Facial Asymmetries of Orbit and Pseudo Orbit

Question 1

pseudo orbital dz: condition with a sign associated with orbital dz

Answer 1

inflammation of one of the upper lids (ie internal hordeolum)

Question 2

unequal palpebral apertures not associated with exophthalmos (2)

Answer 2

1. inflammation of one of the upper lids (internal hordeolum)
2. microphthalmia

Question 3

• closure or winking of an eye because it is irritated,
• blepharospasm (an extreme case of the above)
• levator dehiscence

Answer 3

unequal palpebral apertures NOT associated with exophthalmos

Question 4

weakening of the connection between the levator and the tarsal plate in the upper lid, often observed among the elderly

Answer 4

levator dehiscence

Question 5

• over contraction of the muscles of facial expression in a contralateral facial nerve palsy
• retraction of the contralateral lid
• misdirected facial nerve fibers, after CN7 damage (can lead to a rare and peculiar form of facial
asymmetry known as jaw-winking, in which an eye closes in response to opening and closing the mouth

Answer 5

unequal palpebral apertures not associated with exophthalmos

Question 6

• ocular trauma or any surgery in or around an eye,
• also: enophthalmos, in which the palpebral apertures
are actually of different sizes but due to malposition of the globe.
•physiological pseudoptosis (physiological asymmetry
more than normal but not associated with pathology).

Answer 6

unequal palpebral apertures not associated with exophthalmos

Question 7

! Dorsal midbrain syndrome
! Thyroid-related orbitopathy
! Aberrant regeneration syndromes
! Pseudo lid retraction e.g., contralateral ptosis

Answer 7

lid retraction

Question 8

1. Lid retraction
2. Palsy of up gaze
3. “Retraction nystagmus” on attempted upgaze
4. Tectal pupils
   sluggish, mydriatic, near resp>lite resp

Answer 8

dorsal midbrain syndrome

Question 9

what are the 2 categories of unequal palpebral apertures associated with orbital dz

Answer 9

1. not associated with thyroid dz

2. associated with thyroid dz

Question 10

!  orbital mass
!  venous stasis
!  EOM paralysis (external ophthalmoplegia) 
!  orbital cellulitis
!  orbital pseudotumor
!  surgery
!  other (unusual)

Answer 10

exophthalmos with equal or unequal palpebral apertures not thyroid related

Question 11

orbital contents into a sinus, e.g., in blow-out fracture, sinus surgery

Answer 11

enophthalmos with equal or unequal palpebral apertures

Question 12

what can happen when v pressure is too high (mass lesion)

Answer 12

venous stasis

Question 13

what does it mean if all eye muscles are paretic at the same time

Answer 13

external ophthalmoplegia

Question 14

exophthalmos with equal or unequal caucasian palpebral apertures

Answer 14

> 20 mm

Question 15

exophthalmos with equal or unequal african palpebral apertures

Answer 15

> 24 mm

Question 16

exophthalmos with equal or unequal palpebral apertures will have an asymmetry of what?

Answer 16

2.0 mm or more

Question 17

what type of pathology accounts for 90% of exophthalmos

Answer 17

thyroid related

Question 18

what can be used to find abnormalities even when pt is euthyroid?

Answer 18

modern blood tests

Question 19

!  TRO
!  Thyroid ocular disease
!  Grave's disease / Grave's orbitopathy
!  Grave's ophthalmopathy
!  Dysthroid orbitopathy
!  Dysthroid myopathy
!  Dysthyroid ophthalmopathy

Answer 19

thyroid related orbitopathy synonyms

Question 20

name 3 TRO symptoms

Answer 20

1. binocular diplopia
2. ocular irritation
3. my eyes look funny

Question 21

!  exophthalmos
!  stare, lid retraction
!  inferior punctate staining
!  abnormal eye movements
!  sector injection
!  elevated IOP / optic neuropathy
!  lid edema

Answer 21

TRO signs

Question 22

what are 3 TRO lab tests

Answer 22

1. TSH
2. elevated T4 (not T3)
3. thyroid stimulating antibody (if in doubt)

Question 23

!  educate the patient
!  exophthalmometry
!  measure palpebral aperture
!  check for corneal staining, TBUT
!  muscle field
!  Take IOP & document ONH
!  communicate with endocrinologist

Answer 23

TRO specific procedures

Question 24

!  Adnexa
!  Lids
!  Bulbar conjunctiva
!  Cornea
!  Eyeball
!  Extraocular muscles
!  IOP
!  Optic nerve

Answer 24

TRO checklist tissues

Question 25

``` ! Puffiness ( adnexa) ! Edema, retraction, stare (lids) ! Sector injection (conj) ! Exposure keratitis, staining (cornea) ! Exophthalmos (eyeball) ! Incomitancy, enlargement (EOMs) ! Elevation or elevated on up gaze (IOP) ! Compression, glaucoma (optic nerve) ```

Answer 25

TRO checklist signs

Question 26

during progression what are 3 TRO interventions?

Answer 26

tarsorrhaphy orbital decompression systemic steroids monocular occlusion

Question 27

when progression has stopped, what are 2 TRO interventions?

Answer 27

! lid reconstruction for cosmesis | ! alleviate diplopia

Question 28

what are the 4 steps of TRO management

Answer 28

1. co-manage the endocrine disorder 2. protect the CORNEA (lubricant, tape lids at night) 3. protect the ON 4. help the patient cope with diplopia, cosmesis

Question 29

what are 3 cases when prescribing prism?

Answer 29

1. acquired strabismus 2. spread of comitancy 3. there is incomitancy

Question 30

what are diagnositc tools for Rxing prism in acquired strabismus? (5)

Answer 30

1. CT 2. maddox rod 3. double maddox rod vergences 4. ARFT 5. hess lancaster screen

Question 31

where do we put the direction of base when Rxing prism in acquired strabismus?

Answer 31

move image to where eye points (apex toward direction of deviation)

Question 32

how much prism do we have an acquired strabismus pt?

Answer 32

measure the deviation trial & error: prism bars, TF How: usually must surface, decenter if poss two pairs of glasses