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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.