Common Clinical Presentations and Clinical Evaluation in Orbital Diseases Dr. Ayesha Abdullah 15.09.2017

By the end of this lecture the students would be able to; LEARNING OBJECTIVES By the end of this lecture the students would be able to; Categorize orbital diseases Correlate the common symptoms & signs of orbital diseases with the underlying structural and functional disorder Outline the protocol for the clinical evaluation of a patient with orbital disorder

Review Which of the following is an unavoidable cause of blindness? Age-related Macular Degeneration Cataract Glaucoma Uncorrected Refractive Errors Vitamin A Deficiency A

If a person has VA of 6/60 in the right eye, 3/60 in the left eye If a person has VA of 6/60 in the right eye, 3/60 in the left eye. You would place this person in which of the following categories? Normal Vision Sub-normal Vision Moderate Visual Impairment Severe Visual Impairment Blindness

VIEWS : AXIAL VIEWS RADIOGRAPHIC ANATOMY OF THE ORBIT

CORONAL VIEW

SAGITTAL VIEW

AXIAL CT SCAN

CLASSIFICATION OF ORBITAL DISEASES Congenital anomalies Infections; orbital cellulitis Inflammations; thyroid ophthalmopathy/ Thyroid Eye Disease (TED), Tumours; primary , secondary, benign, malignant Vascular malformations; Carotid-Cavernous Fistula (CCF), orbital varices Traumatic disorders; blow-out fracture

Congenital Abnormalities

Inflammations

Tumours / neoplastic disorder

Vascular malformations Orbital Varices

Caraticocavernous Fistula

COMMON SYMPTOMS & SIGNS OF ORBITAL DISEASES 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

Exophthalmos

Dystopia

Dystopia

Dystopia

Rt Dystopia+enophthalmos Left 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 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

20 mm normal More than 2 mm difference in the two eyes 21-23 mild 24-27 moderate 28 or more- severe

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 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.