Orbit & EOM 2024 PDF

Orbit and EOM E Kruger 2024 This Photo by Unknown Author is licensed under CC BY-SA Orbital pathology: Orbital disease Inflammatory orbital disease Infectious orbital disease Orbital tumours Orbital pathology...

Orbit and EOM E Kruger 2024 This Photo by Unknown Author is licensed under CC BY-SA Orbital pathology: Orbital disease Inflammatory orbital disease Infectious orbital disease Orbital tumours Orbital pathology Traumatic orbital disease Lacrimal gland mass/chronic dacryoadenitis Miscellaneous Orbital diseases Orbital disease symptoms Eyelid and conj oedema Redness Watering Pain (may become worse with eye movement) https://saulrajak.com/eye_socket_conditions/thyroid-eye-disease/ Increased ocular prominence  Orbital disease symptoms Sunken impression of eye Double vision Blurry vision Pulsing sensation https://eye5.com.au/eye-care/diplopia-double-vision/ Soft tissue involvement Causes: Proptosis Enopthalmos Ophthalmoplegia Orbital inflammatory conditions Soft tissue involvement Signs and symptoms: Eyelid and periocular oedema Skin discoloration Ptosis Chemosis Epibulbar injection https://www.researchgate.net/figure/A-soft-tissue-mass-of-the-patients-left-eye-before-A-and- after-B-surgery_fig1_324444683 Proptosis Definition: Abnormal protrution Generally applies to the eye Exophthalmos refers to eyeball alone Due to retrobulbar lesions or shallow orbit  Proptosis Asymmetrical Detect when looking down and from the side Direction May indicate pathology Space-ocupying lesion within muscle cone or optic nerve tumours cause axial proptosis This Photo by Unknown Author is licensed under CC BY Extraconal lesions – combined proptosis and dystopia  Displacement of globe in coronal plane due to extaconal orbital mass such as a lacrimal gland tumour Horizontal displacement measured from nose to centre of pupil Vertical scale perpendicular to a horizonal ruler placed over bridge of nose Measuring eye should fixate straight ahead Dystopia  Pseudoproptosis Due to facial asymmetry Enlargement of globe Pseudoproptosis Iid retraction Contralateral lagopthalmos  Measuring proptosis Exophthalmometer (Hertel) > 20mm indicates proptosis A difference of 2-3mm between eyes is suspicious regardless of absolute values https://image.shutterstock.com/image-photo/young-ophthalmologist-using- exophthalmometer-instrument-260nw-682814002.jpg  Proptosis signs and symptoms Symptoms: similar to lid retraction (see slide 44) Signs: Axial Unilateral / Bilateral Symmetrical / asymmetrical Frequently permanent Severe cases might compromise lid closure https://encrypted- tbn0.gstatic.com/images?q=tbn:ANd9GcR_gZVEzCwL7GmmO325lgZNxw7wSHidKbvFfg Tear disfunction and exposure &usqp=CAU Keratopathy, corneal ulceration, infection  Enophthalmos Recession of the globe within orbit Causes Congenital / traumatic orbital wall abnormalities Atrophy of orbital contents Sclerosis https://miranza.es/wp-content/uploads/2020/09/enoftalmos.jpg Pseudoenophthalmos Small or shrunken eye Ptosis Contralateral proptosis or pseudoproptosis  Ophthalmoplegia Defective ocular motility Causes Orbital myositis (inflammation in muscles) restriction of muscles or tissue after orbital wall fracture Ocular motor nerve involvement Tests Forced duction test https://www.atlasophthalmology.net/atlasimg/1233147055061_lo Differential IOP test w.jpg Saccadic eye movements https://sketchymedicine.com/wp-content/uploads/2013/12/ino.v2.png https://youtu.be/tIOyFsBwUuY  Restrictive vs neurological motility defect: Forced duction test Forced duction test Aneathetisia (local) Insertion of muscles grasped with forceps Globe rotated Restrictive: Difficulty to move the globe https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTM9JS0avST8tk6N8dNXdmIQ- UAnWiFd4s0PcmYBhDZ9xYsQeojB0xEROkre5jeOTtaOgw&usqp=CAU Neurological: No resistence is encountered Restrictive vs neurological motility defect: Differential IOP IOP in primary gaze Second time with patient attempting to look direction of limited mobility Restriction: Increase in IOP > 6 mmHg Neurological: Increase < 6 mmHg  Saccadic eye movement test Restriction: normal velocity with sudden halting (stopping) of ocular movement Neurological: reduced velocity https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(15)00226-4/references  Fundus changes Optic disc swelling Initial feature of compressive optic neuropathy Optic atrophy May be preceeded by swelling Causes include thyroid eye disease and optic nerve tumours https://www.columbiaeye.org/education/digital-reference-of-ophthalmology/vitreous-retina/retinal-vascular-diseases/optociliary-shunt Fundus changes Optocilliary collaterals Enlarged, pre-existing peripapillary capillaries Divert blood from the central retina venous circulation to the peripapillary choroidal circulation When there is obstruction of the normal drainage channel Thyroid eye disease (TED) Orbital disorder that can cause bilateral or unilateral proptosis Most common form is Graves ophthalmopathy Found in adults  Hyperthyroidism Excessive secretion of thyroid hormone Most common form called Graves disease Autoimmune disorder- overstimulation https://d16qt3wv6xm098.cloudfront.net/s3Kg2MUoT-Gx9m54vtKqtYiARu6_Pjx1/_.jpg of thyroid gland due to TSH binding to antibodies Presents 4th to 5th decades  Symptoms: Hyperthyroidism Weight loss Increased bowel frequency Sweating Heat intollerance Nervousness Irritability Palpitations https://i.pinimg.com/originals/61/e5/57/61e557d1a1fcd4f4a7ab2135ed571941. jpg Weakness Fatigue Enlarged thyroid gland  TED Risk factors Major clinical risk factor for developing TED is smoking Proportionate increase in risk and amount of smoking everyday Woman 5 x more likely than men https://vitamindwiki.com/tiki-download_wiki_attachment.php?attId=8749 Radioactive iodine used to treat hyperthyroidism can worsen TED  Pathogenesis of ophthalmopathy Organ specific autoimmune reaction Antibody reacts against thyroid cells Orbital fibroblasts leads to https://www.2minutemedicine.com/wp-content/uploads/2014/11/216-1200x675.jpg Inflammation of extraocular muscles Interstitial tissue  Orbital fat Lacrimal glands with pleomorphic cellular infiltration Increased secretion of glycosaminoglycans Osmotic imbibition (absorption of one substance by another) of water Pathogenesis Increased volume of orbital contents, particularly muscles Muscles swell up to 8 x their normal size Secondary increase in intra-orbital pressure Optic nerve may be compressed Pathogenesis Degeneration of muscle fibres eventually leading to fibrosis Tethering effect on involved muscle Results in restrictive myopathy and diplopia  1. Initial stages: Inflammatory stage where eyes are red and painful Remits within 1-3 years Clinical Only 30% develop serious long-term problems features 2. Fibrotic / quiescent stage Eyes are white Painless motility defect present  Clinical features categorized Soft tissue involvement Lid retraction Proptosis Optic neuropathy Restrictive myopathy Classification for severity of TED i. Sight threatening due to optic neuropathy corneal breakdown ii. Moderate-severe Soft tissue involvement Lid retraction of 2mm or more Diplopia and proptosis of 3mm or more iii. Mild Only a minor impact on daily life https://i.pinimg.com/originals/a2/84/ca/a284cafcb03ad64 d6729ebfca51a2eff.jpg Soft tissue involvement Symptoms Grittiness Red eyes Lacrimation Photophobia Puffy lids Retrobulbar discomfort Soft tissue signs Epibulbar hyperaemia Sensitive sign of inflammatory activity Intense focal hyperaemia may outline the insertions of the horizontal recti Periorbital swelling Oedema and infiltration behind the orbital septum Associated with chemosis and prolapse of retroseptal fat into the eyelids  Tear insufficiency and instability Common sign Corneal signs exacerbated by lid retraction Punctate epithelial erosions Superior limbic keratoconjunctivitis Occasional bacterial keratitis, thinning and scarring TED signs and symptoms Lid retraction Affects both upper and lower lids 50 % of cases High levels of thyroid hormone causes overstimulation of sympathetic system(fight or flight) which in turn causes overreaction of Muller muscle (elevation of upper lid) https://media.sciencephoto.com/c0/36/56/20/c0365620-400px-wm.jpg Fibrotic contracture of levator palpabrae (maintain upper lid posision) and inferior rectus Lid retraction signs Upper lid: lever or above superior limbus with the superior sclera being visible Lower lid: Sclera shows beneath the inferior limbus Dalrymple sign: lid retraction in primary gaze Lid retraction signs Kocher sign: staring and frightened appearance of the eyes with attentive fixation Von Graefe sign: retarded descent of upper lid on downgaze (lid lag) Restrictive myopathy 30% - 50% affected May be permanent Ocular motility restricted by inflammatory oedema and later fibrosis Symptoms: Double vision Discomfort Restrictive myopathy signs Increased IOP in up gaze: fibrotic contracture of inferior rectus therefore elevation defect Abduction defect: fibrosis of medial rectus Depression defect: fibrosis of superior rectus Adduction defect: fibrosis of lateral rectus Optic neuropathy Common and serious complication Compression of optic nerve or blood supply at orbital apex by congested and enlarged recti and swollen orbital tissue Possible permanent vision impairment, even in absence of proptosis Symptoms Impairment of central vision with other signs of TED Ask patient to monitor by alternatively closing one eye Assess intensity of colours Optic neuropathy signs Decreased VA Decreased colour desaturation Decreased light brightness RAPD (cause for marked concern) Visual field defect – central or paracentral scotoma Optic disc: usually normal, occasionally may be swollen Treatment Dependant on classification Always start with cessation of smoking Treatment of thyroid dysfunction Mild disease Lubrication Topical anti-inflammatory treatment Head elevation to reduce peri-orbital oedema Eyelid taping (keeping the eye closed to prevent exposure) when sleeping Treatment Moderate to severely active disease Systemic steroids (control inflammation whereby movement is increased) Orbital steroid injections Low-dose fractioned radiotherapy Treatment Post-inflammatory complications Proptosis: Surgery Restrictive myopathy: Surgery Lid retraction: Botox (prevent contraction of medial rectus muscle)