Common Clinical Presentations and

Clinical Evaluation in Orbital Diseases

Dr. Ayesha Abdullah 20.08.2015

LEARNING OBJECTIVES

By the end of this lecture the students would be able to;

1. Categorize orbital diseases2. 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

CLASSIFICATION OF ORBITAL DISEASES

1. Congenital anomalies2. Infections; orbital cellulitis 3. Inflammations; thyroid

ophthalmopathy, Tumours; primary , secondary, benign, malignant

4. Vascular malformations; Carotid-Cavernous Fistula (CCF), orbital varices

5. Traumatic disorders; blow-out fracture

CLASSIFICATION OF ORBITAL DISEASES

1. Congenital anomalies2. 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

Congenital Abnormalities

Inflammations

Tumours / neoplastic disorder

Vascular malformations

Caraticocavernous Fistula

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

• 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

Proptosis & dystopia

Vertical dystopia

Proptosis

Horizontal dystopia

Proptosis, diplopia, enophthalmos

• 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

Conjunctival, lid & ocular motility signs

• 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

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

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

• Special tests– Exophthalmometry ( measuring globe

protrusion & displacement – proptosis, dystopia)

– Local palpation – Bruit & pulsations– Checking for cranial nerve

dysfunctions (II, III, IV, V, VI, VII,VIII)

Clinical test; measuring proptosis

Exophthalmometer

• IMAGING – Ultrasonography (US)– CT scan– MRI – Plain radiographs ( Caldwell & Waters

view)- mostly taken over by CT & MRI

Our case

A16 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……

• What could have been the cause of the protruding globe?

• Which structures could have been involved?

• What do you need to ascertain that?

• Why the visual loss?• What would be the effect of this

protrusion on the eye?• What would happen to this

patient?

Questions?

What is this?

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.