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

2. 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

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

4. 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

5. VIEWS : AXIAL VIEWS
RADIOGRAPHIC ANATOMY OF THE ORBIT

6. CORONAL VIEW

7. SAGITTAL VIEW

10. AXIAL CT SCAN

13. 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

14. Congenital Abnormalities

15. Inflammations

17. Tumours / neoplastic disorder

19. Vascular malformations
Orbital Varices

21. Caraticocavernous Fistula

22. 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

23. 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

24. Proptosis & dystopia
Vertical dystopia
Proptosis
Horizontal dystopia

25. Proptosis, diplopia, enophthalmos

26. Exophthalmos

27. Dystopia

28. Dystopia

29. Dystopia

31. Rt Dystopia+enophthalmos
Left Enophthalmos

32. 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

33. Conjunctival, lid & ocular motility signs

37. 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

38. 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

39. 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

41. 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)

43. Clinical test; measuring proptosis

45. Exophthalmometer

46. 20 mm normal
More than 2 mm difference in the two eyes
21-23 mild
24-27 moderate
28 or more- severe

47. IMAGING Ultrasonography (US) CT scan MRI
Plain radiographs ( Caldwell & Waters view)- mostly taken over by CT & MRI

48. 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……

49. What is this?

50. 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.