Common Clinical Presentations and Clinical Evaluation in Orbital

Common Clinical Presentations and Clinical Evaluation in Orbital Diseases Dr. Ayesha Abdullah 15. 09. 2017

LEARNING OBJECTIVES By the end of this lecture the students would be able to; 1. Categorize orbital diseases 2. Correlate the common symptoms & signs of orbital diseases with the underlying structural and functional disorder 3. Outline the protocol for the clinical evaluation of a patient with orbital disorder 2

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

• 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? A. Normal Vision B. Sub-normal Vision C. Moderate Visual Impairment D. Severe Visual Impairment E. Blindness 4

RADIOGRAPHIC ANATOMY OF THE ORBIT VIEWS : AXIAL VIEWS

CORONAL VIEW

SAGITTAL VIEW

AXIAL CT SCAN

CLASSIFICATION OF ORBITAL DISEASES 1. Congenital anomalies 2. Infections; orbital cellulitis 3. Inflammations; thyroid ophthalmopathy/ Thyroid Eye Disease (TED), 4. Tumours; primary , secondary, benign, malignant 5. Vascular malformations; Carotid-Cavernous Fistula (CCF), orbital varices 6. Traumatic disorders; blow-out fracture 13

Congenital Abnormalities 14

Inflammations 15

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Tumours / neoplastic disorder 17

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Vascular malformations 19

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Caraticocavernous Fistula 21

COMMON SYMPTOMS & SIGNS OF ORBITAL DISEASES • Symptoms – Pain; orbital/ periorbital/ with ocular movements – Visual disturbances, loss/ blurring/ – Diplopia/ squint – Swelling of the eyelids/ periorbital area/ mass – Protrusion of the eyeball 22

• 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 23

Proptosis & dystopia Vertical dystopia Proptosis Horizontal dystopia 24

Proptosis, diplopia, enophthalmos 25

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• 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 32

Conjunctival, lid & ocular motility signs 33

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• 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 37

Causes of proptosis • Common causes of proptosis in adults – Thyroid eye disease – Tumours • Common causes of proptosis in children – Orbital cellulitis – Tumours – Congenital malformations of the orbital bones 38

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 39

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• Special tests – Exophthalmometry ( measuring globe protrusion & displacement – proptosis, dystopia) – Local palpation – Bruit & pulsations – Checking for cranial nerve dysfunctions (II, IV, V, VII, VIII) 41

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Clinical test; measuring proptosis 43

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Exophthalmometer 45

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

Our case A 16 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…… 48

What is this? 49

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. 50