Orbit

Question 1

What is thyrotoxicosis and its risk factors

Answer 1

• autoimmune disorder which presents in 30-40s

Risks:
- smoking
- female
- radioactive iodine used to treat hyperthryroidism

Question 2

What are the clicical manifestations of TED

Answer 2

• soft tissue involvement
• lid retraction
• proptosis
• restrictive myopathy
• optic neuropathy

Question 3

What are the two stages in the development of the disease

Answer 3

congestive
- inflammatory stage

Fibrotic
-Quiescent stage (inactive stage)

Question 4

Symptoms of soft tissue involvement (TED)

Answer 4

• Grittiness
• photophobia
• lacrimation
• retrobulbar discomfort

Question 5

Signs of soft tissue involvement (TED)

Answer 5

• epibulbar hyperaemia
• periorbital swelling
• superior limbic keratoconjunctivitis
• keratoconjunctivitis sicca (dry eyes)

Question 6

Mangaement for soft tissue involvement (TED)

Answer 6

• lubircants for superior limbic conjunctivitis, corneal exposure and dryness
• head elevation with three pillow during sleep to reduce perioorbital oedema
• eyelid taping during sleep may alleviate mild exposure keratopathy

Question 7

What are the signs of lid retraction (TED)

Answer 7

upper lid retraction- when lid margin is lvl with or above limbus, showing scerla

lower lid retraction- scerla shows below limbus

may occus in isolation. w proprtosis which exaggerates severity

Question 8

What is the management for lid retraction (TED)

Answer 8

• mild lid retraction requires no treatment, improves spontaneously
• consider surgery for significant but stable lid retraction

Question 9

What is proptosis (TED) and how to determine it

Answer 9

• Abnormal protrusion of the globe, detected by looking down at patient from above and behind
• measure using exophthalmometer/ frm lateral orbital margin w plastic ruler

Question 10

What are the signs of proptosis

Answer 10

• is axial, uni/bilateral, a/symmetrical n freq. permanent
• sever proptosis may comprimise lid closure. W resultant exposure keratopathy, corneal ulceration and infection

Question 11

What is the management of proptosis

Answer 11

• systemic steroids (maybe used in rapidly progressive and painful proptosis)
• radiotheraphy (maybe used in addition to steroids or when steroids are contraindicated/ ineffective)
• surgical decompression ( aims to increase the volume of the orbit by removing the bony walls and may be combined with removal of orbital fat to increase the retroplacement of the globe)

Question 12

What is restrivtive myopathy (TED) and its different type of defects

Answer 12

• ophthalmoplegia (paralysis of muscles within or surrounding the eye)

where ocular motility is restrited intially by inflammatory oedema, and later fibrosis

Ocular motility defects:
- elevation (freq)
- adduction (freq)
- abduction
- depression

Question 13

What is the mangament for restrictive myopathy

Answer 13

• surgery if dilopia is present in primary/ reading position of gaze. If disease is quiescent n angle of deviation has been stable for at least 6 months
• If not, diplopia may be alleviated with prisms
• Botox injection into affect muslce may be useful in some cases

Question 14

What is optic neuropathy (TED) caused by

Answer 14

compression of optic nerve or its blood supply at the orbital apex by congested and enlarged recti muscle

Question 15

What could optic neuropathy (TED) lead to and what is its presentation with

Answer 15

• Severe permanent but preventable visual impairment
• presentation is with impairment of central vision

Question 16

How to detect optic neuropathy (TED)

Answer 16

• Advise patients to self monitor visual function
• occulde each eye, read small print and asses the intensity of colours

Question 17

What is the sign of optic neuropathy (TED)

Answer 17

• reduced visual acuity, with RAPD, colour desaturation, diminished light brightness appreciation
• visual field defects may be centeral or paracentral, maybe combined with nerve fibre bundle defects
• optic disc is usually normal, occasionally swollen

Question 18

What is the mangament for optic neuropathy (TED)

Answer 18

refer for systemic steriods. Surgical decompression may be considered

Question 19

Name the infections of the orbit

Answer 19

preseptal cellulitis

bacterial orbital cellulitis

Question 20

What is preseptal cellulitis

Answer 20

An infection of subcutaneous tissues anterior to orbital septum

Occasionally rapid progression to orbital cellulitis may occur

Question 21

What are the causes of preseptal cellulitis

Answer 21

• skin trauma from lacerations or insect bites
• spread of local infection such as acute horeolum or dacryocystitis
• from remote infection of upper respiratory tract or middle ear by haematogenous spread

Question 22

What are the signs of preseptal cellulitis

Answer 22

• unilateral, tender, red periorbital oedema
• CT shows opacification anterior to orbital septum

Question 23

what is the management for preseptal cellulitis

Answer 23

refer to opthalmologist for antibiotics therapy

Question 24

What is bacterial orbital cellulitis

Answer 24

Life threatening infection of the soft tissues behind the orbital septum (more common in children)

Question 25

What are the causes of bacterial orbital cellulitis

Answer 25

- Sinus related - Extension of preseptal cellulitis - Local spread - Haematogenous spread - Post- trauma - Post- surgery

Question 26

What are the signs and symptoms of bacterial orbital cellulitis

Answer 26

- rapid onset of severe malaise, fever, pain and visual impairment - Unilateral, tender, warm, red periorbital and lid oedema - Proptosis is often obscured by lid swelling - painful opthalmoplegia (paralysis of EOM) - optic nerve dysfunction - CT scan shows opacification posterior to the orbital septum

Question 27

What is the management of bacterial orbital cellulitis

Answer 27

- refer to the emergency department - Hospital admission with otolaryngological assessment and frequent ophthalmic review is mandatory. (antibiotic therapy n monitoring of optic nerve function via every 4h test pupillary reactions, VA, colour vision and light brightness appreciation)

Question 28

What is capillary haemangioma

Answer 28

Common tumour of the orbit and periorbital area in childhood Girls affected more commonly

Question 29

What are the signs of capillary haemangioma

Answer 29

- usually in first few months of life - Unilateral, raised, red lesion - typically blanches on pressure may swell with crying - characterized by rapid growth 3-6 mths after diagnosis, followed by a slower phase of natural resolution

Question 30

What is the managment of capillary haemangioma

Answer 30

- treatment is inficated principally for amblyopia secondary to induced astig, ansiometropia, occlusion, strabismus (eyes dont line up)