1. Common Clinical Presentations and Clinical Evaluation in Orbital Diseases
Dr. Ayesha Abdullah

2. By the end of this lecture the students would be able to;
LEARNING OBJECTIVES
By the end of this lecture the students would be able to;
Categorize orbital diseases
Correlate the common symptoms & signs of orbital diseases with the underlying structural and functional disorder
Outline the protocol for the clinical evaluation of a patient with orbital disorder

3. CLASSIFICATION OF ORBITAL DISEASES
Congenital anomalies
Infections; orbital cellulitis
Inflammations; thyroid ophthalmopathy/ Thyroid Eye Disease (TED),
Tumours; primary , secondary, benign, malignant
Vascular malformations; Carotid-Cavernous Fistula (CCF), orbital varices
Traumatic disorders; blow-out fracture

4. Congenital Abnormalities

5. Inflammations

7. Tumours / neoplastic disorder

9. Vascular malformations

11. Caraticocavernous Fistula

12. COMMON SYMPTOMS & SIGNS OF ORBITAL DISEASES
Pain; orbital/ periorbital/ with ocular movements
Visual disturbances, loss/ blurring/
Diplopia/ squint
Swelling of the eyelids/ periorbital area/ mass
Protrusion of the eyeball

13. Signs Related to the eyeball
Proptosis; forward displacement of the eyeball
Dystopia; horizontal/vertical displacement of the eyeball in the coronal plane which may/ may not coexist with the forward displacement
Enophthalmos ; recession of the globe into the orbit
Nanophthalmos ; a very small eyeball
Anophthalmos: No eyeball- empty socket

14. Proptosis & dystopia
Vertical dystopia
Proptosis
Horizontal dystopia

15. Proptosis, diplopia, enophthalmos

22. Conjunctival & lid signs; swelling of the lid, conjunctival chemosis, injection ( redness)
Ocular motility disturbances; restrictive or muscle entrapment disorders, neurological disorders- strabismus
Corneal signs; secondary to exposure of the cornea
Posterior segment signs; venous dilatation & tortuosity , vascular occlusions, optic disc (OD) swelling, optic atrophy, choroidal folds

23. Conjunctival, lid & ocular motility signs

27. Other signs; bruit (carotid-cavernous fistula/CCF), pulsations (CCF, orbital roof defects), palpable mass
Sight threatening signs are exposure keratopathy, pupillary abnormalities ( RAPD) & optic disc or vascular changes in the retina

28. Causes of proptosis Common causes of proptosis in adults
Thyroid eye disease
Tumours
Common causes of proptosis in children
Orbital cellulitis
Congenital malformations of the orbital bones

29. Clinical evaluation of orbital disorders
History
Examination
Assessment of visual functions; Visual acuity & colour vision
Examination of the anterior segment
Examination of the pupils
Examination of the posterior segment
Examination of the Extra Ocular Muscles
Intraocular pressure measurements

31. Special tests
Exophthalmometry ( measuring globe protrusion & displacement – proptosis, dystopia)
Local palpation
Bruit & pulsations
Checking for cranial nerve dysfunctions
(II, III, IV, V, VI, VII, VIII)

33. Clinical test; measuring proptosis

35. Exophthalmometer

37. IMAGING Ultrasonography (US) CT scan MRI
Plain radiographs ( Caldwell & Waters view)- mostly taken over by CT & MRI

38. Our case
A16 year old female patient presented with forward protrusion of the right eye for the last one year, it was developed gradually with an associated visual loss……

39. Our case
What could be the most likely cause of proptosis?
Which structures could have been involved?
What clinical examinations would you perform?
Why the visual loss?
What would be the effect of this protrusion on the eye?
What would happen to this patient?

40. Questions? What could have been the cause of the protruding globe?
Which structures could have been involved?
What do you need to ascertain that?
Why the visual loss?
What would be the effect of this protrusion on the eye?
What would happen to this patient?

41. What is this?

42. Summary
Orbital disease are not common but can have sight threatening & at times life threatening sequelae
Common categories of orbital disorders include; Congenital anomalies, infections, inflammations, tumours, traumatic disorders
Commonest presentation is with proptosis, sight threatening signs include corneal exposure keratopathy, RAPD, optic disc changes
The commonest causes of proptosis in adults include TED & tumours while in children the commonest causes are orbital cellulitis, congenital disorders & tumours/ neoplastic disorders.