive diagnosis
• Thyroxine (T4)
• Auscultation
• Confirmation
• Valsalva
• Triiodothyronine (T3)
• CN testing
• Ordered if T4 is normal
• VF testing
• 5% of patients that are hyperthyroid will have
normal T4 levels
http://www.ncbi.nlm.nih.gov/books/NBK289/
5
3/28/2016
BLOODWORK
IMAGING
TSH
Free T4
Free or Total T3 Probable Interpretation
High
Normal
Normal
Mild (subclinical)
hypothyroidism
High
Low
Low or normal
Hypothyroidism
Low
Normal
Normal
Mild (subclinical)
hyperthyroidism
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• T1 – weighted
• Best anatomical detail of orbit
• T2 – weighted
Low
High or normal
High or normal
Hyperthyroidism
Low
Low or normal
Low or normal
Non-thyroidal illness;
pituitary (secondary)
hypothyroidism
• Gadolinium
Normal
High
High
Thyroid hormone
resistance syndrome
(mutation in the thyroid
hormone receptor
decreases thyroid hormone
function)
• Fat Suppression
IMAGING
• Contrast agent
TREATMENT
CT
MRI
• Lubrication
• Spatial resolution
• Soft tissue definition
• Lid taping
• Cheap
• Subacute trauma
• Quick
• Orbital apex
• Bone or calcification
• Simultaneous imaging
of multiple planes
• Acute
trauma/hemorrhage
• Close monitoring/time
• Referral
• Surgery
• OK for ferromagnetic
metallic FB
6
3/28/2016
TAO TREATMENT GUIDE
PATIENT INFORMATION
• 50 year old AAF
• Medical History
• Headaches
• Hypertension
• Sinus pain
• Sleep apnea
• Hypothyroidism
• Thyroidectomy
Indian J Ophthalmol. 2012 Mar-Apr; 60(2): 87–93.
doi: 10.4103/0301-4738.94048
PATIENT INFORMATION CONT.
INITIAL VISIT – EXAM FINDINGS
• Ocular History
• Vasc
• OD – 20/20
• Reading glasses
• Current Medications
• Synthroid 0.125 mg
• Hydrochlorothiazide
• Clonidine
• OS – 20/25
• EOMS – FROM OU, (+) pain, (-) diplopia
• Exophthalmometry
• Base 105 mm
• OD – 27mm
• OS – 26 mm
• IOP – 16 OU
• Lexapro
• Decreased tear meniscus OU
• OTC sinus medications
• Mild Injection OU
• Optic Nerves 0.4 OU, (-)swelling, pallor OU
7
3/28/2016
INITIAL VISIT - MANAGEMENT
IMAGING RESULTS
• Dry Eye
• CT
Symptoms OD > OS
• Artificial tears preservative free OU
• Ovoid hyperdense mass right orbit
• Exophthalmos OD
• 1.0 cm X 0.5 cm
• CT scheduled
• Located upper – inner quadrant of intraconal
space
• RTC if pressure/pain increases, vision decreases
• RTC for full exam
CT IMAGE
MRI
8
3/28/2016
MRI
MRI
MRI
9