Orbital Disease (Cale)

Question 1

thinnest wall in the orbit

Answer 1

medial

Question 2

ophthalmoplegia

Answer 2

restriction of EOM

Question 3

how can you test for ophthalmoplegia

Answer 3

forced ductions

Question 4

clues to pathology

Answer 4

orbital pulsation (cavernous sinus fistula, defect in orbital roof transmitted via CSF), Bruit (carotid-cavernous fistula, carotid stenosis in CVA, A-V malformations, choroidal folds, disc edema, optic atrophy

Question 5

Orbital septum

Answer 5

dense fibrous sheath acting as barrier between orbit and eyelid. Orignates from periosteum of superior and inferior orbital rims. Inserts into levator aponeurosis just above superior tarsal border and inferior lid retractors just below inferior tarsal border

Question 6

Preseptal cellulitis

Answer 6

red, edematous lids, tender. No proptosis, chemosis, vision change, pupillary involvement, fever or EOM restriction. Staph aureous, strep pyogenes most common. Children H influenza

Question 7

Causes for preseptal cellulits

Answer 7

laceration, insect bite. Infection spread from hordeolum, dacryocystitis, sinusitis, conjunctivitis or URI or middle ear

Question 8

Management preseptal cellulitis

Answer 8

treatment (daily followup)
-afebrile, mild: oral antibiotic for 10 days. for child can use augmentin, cefaclor, bactrim. for adult can use augmentin, cefaclor, bactrim or moxifloxacin. Moderate to severe, febrile (no improvement)- hospital admission for IV antibiotics

Question 9

orbital cellulitis

Answer 9

life-threatening infection of soft tissue behind orbital septum, children> adult. Spnemoniae, S. aureus, S pyogenes, H influenzae. Proptosis, pain, fever, malaise

Question 10

complications of orbital cellulitis

Answer 10

meningitis, brain abscess, cavernous sinus thrombosis

Question 11

orbital cellulitis emergency case

Answer 11

hospital admission, IV ceftazidime (vancomycin) and oral metronidazole (anaerobes)

Question 12

differential Dx of acutely inflammed orbit

Answer 12

orbital cellulitis, fungal infection (mucormycosis), dacryocystitis, dacryoadenitis, vascular, neoplasm, thyroid eye disease, idopathic orbital inflammatory dz, myositis, collagen vascular dz or autoimmune, scleritis, conjunctivitis

Question 13

Lacrimal gland disease

Answer 13

dacryoadenitits

Question 14

dacryoadenitis

Answer 14

inflammatory w/ or w/o autoimmune dz, neoplastic (least common), biopsy is gold standard of diagnosis

Question 15

inflammatory lacrimal gland disease

Answer 15

idiopathyc dacryoadenitits. autoimmune comorbidity frequent. acute or subacute with pain, erythema, dry eye,s welling, unilateral (80%)
autoimmunity- primary target of immune system in autoimmune disorders: sarcoid sjogren’s, wegener, IgG4-related older pt, painless swelling often bilateral

Question 16

neoplastic

Answer 16

unilateral palpable mass, dystopia, proptosis, low incidence of pain, redness, lympocytic infiltration (elderly), pleomorphic adenoma (young mild), carcinoma (mid-aged with high mortality)

Question 17

lymphocytic infiltration of lacrimal gland

Answer 17

can run from benign hyperplasia to malignant lymphoma (subconjunctival “salmon patch” extension

Question 18

Infectious Dacryoadenitis

Answer 18

pain, erythema, edema lateral upper lid’s curve (kids), viral typically, bacterial rare

Question 19

how to treat infectious dacryoadenitis

Answer 19

if mild and uncertain etiology follow daily with oral antibiotics, in kids with augmentin 20-40mg/kg/day, in adults augmentin 250-500mg po q8h.
If moderate to severe-hospitilize

Question 20

viral infectious dacryoadenitis

Answer 20

most common epstein-barr virus, mumps, adenovirus, Hzoster, Hsimplex, rhinovirus, bilateral 40%, fever 25%

Question 21

bacterial infectious dacryoadenitis

Answer 21

staph, MRSA, strep, haemophilus, neisseria, gonorrhea. Unilateral typically, afebrile

Question 22

differential not responsive to antibiotics

Answer 22

viral (cold compresses, analgesic), idopathic orbital inflammatory disease (CT scan, blood tests, improves with oral steroid), tumor (non-painful, orbital CT scan, biopsy)

Question 23

grave’s ophthalmopathy in hyperthyroidism

Answer 23

clinical eye involvement more common in females. majority have increase in orbital fat (younger) or EOM volume (older). Smoking is primary risk factor for GO in Graves. Manifestations largely due to expanding orbital content in unyielding bony orbit

Question 24

grave’s autoimmunity etiology

Answer 24

attack of TSH receptor by TSH receptor auto-antibodies. Abnormal circulating T3-T4 levels (TSH cause release of these)

Question 25

clinical signs of thyroid ophthalmopathy

Answer 25

lid retraction (dalrymple's sign), lid lag (von graefe sign), proptosis (measure with exophthalmometer), hyperemia over lateral/medial recti, exposure keratitis, periorbital swelling, chemosis, fat prolapse, EOM restriction and diplopia, optic nerve compression, superior limbic keratoconjunctivitis

Question 26

chief complaints for thyroid ophthalmopathy

Answer 26

dry, gritty, blur, tearing, diplopia, pressure sensation behind the eye, other vision loss if optic nerve involved

Question 27

Management of eye in mild disease

Answer 27

lubrication of SLK, exposure dryness, topical antiinflammatory agents (Steroid, NSAID, cyclosporin), sleep with head elevated to reduce periorbital edema, tape eyelids shut during sleep

Question 28

management Grave's

Answer 28

endocrinologist (corticosteroids concurrently), treat exposure keratitis, orbital decompression, new approaches designed to avoid the need for orbital decompression (monoclona antibodies to target B and T cell activation and adipogenesis)

Question 29

idopathic orbital inflammatory disease

Answer 29

non-infective, non-neoplastic space-occupying lesions. Unilateral (Can be bilateral in kids), F=M middle age to older. Periorbital red, swelling, pain, proptosis, ophthalmoplegia, optic nerve involvement, spontaneous remission, intermittent possible, protracted

Question 30

treatment IOID

Answer 30

observation if mild, biopsy to rule out neoplasia, NSAID often effective (Ibuprofen), Oral steroids only after confirmed dx, radiotherapy if no improvement, antimetabolites if no improvement

Question 31

Orbital myositis

Answer 31

idiopathic inflammation of one or more EOMs in absence of thyroid orbitopoathy, often spontaneous resolution 3-6wk, etiology unknown

Question 32

Orbital myositis epidemiology

Answer 32

F>M young adult, 50% bilateral, acute (single episode lasting), chronic (persistent episode lasting), recurrent result in more chronic disease, fibrosis

Question 33

orbital myositis signs

Answer 33

pain exacerbated by eye movement, diplopia (restricted EOM), injection over involved muscle, lid edema, ptosis, fibrosed muscle enlargement - NSAID (Ibuprofen) - oral steroids if persisting

Question 34

Tolosa-Hunt Syndrome

Answer 34

Dx of exclusion, rare, idiopathic, granulomatous inflammation of cavernous sinus, superior orbital fissure, orbital apex, remissions and recurrences, proptosis, mild, oculomotor nerve palsies usually with pupil involvement, sensory loss V1, V2 of trigemina

Question 35

tolosa hunt syndrome treatment

Answer 35

steroid

Question 36

cavernous sinus Fistula

Answer 36

elevated venous sinus and episcleral venous pressure (signs of orbital arterial and venous stasis), hemorrhagic chemosis, pulsatile proptosis, whoosing noise in head, bruit, increase IOP, vision loss and neuro impact immediate or delayed (Optic nerve and nerves VI, III, IV, V), most not life threatening

Question 37

Cavernous Sinus thrombosis

Answer 37

clotting within sinus, high mortality, rapid onset: HA, malaise, nausea/vomiting, proptosis, chemosis, reduced VA, CN III-VI involved

Question 38

what does cavernous sinus thrombosis result from

Answer 38

infection (sinusitis), preseptal and orbital cellulitis, otitis

Question 39

epiphora

Answer 39

defective drainage -anatomical: malposition of puncta (ectropion) -obstruction/stenosis -lacrimal pump failure (horner's muscle, lower lid laxity) hypersecretion secondary to inflammation

Question 40

tests for epiphora

Answer 40

fluorescein disappearance test, johns dye, probing and irrigation, dacryocystography, nuclearl lacrimal scintigraphy

Question 41

dacryocystitis

Answer 41

pain and epiphora

Question 42

dacryocystitis treatment

Answer 42

warm compresses, oral antibiotics follow daily- kids give augmentin or cefaclor, adults give cephalexin or augmentin. can also give topical antibiotics in addition (trimethoprim/polymixin B (Polytrim) qid). probing is contraindicated. Consider CT scan if atypical. Incision and drainage carries risk of developing lacrimal fistula. DCR required after infection resolved

Question 43

chronic canaliculitis

Answer 43

swelling and mucopurulent

Question 44

congenital conditions

Answer 44

nasolacrimal duct obstruction or dacryocele

Question 45

nasolacrimal duct obstruction

Answer 45

common, usually spontaneous resolution. Massage over canaliculus, lid hygiene, erythromycin ung if bacterial conj, probe after 12 months resolved

Question 46

dacryocele

Answer 46

collection of amnionic fluid (noninflammatory) or mucus in lacrimal sac, due to imperforate hasner valve

Question 47

inflammatory disease

Answer 47

``` chalazion idiopathic orbital ID Orbital myositis tolosa-hunt syndrome dacryoadenitis ```

Question 48

infectious disease

Answer 48

``` dacryoadenitis preseptal cellulitis orbital cellulitis dacrocystitis chronic canaliculitis ```

Question 49

autoimmune disease

Answer 49

graves thyroid ophthalmopathy

Question 50

congenital conditions

Answer 50

nasolacrimal duct obstruction | dacryocele