Orbital Disease

Question 1

What makes up the roof of the orbit?

Answer 1

Frontal bone and lesser wing of sphenoid

Question 2

What makes up the lateral roof of the orbit?

Answer 2

zygomatic bone and greater wing of sphenoid

Question 3

What makes up the floor of the orbit?

Answer 3

3 bones: zygomatic bone, maxillary and palatine bone

Question 4

What makes up the medial wall of the orbit?

Answer 4

4 bones: maxillary, lacrimal, ethmoid and sphenoid bones

Question 5

What are the signs of orbital disease?

Answer 5

soft tissue 
proptosis 
enophthalmos
ophthalmoplegia
visual dysfunction
dynamic changes
fundus changes

Question 6

What are the symptoms of orbital disease?

Answer 6

double vision
pain
discomfort
decreased vision

Question 7

What soft tissue involvements are there in orbital disease

Answer 7

Lid/periorbital oedema, ptosis and conjunctival swelling due to inflammation or vascular abnormalities

Question 8

What is PROPTOSIS (EXOPHTHALMOS)

Answer 8

The abnormal protrusion of the globe externally - the protrusion can be intra/extraconal

Question 9

What is the cause of proptosis?

Answer 9

thyroid eye disease
tumours
Inflammation
Infection

Question 10

What is enophthalmos?

Answer 10

A condition in which the globe is recessed within the orbit

Question 11

What are the causes of enopthalmos?

Answer 11

Small globe - nanophthamos, microphthalmos, phthisis bulbi

Structural abnormalities e.g. blow out fracture

Atrophy of the orbital contents - irradiation or scleroderma

Question 12

What is ophthalmoplegia?

Answer 12

restriction or disability of the ocular muscles

Question 13

What are the common causes of ophthalmoplegia?

Answer 13

tumour
restrictive myopathy - thyroid eye disease (TED) or myositis

Ocular motor nerve lesions

Trauma - longstanding blow-out fracture

Question 14

What are the dynamic properties of the eye?

Answer 14

Increased venous pressure - thyroid eye disease or vascular problems

Pulsation - AV communication

Question 15

What fundus changes can be seen in orbital disease?

Answer 15

Optic disc changes - disc swelling, atrophy, opticociliary shunts

Choroidal folds

Retinal vascular changes

Question 16

What are the most common signs of thyroid eye disease?

Answer 16

Eyelid retraction
periorbital oedema

Exophthalmos - 1/3 patients

Diplopia - 5-10%

Rarely, compression of the optic nerve

Question 17

What are the soft tissue involvements in thyroid eye disease?

Answer 17

1. eyelid erythema
2. conjunctival injection
3. chemosis
4. swelling of caruncle
5. eyelid oedema

Question 18

What should a doctor assess in optic neuropathy?

Answer 18

CT scan
assess VA
assess colour vision
assess papillary reactions, visual fields
fundoscopy

Question 19

What is the cause of restrictive myopathy?

Answer 19

oedema in active stages

fibrosis in later stages

Question 20

What muscles are affected by restrictive myopathy?

Answer 20

inferior rectus
medial rectus
superior rectus
lateral rectus

Question 21

What is orbital cellulitis?

Answer 21

infection located below the orbital septum, usually secondary to ethmoiditis

Question 22

What is the presentation of orbital cellulitis?

Answer 22

severe malaise
fever
orbital signs: 
Severe orbital oedema
Redness
Ptosis 
Painful ophthalmoplegia
Optic nerve dysfunction - if advanced

Question 23

What are the complications of orbital cellulitis?

Answer 23

Optic neuropathy, abscess formation

infection of the cranial cavity

Question 24

What is idiopathic orbital inflammatory disease?

Answer 24

neoplastic, non-infectious orbital lesion - involve any soft tissue component

Question 25

What is the presentation of idiopathic orbital inflammatory disease?

Answer 25

20-50 years Abrupt, painful onset Unilateral - proptosis, chemosis, periorbital swelling and ophthalmoplegia

Question 26

What kinds of vascular orbital disorders are there?

Answer 26

1. Orbital venous abnormalities (varices): isolated orbital varices 2. Carotid-cavenous fistula (direct or indirect)

Question 27

What is the cause of orbital venous varices?

Answer 27

congenital - usually unilateral and may bleed or become thrombosed

Question 28

What is the clinical appearance of orbital venous varices

Answer 28

Intermittent proptosis accentuated by the valsalva manoeuvre

Question 29

What is a direct carotid-cavernous fistula?

Answer 29

Abnormal communication between the carotid after and cavernous sinus High velocity flow shunt

Question 30

What are the causes of direct carotid-cavernous sinus

Answer 30

head trauma | spontaneous rupture

Question 31

What are the features of carotid-cavernous sinus?

Answer 31

``` Ptosis Chemosis Conjunctival injection Ophthalmoplegia Raised IOP ``` Pulsaile proptosis with bruit and thrill, abolished by ipsilateral carotid compression Retinal venous congestion and haemorrhage

Question 32

What is an indirect carotid-cavernous fistula?

Answer 32

Abnormal indirect communications between meningeal branches of the internal carotids and cavernous sinus. Mostly congenital malformation or spontaneous rupture

Question 33

What is the presentation of an indirect carotid-cavernous fistula?

Answer 33

Dilated episcleral vessels Raised IOP Occasional ophthalmoplegia Mild proptosis

Question 34

What is encephaloceles?

Answer 34

Herniation of intracranial content through the congenital skull defect

Question 35

What does a meningocele contain?

Answer 35

dura only

Question 36

What does a meningoencephaocele contain?

Answer 36

dura and brain tissue

Question 37

What are the four types of tumours that can affect the orbit?

Answer 37

1. Vascular tumour - capillary or cavernous haemangioma 2. Lacrimal gland tumours - pleomorphic adenoma 3. Neural tumours - optic nerve glioma or optic sheath meningioma 4. Miscellaneous tumours - metastases or invasion from sinuses

Question 38

What is the most common orbital tumour in children?

Answer 38

Capillary haemangioma

Question 39

What conditions are capillary haemangiomas associated with?

Answer 39

high output cardiac failure | Maffuci syndrome

Question 40

What is the Tx for capillary haemangiomas

Answer 40

steroid injections systemic steroids local resection (if possible)

Question 41

What is the most common adult orbital benign tumour?

Answer 41

cavernous haemangiomas

Question 42

Where are cavernous haemangiomas found?

Answer 42

Just behind the globe

Question 43

Who are cavernous haemangiomas most common in?

Answer 43

Women 40-60

Question 44

What is the treatment of cavernous haemangiomas?

Answer 44

surgical excision

Question 45

When do pleomorphic lacrimal gland adenomas present?

Answer 45

4th-5th decades - painless and slow growing

Question 46

How are pleomorphic lacrimal gland adenomas managed?

Answer 46

Well encapsulated, can be easily surgically removed

Question 47

When do lacrimal gland carcinomas present?

Answer 47

4th-5th decades

Question 48

What is the prognosis for lacrimal gland carcinoma?

Answer 48

Poor

Question 49

What is the Mx for lacrimal gland carcinoma?

Answer 49

Biopsy to diagnose treatment is radical surgery and radiotherapy

Question 50

Who do optic nerve gliomas affect?

Answer 50

Young girls - associated with NF-1

Question 51

how do optic nerve gliomas present?

Answer 51

end of 1st decade with gradual visual loser

Question 52

How are optic nerve gliomas managed?

Answer 52

Excision if affecting vision or cosmoses

Question 53

Who do optic sheath meningiomas affect? How do they present?

Answer 53

Middle aged women | Cause gradual visual loss due to optic nerve compression

Question 54

What are the management options for optic sheath meningiomas?

Answer 54

Excision | radiotherapy

Question 55

What are the primary sites of metastatic tumours that spread to the eye?

Answer 55

``` breast bronchus prostate skin melanoma GIT kidney ```

Question 56

What is the treatment of orbital cellulitis?

Answer 56

``` systemic antibiotics surgery if: resistance to antibiotics orbital or subperiosteal abscess optic neuropathy ```

Question 57

What are the management options for idiopathic orbital inflammatory disease?

Answer 57

1. early spontaneous remission - no treatment | 2. prolonged intermittent activity with eventual remissions: steroid therapy, radiotherapy, cytotoxic usage