Facial Asymmetries - Orbit and Pseudo-Orbit

Question 1

Pseudo-orbital disease -

Answer 1

Conditions that have some signs associated w orbital disease

Ex. Inflammation of the upper lid (internal hordeolum)

Question 2

Unequal palpebral apertures - NOT associated w Exophthalmos:

Hint (12)

Answer 2

• Inflammation of the upper lid
• Microphthalmia
• Closing or winking eye due to irritation
• Blepharospasm
• Levator dehiscence
• Over contraction of the muscles of facial expression in contralateral facial nerve palsy
• Lid retraction
• Retraction of the contralateral eye
• Misdirected facial nerve fibers - can lead to jaw-winking
• Ocular trauma or surgery
• Enophthalmos
• Physiological pseudoptosis

Question 3

4 causes of lid retraction:

Answer 3

1. Dorsal midbrain syndrome
2. Aberrant regeneration syndrome
3. TRO (typically one eye)
4. Pseudo lid retraction

Question 4

Dorsal midbrain syndrome (urgent referral - pineal gland tumor) signs:

Answer 4

• Lid retraction
• Up-gaze palsy (both eyes affected)
• Retraction nystagmus (eye pulsating in and out)
• Tectal pupils (sluggish, mydriatic, near response > light response)

Question 5

2 categories of unequal palpebral apertures - associated with orbital disease:

Answer 5

1. Associated w thyroid disease (90%)

2. Not associated w thyroid disease

Question 6

Exophthalmos (equal or unequal PA) NOT associated w TRO:

Answer 6

• Orbital cellulitis
• Orbital mass
• Orbital pseudotumor
• Orbital surgery/trauma
• Venous stasis
• EOM paralysis

Question 7

Enophthalmos (equal or unequal PA) NOT associated w TRO:

Answer 7

Orbital contents go into a sinus - blow out fracture (orbital floor) or sinus surgery

Question 8

TRO symptoms:

Answer 8

• Bino diplopia
• Ocular irritation
• “My eyes look funny”

Question 9

TRO signs:

Answer 9

• Exophthalmos
• Lid retraction
• Inf punctate staining
• Abnormal eye movements
• Sector injection
• Elevated IOP/optic neuropathy
• Lid edema

Question 10

TRO lab tests:

Answer 10

• TSH
• Elevated T4 (not T3)
• Thyroid stimulating antibody

Question 11

TRO mgmt:

Answer 11

• Endocrine workup
• Protect cornea (lubricants, tape lids at night)
• Protect ON
• Help pt cope w diplopia (prisms) and cosmesis

Question 12

T/F: To diagnose orbital or eyelid mass, perform retropulsion to see and feel for asymmetrical resistance

Answer 12

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