1 / 36

Exophthalmometry

Exophthalmometry. Dr. Diana Shechtman. Introduction. Orbital disorders can be associated with forward protrusion or backward displacement of the eyes Proptosis (exophthalmos) Abnormal forward protusion of the eyeball

lilike
Download Presentation

Exophthalmometry

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Exophthalmometry Dr. Diana Shechtman

  2. Introduction • Orbital disorders can be associated with forward protrusion or backward displacement of the eyes • Proptosis (exophthalmos) • Abnormal forward protusion of the eyeball • orbital volume is fixed, thus, excess in volume will result in protrusion of the globe • Orbit is made out of BONE…It does not yield to increase pressure within it • Enophthalmos • abnormal posterior displacement of globe • Sinking of eyeball into orbit mni.mcgill.ca/neuroimage/

  3. Causes of proptosis & enophthalmos Proptosis • Graves Disease • #1 causes (endocrine) • Orbital Cellulitis • Orbital Infection • Orbital Inflammation • Orbital Tumor (neoplasm) • Cavernous Sinus Fistula • vascular anomaly Enophthalmos • decrease orbital fat • age • degenerative atrophy • Orbital Fracture Mnemonic for proptosis: VEIN

  4. Orbital examination • May include** • Case Hx • Prelims • VA, CV • Neuro evaluation: pupils & EOMs • SL evaluation • Conjunctival injection • Lid position • Tonometry & DFE • Globe evaluation • Observation • Above, below and from the side • Resistant to retropulsion & FD testing • Displacement measurement (Exophthalmometry) ** orbital examination is not restricted to above mentioned tests

  5. Proptosis Evaluation: Direct Observation • Family album tomography (FAT) • old photos • View from above • position of lids under the brow • Detect relative position of cornea under lids

  6. Exophthalmometry • Measurement of position of globe in the orbit • relative to lateral angle of the orbital rim • anterior corneal projection is commonly used as landmark for anterior position of the globe • cornea is viewed in profile Casser’s Atlas of primary care

  7. Why perform exophthalmometry? • Exophthalmos appearance is not always confirmed by direct observation • proptosis may be subtle • pseudo-proptosis appearance may be cause by • contralateral ptosis • Presence of lid retraction • normal asymmetry of palpebral fissure

  8. Clinical use of exophthalmometry • differential b/t pseudo and true exophthalmos/enophthalmos • detection of • exophthalmos • enophthalmos • monitoring disease process associated with exophthalmos

  9. Examples of clinical use Proptosis as CC Proptosis obs. during exam • Enophthalmos • 2nd to blow-out fracture Orbital tumor suspect Orbital cellulitis or inflammation Pt with Grave’s disease

  10. Other indications • Rule out pseudoproptosis • Long axial length (case discussed later) • Asymmetrical palpebral fissure • Congenital glaucoma • Orbital asymmetry

  11. Determining globe position • CT • Optical 3D imaging eyecasualty.co.uk

  12. Common ways to determining globe position: Exophthalmometers • Allows for images of corneal apex to project on a mm ruler • Hertel (1905)1 • Most common • Criticizes in literature for low reliability1 • Luedde (1938)

  13. The Hertel Pictures: store1.yimg.com/I/ Marco’s uses prisms B&L’s or Lombart’s mirrors incline at 45 degrees from sagittal plane

  14. The Hertel • Foot-plates (or yokes) “ grooved arc” fit over bony temporal margin of lateral orbital rim • crossbar • Establish baseline to allow for biocular reading Lock **B&L’s or Lombart’s design

  15. The Luedde • Transparent plastic mm ruler • Notch conforms to angle of lateral orbital rim • scale readings: 0mm (end of notch**) to 40mm • parallax is minimized by using scale on both sides of the rod** ** Are advantages of using Luedde over a standard ophthalmic mm ruler

  16. ExophthalmometrySet up • Pt to look straight ahead • Palpate the bony ridge • locating deepest angle of the orbital rim

  17. Hertel Procedure • Loosen the lock (B&L or Lombart) • slide mirrors or prisms along the horizontal bar to adjust footplates with corresponding lateral orbital rims • Bring Hertel forward toward pt, keeping it parallel to floor with crossbar scale visible in front • pt eye should be closed Casser’s Atlas of primary care

  18. Hertel Procedure • Position footplates against each lateral orbital rim independently Casser’s Atlas of primary care

  19. Hertel Procedure • pts eye open widely & at your eye level • Look at the mirror • Take mm measurement where apex of cornea(lower) is superimposed on the mm scale (upper) • corneal reflex lower mirror & mm scale upper mirror • OU

  20. Hertel Procedure • Read of the cross bar scale (near BASE)

  21. Luedde Procedure • Place notch against orbital rim • Scale should face out on the side • Keep luedde perpendicular to plane of face • move your head until mm rule numbers are superimposed above and below • Read the mm scale where corneal apex intersects • On temporal side Casser’s Atlas Clinical Pearlyou may shine a penlight on cornea from below to enhance corneal apex

  22. Hertel vs. Luedde • Hertel • biocular reading • baseline for sequential readings • parallax cues • Luedde • Strabismus • Facial asymetry • Since facial asymmetry can cause measurement error in particular with Hertel, Luedde are use for those occasions • parallax cues

  23. Recording • measurement is made in mm • For Hertel measurement record finding for each eye along with separation of instrument (BASE)

  24. Example • Hertel • 17/18mm @ 100 • OD 20mm & OS 21mm @ 115 • Luedde • OD,OS 17mm

  25. Analysis measurements • Eyes are compared… • Comparative • Relative • Absolute

  26. Interpretation • Comparative • serial exophthalmometry readings of the same eye are compared over time • Use same instrument • best to use Hertel over Luedde • Base reading • Commonly employed as a test on pt’s with Grave’s disease

  27. Interpretation • Relative • comparison of readings b/t two eyes • norm: </= 2mm • Absolute • comparison of readings to norms • whites 12 to 20 mm1 (10-22mm)2 • average 15 -17mm • blacks 12 to 24 mm1 • average 2mm higher than whites 1: Atlas 2: Eskridge

  28. Exophthalmometry interpretations • Age • lower readings for children • average 14mm • b/t age 10-18 there is a 3mm increase • Sex • males have higher readings • ~1mm • Posture • In supine position NORMAL eyes sink back 1-3mm • Grave’s disease pt’s eye are not affected by this phenomena

  29. Exophthalmometry interpretations • Ethnicity • Blacks have higher reading • 12-24mm • Asian have smaller ranges • 12-18mm

  30. Final Note • Reliability may be affected by • poor fixation or convergence • parallax errors (tilting instrument) • minor deviations in position result in gross variations in reading • Narrow base on Hertel • Blepharospasm • Facial bone dysformity may cause unreliable measurements due to unparallel placement of device Inter-observer variation is common problem associate with reliability

  31. AFTER exophthalmometry measurements:When to further evaluate… • Difference of >/=3 mm b/t eyes • Readings greater than the norm

  32. Further testing • Ultrasonography • CT scan • Evaluation of bony components of orbit • MRI • Valuable in displaying orbital contents • Endocrine evaluation • Grave’s disease is most common cause of proptosis

  33. CASE ANALYSIS • 34 y.o. WF • no complaints • here for annual exam • POHx: amblyopia OS since very young • PMhx: LME 2M ago • “clean bill of health”

  34. CASE ANALYSIS • VA(d)cc • 20/20 OD CF at 5 ft. OS • Pupils: (-) APD • EOM: SAFE OU • CF: FULL OD, OS

  35. CASE ANALYSIS • M: • -1.00 -0.50 X 180 20/20 • -12.00 sph 20/70 • General observation • proptosis OS • Exophthalmometry • OD17mm/22mm @ 109 www.scielo.br/img/

  36. References • Eskridge’s Clinical procedure in optometry • Glaser’s neuro-ophthalmology

More Related