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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
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
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.
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!