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Anterior Segment Disease > Dacryoadenitis, Orbital Pseudotumor, and TED > Flashcards

Dacryoadenitis, Orbital Pseudotumor, and TED Flashcards

1
Q

dacryoadenitis

A

acute or chronic inflammation of the lacrimal gland

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2
Q

dacryoadenitis etiology/associations

A
  • idiopathic (idiopathic orbital inflammatory syndrome)
  • bacterial infection; most common bacteria include Staph, Strep, Neisseria gonorrheae, syphilis, TB
  • viral infection; most common viral infections include mumps, infectious mononucleosis, influenza, varicella zoster
  • autoimmune, inflammatory systemic disease; most common diseases include sarcoidosis, RA, SLE, Sjogren’s syndrome, GPA, IgG4-related disease
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3
Q

dacryoadenitis demographics

A

depends on etiology

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4
Q

dacryoadenitis laterality

A
  • depends on etiology
  • systemic disease and idiopathic are typically bilateral
  • bacterial is typically unilateral
  • viral can be unilateral or bilateral
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5
Q

dacryoadenitis symptoms

A
  • temporal upper eyelid swelling, redness, and tenderness/pain
  • droopy eyelid
  • tearing
  • if infectious, fever
  • if bacterial, discharge
  • if chronic, dry eye
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6
Q

dacryoadenitis signs

A
  • temporal upper eyelid edema, erythema, and tenderness/pain
  • S-shaped eyelid
  • lacrimal gland edema and hyperemia, lacrimal gland may be palpable
  • globe displacement inferiorly and medially
  • inflammation may extend to conjunctiva; seen as conjunctival injection and chemosis
  • if infectious, fever
  • if bacterial, purulent discharge
  • if viral, tender and/or swollen preauricular lymph nodes
  • if chronic, signs of aqueous-deficient dry eye
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7
Q

dacryoadenitis complications

A

orbital cellulitis

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8
Q

dacryoadenitis management

A
  • orbital CT scan or MRI; confirm the diagnosis and rule out other processes such as orbital cellulitis or tumor
  • treat empirically as a bacterial infection with oral antibiotics for 24 hours with careful reassessment; if no response to treatment, consider another etiology
  • bacterial: mild or moderate- oral antibiotic; severe: hospitalize and treat as orbital cellulitis
  • viral: cold compresses and analgesic for palliative therapy; if zoster, oral antiviral
  • non-infectious: oral steroids; order lab work based on most likely etiologies; if systemic etiology, refer out for systemic treatment
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9
Q

dacryoadenitis pearls: non-infectious etiologies

  • typically ____ with ____ signs and symptoms
  • ____ common than infectious
  • ____ is the most common non-infectious etiology
A

chronic;
milder;
more;
sarcoid

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10
Q

dacryoadenitis pearls: infectious etiologies

  • typically _____ with _____ signs and symptoms
  • ____ is the most common infectious etiology
  • ____ infection is rare
  • ____ common than non-infectious etiologies
A 
acute;
more severe;
viral;
bacterial;
less
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11
Q

idiopathic orbital inflammatory syndrome

A
  • also called IOIS or orbital pseudotumor
  • acute inflammation of soft tissues in the orbit to varying degrees: fat, connective tissue, muscle (myositis), lacrimal gland (dacryoadenitis), inflammation may extend to the globe- Tenon’s capsule (tenonitis), sclera (scleritis), uvea (uveitis)
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12
Q

idiopathic orbital inflammatory syndrome etiology

A

idiopathic

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13
Q

idiopathic orbital inflammatory syndrome demographics

A

no predilection

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14
Q

idiopathic orbital inflammatory syndrome laterality

A

typically unilateral in adults and bilateral in children

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15
Q

idiopathic orbital inflammatory syndrome symptoms

A
  • eyelid swelling, redness, and pain
  • red eye(s)
  • bulging/displaced eye
  • double vision
  • pain on eye movement
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16
Q

idiopathic orbital inflammatory syndrome signs

A
  • eyelid edema, erythema, and tenderness/pain
  • conjunctival chemosis and injection
  • proptosis
  • globe displacement
  • if EOMs involved, signs of myositis (restricted EOM and pain with eye movement)
  • if lacrimal gland is inflamed, signs of dacryoadenitis
  • if sclera/Tenon’s capsule involved, signs of posterior scleritis
  • if uvea involved, signs of uveitis
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17
Q

idiopathic orbital inflammatory syndrome complications

A

compression on the globe and/or optic nerve

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18
Q

idiopathic orbital inflammatory syndrome management

A
  • orbital CT scan or MRI: confirm the diagnosis and rule out other processes such as orbital cellulitis or tumor
  • oral steroid 1-1.2 mg/kg/day as initial dose; patients typically show improvement within 48 hours
  • IV steroid for severe cases
  • orbital radiotherapy if no response to steroid or disease recurs as steroid is tapered
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19
Q

idiopathic orbital inflammatory syndrome pearls:

  • ____ is the hallmark of IOS, but is only present in 65% of patients
  • diagnosis of exclusion
A

an explosive, painful onset

20
Q

thyroid orbitopathy

A
  • also called thyroid eye disease (TED) and/or thyroid ophthalmopathy
  • autoimmune, inflammation of orbital tissue in patients with thyroid disease
21
Q

thyroid orbitopathy etiology/associations

A
  • stimulation of orbital fibroblasts
  • orbital fibroblasts upregulate the synthesis of GAGs that deposit in orbital tissues leading to congestion and edema
  • orbital fibroblasts differentiate into adipocytes which then proliferate and deposit in and around the orbit
  • orbital fibroblasts differentiate into myofibroblasts which then proliferate and lead to muscle enlargement
  • 90% of cases are associated with Graves’ disease; may also be associated with hyperthyroidism, hypothyroidism, Hashimoto’s disease
22
Q

thyroid orbitopathy demographics

A
  • women&raquo_space; men; women more commonly have Graves’ disease

- typically occurs during the ages of 40 years and 60 years

23
Q

thyroid orbitopathy laterality

A

bilateral > unilateral

24
Q

thyroid orbitopathy symptoms

A
  • dry eye: FBS (foreign body sensation), redness, tearing, intermittent blurred vision
  • elevation of the upper eyelid
  • bulging eyes
  • eyelid swelling
  • double vision
  • pain on eye movement
25
Q

thyroid orbitopathy signs

A
  • upper eyelid retraction
  • Dalrymple’s sign
  • lagophthalmos
  • temporal flare
  • exophthalmos
  • periorbital edema and erythema
  • conjunctival injection and chemosis; more pronounced at the site of the rectus muscle insertion
  • exposure keratopathy
  • superior limbic keratoconjunctivitis
  • Von Graefe’s sign
  • eyelid lag
  • restricted EOM with possible pain on eye movement; inferior and medial rectus muscles most commonly affected, leading to hypotropia and esotropia, respectively
26
Q

Dalrymple’s sign

A

widening of the palpebral fissure with superior scleral show

27
Q

lagophthalmos

A

inability to close the eyes completely

28
Q

temporal flare

A

elevation of the temporal upper eyelid compared to its normal anatomical location

29
Q

exophthalmos

A

same as proptosis, globe protrudes anteriorly in relation to the lids

30
Q

exposure keratopathy

A

corneal damage that occurs from prolonged exposure to the outside environment; due to lagophthalmos and/or exophthalmos

31
Q

superior limbic keratoconjunctivitis

A

inflammation of the superior limbus, cornea, bulbar and tarsal conjunctiva

32
Q

Von Graefe’s sign

A

delayed descent of upper eyelid DURING downgaze; dynamic finding

33
Q

eyelid lag

A

upper eyelid is higher than normal when the eye is IN downgaze; static finding

34
Q

thyroid orbitopathy complications

A
  • compression on the globe and/or optic nerve

- compressive optic neuropathy occurs in ~5% of cases

35
Q

thyroid orbitopathy management: for mild cases

A
  • topical lubrication
  • Restasis or Xiidra
  • eyelid taping or patching phs in addition to topical lubrication
  • cold compresses qam and head elevation qhs for periorbital/orbital edema
  • sodium restriction to reduce water retention and periorbital/orbital edema
  • selenium supplementation 100 ug bid
  • prism for diplopia
36
Q

thyroid orbitopathy management: for moderate to severe cases of compressive optic neuropathy

A
  • oral or IV steroids
  • orbital radiotherapy
  • orbital decompression surgery: following orbital decompression surgery, strab surgery (for diplopia) and eyelid lid surgery (for eyelid retraction) may be performed
37
Q

thyroid orbitopathy management:
_____ if severe congestive orbitopathy or optic neuropathy or atypical cases (i.e., unilateral proptosis or bilateral proptosis without upper eyelid retratcion)

A

orbital CT or MRI

38
Q

thyroid orbitopathy management:

  • monitor exophthalmos with _____; normal limits are ____ in whites, ____ in blacks, and within ____ between the 2 eyes
  • discuss _____; increases severity of disease; 7x more likely to develop TED
  • _____ for treatment of systemic disease
A 
exophthalmometry;
12-20 mm;
12-24 mm; 
2 mm;
smoking cessation;
refer to PCP/endocrinologist
39
Q

thyroid orbitopathy clinical pearls:

  • most common cause of _____
  • ____ is the most common presenting sign of TED; up to ____% of patients are affected; it is due to ____
  • _____ is the second most common sign associated with TED
A 
orbital disease in adults;
upper eyelid retraction; 
90;
increased sympathetic tone acting on Muller's muscle, contraction of the levator palpebrae superioris, proptosis, and/or scarring between the lacrimal gland and the levator palpebrae;
exophthalmos
40
Q

thyroid orbitopathy: new treatment option

A
  • Tepezza
  • FDA approved Jan 2020
  • monoclonal antibody injection therapy for TED
  • MOA: insulin-like growth factor-1 (IGF-1R) antagonist, prevents orbital fibroblast stimulation
  • showing great promise and will probably become more common in the next few years
41
Q

thyroid orbitopathy is divided into _____ phases

A

active and stable

42
Q

thyroid orbitopathy: active phase

A
  • i.e., clinically progressive
  • typically lasts between 1-3 years
  • symptoms wax and wane
  • 5-10% risk of recurrence
43
Q

thyroid orbitopathy: stable phase

A
  • aka quiescent phase

- spontaneous resolution of active phase

44
Q

majority of patients with TED have ____ disease and require primarily ____ as a means of symptom management

A

mild to moderate;

supportive care

45
Q

thyroid orbitopathy:

  • as a general guideline, surgery is not advised until ____
  • exceptions include: _____
  • ____% of patients with TED undergo some type of surgical intervention
A

a euthyroid state is maintained and the TED has been in the stable phase for at least 6-9 months;
vision loss from compressive optic neuropathy or exposure keratopathy, in which cases urgent surgical intervention is warranted;
~20

46
Q

thyroid orbitopathy:

  • TED does not necessarily follow the associated thyroid dysfunction and may occur _____
  • concomitant ____ may occur in a minority of patients
A

months to years before or after thyroid dysfunction;

myasthenia gravis

Anterior Segment Disease (22 decks)

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