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Differential Diagnosis of Orbital Disease . Optometry 8570 Fall, 2008 Edward S. Jarka , O.D., M.S. Anatomy of Importance:. Intraorbital part of the optic nerve is longer than the distance between the back of the globe and the optic foramen.

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Differential diagnosis of orbital disease

Differential Diagnosis of Orbital Disease

Optometry 8570

Fall, 2008

Edward S. Jarka, O.D., M.S.

Anatomy of importance
Anatomy of Importance:

  • Intraorbital part of the optic nerve is longer than the distance between the back of the globe and the optic foramen.

  • The roof of the orbit is adjacent to the frontal sinus & the anterior cranial fossa.

  • Floor is adjacent to the maxillary sinus.

  • Medial wall is thin and adjacent to the ethmoid sinus.

  • What passes through the orbital fissurres?

Clinical signs

Clinical Signs

9 General Signs – Name them

Signs of orbital disease
Signs of Orbital Disease

  • Soft tissue signs

  • Proptosis

  • Enophthalmos

  • Ophthalmoplegia

  • Dynamic signs

  • Optic disc changes

  • Choroidal folds

  • Retinal vascular changes

  • Vision reduction

General causes of orbital disease
General Causes of Orbital Disease

  • Thyroid disease

  • Infections in/around the Orbit

  • Inflammatory

  • Vascular malformations

  • Space occupying lesions

  • Craniosynostoses

A quick graves disease review
A Quick Graves Disease Review

  • Autoimmune

  • EOM enlargement

  • Increase in orbital contents

  • Signs:

    • Dalrymple

    • Von Graefe

    • Kocher

Von graefe sign
von Graefe Sign:

Infections in around the orbit


No Proptosis

F.R.O.M. of EOM’s

Normal Pupils

Normal Visual Acuity





Reduced Visual Acuity

Infections in/around the Orbit

Preseptal or orbital
Preseptal or Orbital?

Preseptal or orbital1
Preseptal or Orbital?

Orbital mucormycosis
Orbital Mucormycosis

  • Rare, but seen in diabetics and immunosuppressed patients.

  • Spores check-in but the patient checks-out.

    • Sinuses to orbit to brain.

  • Treatment?

Inflammatory orbital disease

Inflammatory Orbital Disease


Acute Dacryoadenitis

Orbital Myositis

Tolusa-Hunt Syndrome

Orbital inflammation
Orbital inflammation:

  • Can affect any or all structures within the orbit.

  • Can be nonspecific, granulomatous, or vasculitic.

  • The inflammation can be part of an underlying medical disorder or can exist in isolation.

Idiopathic orbital inflammatory disease orbital pseudotumor
Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor)

  • Inflammation can involve any or all or the orbital soft tissues.

  • Unilateral in adults, can be bilateral in children.

  • Spontaneous remission in about 3 weeks, but prolonged cases may lead to fibrosis of the EOM’s leading to a “frozen orbit”.

Idiopathic orbital inflammatory disease orbital pseudotumor1
Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor)


  • Observation in mild cases.

  • Steroids are effective in 50% to 75% of cases that are moderate to severe.

Acute dacryoadenitis
Acute Dacryoadenitis

  • Can be seen along with IOID

  • Patient presents with sudden discomfort around the lacrimal gland.

    • S-shaped ptosis

    • Displacement of the globe down and in

    • Lacrimal secretion decreased.

  • Rule out infection and space occupying lesions of the lacrimal gland.

Acute dacryoadenitis1
Acute Dacryoadenitis

Orbital myositis
Orbital Myositis

  • Inflammation of one or more EOMs.

  • Usually a young adult with acute pain worsened by eye movements and diplopia.

  • Injection over the involved muscle.

Tolosa hunt syndrome
Tolosa-Hunt Syndrome

  • Non-specific granulomatous inflammation of the cavernous sinus, superior orbital fissure and/or the orbital apex.

  • Diplopia with severe headache pain on the involved side

Vascular malformations

Vascular Malformations

Carotid-cavernous fistula

Carotid cavernous fistula ccf
Carotid-Cavernous Fistula (CCF)

  • When the carotid arterial blood flows anteriorly into the ophthalmic veins, ocular signs may occur because of venous and arterial stasis around the eye and orbit.

    • Increased episcleral venous pressure

    • Decrease in arterial flow to the CN in the cavernous sinus

The cavernous sinus
The Cavernous Sinus:

In Wall: 1 = Oculomotor; 2 = Trochlear; 4 = V1; 5 = V2

In Sinus: 3 = Abducens; 6 = Autonomic Plexus; 7 = Internal Carotid

Classification of ccf s
Classification of CCF’s

1) Etiology

  • Spontaneous

  • Traumatic

    2) Blood flow Dynamics

  • High flow

  • Low flow

    3) Anatomy

  • Direct

  • Indirect

High flow ccf
High-flow CCF

  • Represents 70% to 90% of all CCF’s

  • Blood from the carotid artery flows directly into the cavernous sinus

    • Defect is in the internal carotid artery

      • Trauma (most common)

      • Spontaneous rupture

  • Classical Signs:

    • Pulsatileproptosis, Chemosis, Intracranial noise

Other ocular signs from high flow ccfs
Other Ocular Signs from High-flow CCFs

  • Ocular Bruit

    • Reduced with carotid compression in the neck

  • IOP

  • Anterior segment ischemia

  • Ophthalmoplegia

  • Fundus signs

Low flow ccf
Low-flow CCF

  • The arterial blood of the carotid arteries indirectly flows into the cavernous sinus via the meningeal branches.

    • More subtle symptoms

  • Causes:

    • Spontaneous (after trauma)

    • Congenital malformations

Ocular signs of low flow ccfs
Ocular Signs of Low-flow CCFs

  • Gradual, chronic redness due to episcleral venous engorgement.

  • Greater than the normal pulsation seen during applanationtonometry

  • All signs of high-flow CCFs (milder)

Cystic lesions and tumors
Cystic lesions and Tumors

  • Displacement of the globe

  • Seen in all ages

  • Must be differentiated by CT/MRI/Biopsy

So what s important to know
So – What’s important to know?

  • Given that a patient presents with proptosis, what guides you to the diagnosis?

    • Diplopia?

    • Pain?

    • Time of onset?

    • Severity of symptoms?

    • Red eye?

    • Chemosis?

    • Dynamic symptoms?

What is the optometrists role
What is the Optometrists Role?

  • Identify the signs and symptoms

  • Help initiate the diagnosis

  • Follow-up

  • Managing the patient after surgery

    • Diplopiamanagement


It could be worse
It could be worse.

“Halloween is gonna suck this year”

Advice for test and boards
Advice for Test and Boards

  • Work hard

  • Put time into understanding

  • You will succeed…

… Eventually

Wait till next year!