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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:. 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

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  1. Differential Diagnosis of Orbital Disease Optometry 8570 Fall, 2008 Edward S. Jarka, O.D., M.S.

  2. 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?

  3. Orbit Anatomy:

  4. Clinical Signs 9 General Signs – Name them

  5. Signs of Orbital Disease • Soft tissue signs • Proptosis • Enophthalmos • Ophthalmoplegia • Dynamic signs • Optic disc changes • Choroidal folds • Retinal vascular changes • Vision reduction

  6. General Causes of Orbital Disease • Thyroid disease • Infections in/around the Orbit • Inflammatory • Vascular malformations • Space occupying lesions • Craniosynostoses

  7. A Quick Graves Disease Review • Autoimmune • EOM enlargement • Increase in orbital contents • Signs: • Dalrymple • Von Graefe • Kocher

  8. von Graefe Sign:

  9. Preseptal: No Proptosis F.R.O.M. of EOM’s Normal Pupils Normal Visual Acuity Orbital: Proptosis Ophthalmoplegia + APD Reduced Visual Acuity Infections in/around the Orbit

  10. Preseptal or Orbital?

  11. Preseptal or Orbital?

  12. Orbital Mucormycosis • Rare, but seen in diabetics and immunosuppressed patients. • Spores check-in but the patient checks-out. • Sinuses to orbit to brain. • Treatment?

  13. Inflammatory Orbital Disease Idiopathic Acute Dacryoadenitis Orbital Myositis Tolusa-Hunt Syndrome

  14. 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.

  15. 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”.

  16. Mild to moderate IOID

  17. Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor) Treatment: • Observation in mild cases. • Steroids are effective in 50% to 75% of cases that are moderate to severe.

  18. 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.

  19. Acute Dacryoadenitis

  20. 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.

  21. 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

  22. Vascular Malformations Carotid-cavernous fistula

  23. 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

  24. The Cavernous Sinus: In Wall: 1 = Oculomotor; 2 = Trochlear; 4 = V1; 5 = V2 In Sinus: 3 = Abducens; 6 = Autonomic Plexus; 7 = Internal Carotid

  25. Classification of CCF’s 1) Etiology • Spontaneous • Traumatic 2) Blood flow Dynamics • High flow • Low flow 3) Anatomy • Direct • Indirect

  26. 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

  27. Other Ocular Signs from High-flow CCFs • Ocular Bruit • Reduced with carotid compression in the neck • IOP • Anterior segment ischemia • Ophthalmoplegia • Fundus signs

  28. High-flow CCF:

  29. 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

  30. 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)

  31. Low-flow CCF:

  32. Space Occupying Lesions

  33. Cystic lesions and Tumors • Displacement of the globe • Seen in all ages • Must be differentiated by CT/MRI/Biopsy

  34. 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?

  35. What is the Optometrists Role? • Identify the signs and symptoms • Help initiate the diagnosis • Follow-up • Managing the patient after surgery • Diplopiamanagement Scared?

  36. It could be worse. “Halloween is gonna suck this year”

  37. Advice for Test and Boards • Work hard • Put time into understanding • You will succeed…

  38. … Eventually Wait till next year!

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