Orbital Diseases, Differential Diagnosis, and Management
Overview:
Signs and symptoms
Differential diagnosis
Labs:
Imaging:
Six P’s of orbital disease:
1) pain
2) proptosis
3) progression
4) palpation
5) pulsation
6) periorbital changes
Case 1: Idiopathic Inflammatory Orbital Pseudotumor
1. History: 50% of orbital disease and proptosis
2. Acute, recurrent, chronic
3. Classification:
A. Orbital tumor with subsides spontaneously
B. Exophthalmos w/o tumor, but shows chronic inflammation
C. Exophthalmos with tumor and inflammation
4. Clinical features:
A. pain,erythema, lid swelling, diplopia
B. proptosis, decreased ocular motility
5. Differential diagnosis: R/o infection, inflammation, immunologic, systemic and neoplastic
diseases
A. orbital myositis
B. apical idiopathic orbital inflammation
C. idiopathic sclerosing inflammation
D. lacrimal gland: granumomatouis, vasculitic, eosinophilic
6.Testing:
1) Examination and vitals
2) Ultrasound: irregular, uniform density lesion with low reflectivity the “T” sign
3) CT/MRI: MRI has greater specificity for soft tissues
4) Orbital biopsy
7.Treatment:
Steroids
Radiotherapy
Treatment success rates:
Case 2: Thyroid Eye Disease
1.General:
1) most common cause of orbital disease
2) most common cause of proptosis
3) F > M 6:1
4) course of eye involvement does not parallel systemic disease
5)diagnosis is clinical
2. Grave’s Clinical Features:
a. lid retraction: 90%
b. exophthalmos: 60%
c. EOM restriction: 40%
d. optic neuropathy: 6%
e. injection
on
EOM
insertion
f. lid lag and exposure
g. retropulsion
h. asymmetric,
slowly
progressive disease
i. painless,
prominent
eyes
j.
k.
l.
pain and discomfort:
30%
diplopia: 17%
blurryvision:7.5%
3. Mechanism:
» unknown immune response
» circulating T-cells and antigen on thyroid follicular cells
4. Systemic Disease:
» Hyperthyroidism: 90%, 75% develop eye findings
» Primary Hypothyroidism: 1%
» Hashimoto’s Thyroiditis: 3%
» Euthyroid: 6%
» Myasthenia Gravis: 1%
5. Classification:
NO SPECS:
N (0) = no signs or symptoms
O (1) = only signs, no symptoms
S (2) = soft tissue involvement only
P (3) = proptosis
E (4) = EOM restriction
C (5) = corneal involvement
S (6) = sight loss
6.Testing
a) Ancillary testing:
b) Labs: T3, T4, TSH , others; TSH, TRH or TSH-IRMA, CBC with differential, chemistry
panel
anticholinergic Ab and tensilon test
7. Imaging:CT/MRI:
8.Treatment
a) Referral to internist and/or endocrinologist
b) return patient to euthyroid state
c) Topical/supportive therapy
d) Optical and medical therapies
e) Elevate patient’s head for sleep
f) Active congestion treated more aggressively
g) General:
Steroids, orbital radiation, orbital decompression, strabismus surgery, lid surgery
Case 3: Orbital Cellulitis with a subperiosteal abscess
1) Clinical Features:
2) Etiology/Histology:
a) extension from sinus infection: 90%
b) ethmoidal sinus: 90%
c) orbital trauma/surgery
d) vascular infection or infection via other tissue
e) Organisms: staph, strep, H-flu, and gram - rods
Testing:
a) Exam/Vitals:
b) Labs: CBC with differential, chemistry panel, culture: blood, wounds, debrided, material
c) LP with CSF analysis
d) CT/MRI:inflammatory/infectious material and cells in sinus/orbit
Classification:: Chandler
Inflammatory Edema:
Orbital Cellulitis:
Subperiosteal Abscess:
Orbital Abscess:
Cavernous Sinus Thrombosis:
Treatment:
a) Admission to hospital: referral to ENT, Internal Medicine, and Ophthalmology
b) Nasal decongestant spray prn, Ab ointment topically: culture specific
c) Surgical drainage of abscesses
d) I.V. Abx x 1 week, response w/in 48 hrs
Case 4) Lacrimal Gland Inflammation/Infiltration:
1)Features:
Persistent, progressive swelling of outer 1/3 of upper eyelid (S-Shaped)
Pain, Tenderness, Temporal lid injection, Conjunctival fornix injection, Displacement of globe
2)Etiology: Inflammatory disease, Structural disease, Neoplastic disease
3)Tests:Labs, CT/ MRI: Lacrimal gland biopsy:
Suspected tumor
Uncertain inflammatory/infectious process
5) differential diagnosis:
6) Treatment: referral to internist/hematologist/ oncologist, steroids, antibiotics, surgical
removal
Case 5) Paraocular Sinus Mucoceles
1) Clinical Features: Slow space-occupying lesions; May be sterile or harbor infection
Increase in size, May be worsened by active sinusitis, Proptosis, Restricted EOM’s
Orbital displacement
2) Etiology / Histology: Form as a result of blockage of sinus cell ostium
3)Testing: CT/MRI
4) Treatment: Consultation with ENT, Surgical excision and removal of sinus mucosa
Establish normal drainage, Obliteration of sinus
Case 6) Orbital Metastasis
1)features: May arise from various sources, Seeds to sinuses via blood stream, or lymphatic
dissemination
Similar signs and symptoms to other orbital diseases, Pain and proptosis may be a prominent
early sign, Diplopia earlier, Less proptosis due to earlier presentation
2)Differential diagnosis:
3)testing: CT/MRI/Ultrasound: Ultrasounic differences
4)Treatment: Radiation therapy, Chemotherapy, Surgery, Hormonal therapy