The intraorbital part of the optic nerve…

1. The intraorbital part of the optic nerve… • is longer than the distance from the back of the globe to the optic foramen.

2. the roof of the orbit is adjacent to… • frontal sinus • anterior cranial fossa

3. the floor of the orbit is adjacent to… • maxillary sinus

4. The medial wall of the orbit is… • thin and adjacent to the ethmoid sinus • “lamina paprycia”

5. what passes through the orbital fissures? • blood • nerves (branches of III, IV, V, VI

6. name the 9 general signs of orbital disease • soft tissue signs • proptosis • enophthalmos • ophthalmoplegia • dynamic signs • optic disc changes • choroidal folds • retina vascular changes • vision reduction

7. general causes of orbital disease • thyroid (Graves) disease • infections in & around orbit • inflammation • vascular malformations • space occupying lesions • craniosynostoses

8. quick review of Grave’s disease • autoimmune • IgG causes EOM enlargement (as well as hyperthyroidism due to IgG “fitting” the TSH receptors in thyroid) • results in increased orbital contents endophthalmos • Signs: • Dalrymple • VonGraefe • Kocher

9. describe the Dalrymple sign in Graves disease • lid retraction in primary gaze • “Do you see superior sclera on forward gaze?” • Normally the superior lid should rest 2mm below the limbus.

10. Describe the VonGraefe sign in Graves disease • retarded descent of the upper lid on downward gaze

11. Describe the Kocher sign in Graves disease • a staring and frightened appearance of the eyes which is particularly marked on attentive fixation

12. Differentiate between: Preseptal Orbital proptosis ophthalmoplegia (+) APD reduced VAs • no proptosis • FROM of EOM’s • normal pupils • normal VAs

13. Overview of rhino-orbital mucormycosis • rare opportunistic infection caused by Mucoraceae fungi • typically affects patients with: • diabetic ketoacidosis • compromised immune systems • inhalation of spores  upper respiratory infection  contiguous sinuses  orbit & brain

14. signs & symptoms of rhino-orbital mucormycosis • symptoms: • gradual-onset facial and periorbital swelling • diplopia • visual loss • signs: • ischemic infarction superimposed on septic necrosis responsible for black eschar which may develop on palate, turbinates, nasal septum, skin and eyelids • ophthalmoplegia • progression is slower than orbital cellulitis

15. treatment of mucormycosis • IV amphotericin • daily packing & irrigation of involved areas with amphotericin • wide excision of devitalized & necrotic tissues • hyperbaric oxygen may be helpful • correction of underlying metabolic defect • exenteration may be required in severe unresponsive cases

16. Name the inflammatory orbital diseases • idiopathic • acute dacryoadenitis • orbital myositis • Tolusa-Hunt Syndrome

17. “new name” for orbital pseudo-tumor • idiopathic orbital inflammatory disease (IOID)

18. IOID symptoms, signs, treatment • Symptoms • 3rd to 6thdecate • acute readness • swelling • pain • usually unilateral in adults; can be bilateral in children • Signs • congestive proptosis • ophthalmoplegia • optic nerve dysfunction if posterior orbit involved • Treatment • observation for mild cases • oral steroids effective for 50-75% of moderate—severe cases.

19. IOID differential • bacterial orbital cellulitis • severe acute thyroid eye disease • systemic disorders • Wegener granulomatosis • polyarteritisnodosa • Waldenströmmacroglobulinemia • ruptured dermoid cyst

20. acute dacryoadenitis symptoms, signs & treatment • Symptoms • acute discomfort in region of lacrimal gland (superior temporal globe) • Signs • swelling of lateral aspect of eyelid  ‘S’ shaped ptosis • globe displaced downward & inward • tenderness over lacrimal gland fossa • injection of palpebral portion of lacrimal gland & adjacent conjunctiva • lacrimal secretion may be reduced • Treatment • ~25% occur with IOID • more commonly, occur in isolation & resolve spontaneously • usually does NOT require treatment • Must rule-out infection & space occupying lesion of lacrimal gland.

21. orbital myositis general points • inflammation of at least one EOM • usually young adult with acute pain worsened by eye movements & diplopia • injection over involved muscle

22. orbital myositis differential & treatment • differential • orbital cellulitis • thyroid eye disease • Tolosa-Hunt syndrome • Treatment • NSAIDs for mild disease • systemic steroids (although recurrences occur in 50% of cases) • radiotherapy

23. Tolosa-Hunt syndrome • non-specific granulomatous inflammation of cavernous sinus, superior orbital fissure and/or orbital apex • Symptoms • diplopia associated with ipsilateralperiorbital or hemicranial pain • Signs • proptosis (mild if present) • CN III palsies w/pupil involvement • sensory loss along 1st & 2nd divisions of CN V • Treatment • systemic steroids

24. describe carotid-cavernous fistula • when carotid arterial blood flows into ophthalmic veins leading to ocular signs because of venous and arterial stasis around eye and orbit • increased episcleral venous pressure • decrease in arterial flow to CN in cavernous sinus

25. describe anatomy of cavernous sinus • Wall • CN III • CN IV • CN V1 & V2 • Sinus • CN VI • autonomic plexis • internal carotid

26. classification of carotid-cavernous fistulas • high flow • 70—90% of all CCFs • blood from carotid artery flows directly into cavernous sinus • defect in internal carotid • caused by trauma (most common) or spontaneous rupture • signs: pulsatileproptosis, chemosis, intracranial noise • low flow • blood flows indirectly via meningial branches • more subtle symptoms • greater than normal pulsation on Goldmann measurement

27. high-flow carotid cavernous fistula ocular signs • ocular bruit  reduced with carotid compression against neck • increased IOP • anterior segment ischemia (corneal epithelial edema, cells & flare, iris atrophy, cataract and rubeosisiridis) • ophthalmoplegia • fundus signs: optic disc swelling, venous dilation, intraretinal hemorrhage

28. low-flow carotid-cavernous fistula ocular signs • gradual, chronic redness due to episcleral venous engorgement • greater than normal pulsation on Goldmanntonometry • milder signs of high-flow CCF