lacrimal system IV: disorders of the orbit

what is the general aeitology of orbital diseases (6) 

• inflammatory

• infectious

• neoplastic - tumours/malignants

• trauma - surgery

• malformation

• vascular 

• any abnormalities with the above categories that occur behind the globe/within the orbit can lead to orbital diseases 

describe the general symptoms of orbital diseases (6)

•Eyelid swelling

•Bulging eye(s) - eyes pushed forward

•Double vision - as extraocular muscles effected and eyes do not work as well together

•Pain (sometimes ↑ on ocular movement)

•Blurring - as optic nerve is compressed

•Change in colour vision - due to effects on optic nerve

what are the general CRITICAL signs of orbital diseases (3:1:1)

• Globe dystopia (abnormal displacement of the eyeball within the orbit):

•Proptosis/exophthalmos (linked to thyroid disease) - forward protrusion of the eyeball from the orbit 

•Hyperglobus (upwards) & hypoglobus (downwards) - vertical displacement of the globe 

• Restricted ocular motility

• if these signs occur = urgent referral

describe other/non-critical general signs of orbital disorders (3:3)

Soft tissue involvement: 

• Eyelid & periorbital oedema - swelling of eyelids and tissues around the orbit

• ptosis - abnormal drooping of upper lid 

• Chemosis - conjunctival swelling 

Fundus changes: 

• Optic disc swelling/atrophy

• Collaterals - new blood vessels around optic disc - right at discs - tend not to leak/bleed

• Choroidal folds - lines/streaks along the retina as seen in image below

explain the aeitology of thyroid eye disease - TED (2)

• Systemic autoimmune disease/condition - increased or decreased thyroid production

• Ocular effects - in soft tissue around the eyes - and ocular muscles

describe the early (5) and late (5) ocular symptoms of thyroid eye disease 

Early/non speific ocular symptoms: 

• Non-specific FB sensation

• Redness

• Tearing

• Photophobia - abnormal sensitivity/discomfort in bright light

• Eyelid puffiness

Late ocular symptoms: 

• Persistent lid swelling

• Chemosis - conjunctival oedema 

• Prominent eyes

• Double vision (thickened muscles)

• Loss of vision (optic nerve/corneal involvement

what are the signs of TED (8)

• Eyelid retraction - eyelid lag on downgaze - lagophthalmos (inability to close eyelids properly - exposure keratopathy)

• Uni or bilateral proptosis - 50% of patients - these px will often have choroidal folds

• Variable ocular motility restriction - 40% of patients - due to EOM fibrosis and contracture

• Higher IOP in up gaze

• Conjunctival/lid hyperaemia/ oedema

• Superior limbic keartoconjunctivits - kerato - involving cornwa

• Optic nerve swelling/pallor

• pupil abnormalities - RAPD & defective colour vision

what is the management of TED (4)

•Referral to GP or Ophthalmologist

•Steroids

•Radiotherapy

•Surgical decompression

state and briefly explain the 2 types of cellulitis (3

• preseptal and orbital 

• cellulitis - inflammation of subcutaneous connective tissue

• affects periorbital or orbital tissue (depending on type) 

what is the aetiology of preseptal and orbital cellulitis (3)

• caused by a bacterial infection

• most commonly < 10 years old

• severity varies form minor to life-threatening

what is preseptal cellulitis (3)

• affects tissues lying anterior to the orbital septum (periorbital tissue)

• High risk of extension into the orbit in young children

• mild condition compared to orbital cellulitis

what is orbital cellulitis (2)

• Affects tissues lying posterior to the orbital septum (within the orbit) - orbital tissue

• Severe sight and life-threatening emergency - needs prompt treatment and management

how do we clinically differentiate between preseptal and orbital cellulitis and what is the management for them (2) 

• difficult to clinically differentiate between preseptal or orbital - not job of optometrists to differentiate between them

• same management for both types - same day emergency referral 

what are the predisposing factors of both preseptal and orbital cellulitis (4)

• fever/malaise/unwell - more severe in orbital cellulitis

• infection - P: upper respiratory tract infection // O: acute sinusitis (ethmoid) dental abscess

• ocular infection - P: dacryocystitis, hordeolum, impetigo // O: dacryocystitis, preseptal cellulitis

• trauma - P: recent surgery // O: orbital fracture

describe the symptoms of preseptal cellulitis (4)

• are acute/sudden onset

• lid swelling

• lid redness

• lid tenderness

describe the symptoms of orbital cellulitis (8)

• are acute/sudden onset

• lid swelling

• lid redness

• lid tenderness

• conjunctival swelling/oedema

• pain on eye movements

• blurred vision

• double vision 

compare the signs of preseptal and orbital cellulitis (5)

• essentially if any of these signs occur - will be orbital cellulitis as they are not present in preseptal 

what is the optometric management (1) and secondary care (5) of preseptal and orbital cellulitis

• optometric management - emergency same day referral - both preseptal and orbital present in the same way so need to emergency refer for both - not take any risks - preseptal milder while orbital is much more severe and sight/life threatening 

secondary care:

• systemic antibiotics

• hospital admission

• blood tests

• CT scan

• co-management ENT

name 3 orbital disorders that are good to know

• dermoid cysts

• blow-out fracture

• mucormycosis

explain what a dermoid/epidermoid cyst is (also known as choristoma) (4) and management (1)

• mass of normal tissue in an abnormal location

• thin walled, cystic lesion

• may contain sweat glands, sebaceous glands, hair follicles

• formed at birth but may not present until adulthood

• management: refer routinely for removal - slow growing and can rupture

what are the 2 types of dermoid cysts and describe them (2)

• superficial: painless slow growing nodule - often around the eyelid/brow

• deep: presents in adolescence or adulthood - increasingly protruding eye, acute inflammation if ruptures

what is a blow-out fracture (3)

• caused by blunt trauma - force/injuries (squash injury)

• causes fracture of an orbital wall - typically the orbital floor or medial wall

• tissue or muscle trapped 

describe the signs (3) and management (1) of blow-out fractures

signs:

• double vision - eye muscles tethered

• bruising, tenderness and periorbital swelling

• loss of sensation in cheek (infraorbital nerve trapped)

management:

• same day referral - make it clear seen abnormal motility and double vision - needs to be seen to promptly

what is mucormycosis (4)

• rare aggressive fungal infection

• often fatal

• typical affects patients with diabetic ketoacidosis or immunosuppression

• Inhaled spores — upper respiratory tract infection — spreads to orbit and brain

what are the signs (3) and management (1) of mucormycosis

signs:

• Gradual onset periorbital swelling

• diplopia and loss of vision

• appears similar to orbital cellulitis

management:

• same day referral