Differential diagnosis of orbital disease
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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

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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?


Orbit anatomy

Orbit Anatomy:


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

Preseptal:

No Proptosis

F.R.O.M. of EOM’s

Normal Pupils

Normal Visual Acuity

Orbital:

Proptosis

Ophthalmoplegia

+ APD

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

Idiopathic

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”.


Mild to moderate ioid

Mild to moderate IOID


Idiopathic orbital inflammatory disease orbital pseudotumor1

Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor)

Treatment:

  • 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


High flow ccf1

High-flow CCF:


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)


Low flow ccf1

Low-flow CCF:


Space occupying lesions

Space Occupying Lesions


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

      Scared?


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

… Eventually

Wait till next year!


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