Orbital examination

Question 1

What are 12 stages of orbital examination?

Answer 1

1. vision - VA, colour
2. observe
3. observe from above
4. palpate orbital margins
5. palpate globe (gentre retropulsion)
6. check infraorbital sensation
7. perform exophthalmometry
8. if proptosis, assess whether axial or non-axial
9. auscultate globe/temporal region for bruit
10. assess any effect of valsalva manoeuvre
11. check corneal sensation
12. proceed to full ophthalmic examination

Question 2

What are 4 things to look for in the observe stage of orbital examination?

Answer 2

1. behaviour
2. habitus
3. face
4. lids

Question 3

What are you looking for when observing from above in the orbital examination?

Answer 3

globe position

Question 4

What are 4 things to check when palpating the orbital margins?

Answer 4

1. notches
2. instability
3. soft tissue signs
4. check for lacrimal gland

Question 5

What are you palpating the globe for?

Answer 5

pulsation, resistance, pain

Question 6

What are 2 examples of models used for exophthalmometry (for globe position)?

Answer 6

1. Hertel
2. Rodenstock

Question 7

What are 2 groups into which proptosis can be classed?

Answer 7

axial or non-axial

Question 8

How can proptosis be classed as axial or non-axial?

Answer 8

use 2 clear rulers, one horizontally over the bridge of the nose and one vertically to detect whether axial or non-axial

Question 9

What are you looking for with the valsalva manoeuvre?

Answer 9

whether it increases proptosis

Question 10

How does Hertel exophthalmometry work?

Answer 10

• instrument placed level with the orbits and separation adjusted so that foot plates rest on lateral orbital rims at level of lateral canthi.
• examiner closes R eye, ask pt to fix on L eye, whilst you align parallax markers (usually red) and read off where patient’s R corneal apex appears on scale
• repeated with examiner R eye and patient L eye

Question 11

What Hertel exophthalmometry reading is suggestive of proptosis?

Answer 11

> 20mm or >2mm between globes

Question 12

What are 3 types of variables which can influence the reading from a Hertel exophthalmometer?

Answer 12

1. Patient variables - racial differences, lateral orbitotomy
2. Instrument variability - between exophthalmometers
3. Operator inconsistency

Question 13

How can the consistency of serial Hertel exophthalmometer measurements be improved?

Answer 13

ensuring the intercanthal distance is kept the same

Question 14

What is the two-ruler test used for?

Answer 14

horizontal and vertical displacement of the globe may be demonstrated by using two clear plastic rulers

Question 15

How is the two-ruler test performed?

Answer 15

• one clear ruler placed horizontally over bridge of nose at level of lateral canthi - look for horizontal displacement by comparing distance from **centre of nasal bridge to equivalent points on globe **e.g. nasal limbus
• look for vertical displacement by measuring vertically (second ruler) to compare distance from horizontal meridian (i.e. first ruler) to equivalent points on the globe (e.g. inferior limbus)