common clinical presentations and clinical evaluation in orbital diseases dr. ayesha abdullah...

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 diseases2. 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 anomalies2. 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 anomalies2. 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……

• 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?

Questions?

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.