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Orbital and Ocular Adnexal Disorders with Red Eyes Practical Ophthalmology for the Family Physician 21 Jan 2017 Jason Lee Associate Consultant Department of Ophthalmology and Visual Sciences

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Page 1: Orbital and Ocular Adnexal Disorders with Red Eyes - KTPH and Ocular Adnexal... · Orbital and Ocular Adnexal Disorders with Red Eyes Practical Ophthalmology for the Family Physician

Orbital and Ocular Adnexal Disorders with Red Eyes

Practical Ophthalmology for the Family Physician

21 Jan 2017

Jason Lee Associate Consultant

Department of Ophthalmology and Visual Sciences

Page 2: Orbital and Ocular Adnexal Disorders with Red Eyes - KTPH and Ocular Adnexal... · Orbital and Ocular Adnexal Disorders with Red Eyes Practical Ophthalmology for the Family Physician

No financial disclosures

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Overview

• Case Scenarios

• Not an exhaustive list of conditions

• Important orbital and ocular adnexal conditions to recognise

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Orbit

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Ocular adnexae

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Scenario 1

30yo male presents with a 1 day history of left periorbital swelling, blurring of vision, fever and headache.

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Scenario 1

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Orbital Cellulitis

• OCULAR EMERGENCY!!!

• Occur at any age but more common in children

• Inflammation of orbital soft tissues behind the orbital septum

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Extension from preseptal cellulitis

Local spread from periorbital infection

/ sinuses

ORBITAL CELLULITIS

Haematogenous spread

Direct inoculation

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Preseptal vs Orbital Cellulitis

9 Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. The Laryngoscope

1970;80:1414-28.

Chandler’s Classification

• Preseptal cellulitis(I)

• Orbital cellulitis (II)

• Subperiosteal abscess (III)

• Orbital abscess (IV)

• Cavernous sinus thrombosis (V)

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Orbital Cellulitis • Signs

– Eyelid oedema and erythema

– Increased orbital pressure

• Decreased vision

• RAPD

• Proptosis

– Soft tissue inflammation

• Ophthalmoplegia

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• Intracranial sequelae:

– Cavernous sinus thrombosis

– Meningitis

– Cerebral abscess

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Orbital Cellulitis

• Management

– CT Orbits and Sinuses

– Hospital Admission • Serological investigations – Blood cultures,

FBC, wound swab if applicable

• Broad spectrum IV antibiotics – Conversion to oral antibiotics when cellulitis

improving (depending on culture and sensitivity)

• May require surgical drainage if presence of abscess

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Scenario 2a • 37yo male presents after falling onto his right after an RTA.

• Complaining of diplopia on upgaze

• Vision normal and optic nerve function normal.

• Right infraorbital anaesthesia

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CT Orbits

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Scenario 2a

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Orbital Blow-out fracture

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• Fracture of orbital walls but orbital rim intact from a blunt trauma to the orbit

• 2 proposed mechanisms:

–Hydraulic Theory

–Buckling theory

• Sequelae?

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Orbital Blow-out fracture

• Signs:

– Periorbital haematoma

– Restricted EOM

– Subcutaneous emphysema

– Infraorbital anaesthesia

– Enophthalmos

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Orbital Blow-out fracture

• Work-up:

– Exclude injuries to other parts of body and face

– Full ophthalmic examination to rule out globe rupture, traumatic optic neuropathy

– CT orbits and face

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Orbital Blow-out fracture

• Management:

– Cold compress

– No nose blowing

– Broad spectrum oral antibiotics for 1 week

– Short course of oral steroids

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Orbital Blow-out fracture

• Surgical repair:

– Immediate repair – muscle entrapment

– Repair in 1 – 2 weeks (Indications)

• Large orbital floor fractures of >50%

• Enophthalmos of 2mm or more

• Persistent, symptomatic diplopia on primary gaze

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Beware of the White-eyed Blow-out fracture

• Young patients (<18yo)

• Inferior “trapdoor” orbital floor fractures with muscle and soft tissue incarceration

• Entrapment of inferior rectus muscle can produce an oculocardiac reflex:

– Bardycardia

– Nausea

– Syncope 20

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Scenario 2b

• 55yo male presents after falling onto his left face. He is unable to spontaneously open his eye. Examination reveals a very tense orbit with a left RAPD.

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Retrobulbar haemorrhage

• Ocular emergency!

• Signs:

– Diffuse subconjunctival haemorrhage without a posterior margin

– Tense proptosis with resistance to retropulsion

– Very elevated intraocular pressure

– Very limited extraocular motility

– Compressive optic neuropathy

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Retrobulbar haemorrhage

• Management

– Timely and aggressive decompression

– If optic neuropathy is present, need to release orbital pressure with lateral canthotomy and cantholysis

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Scenario 3

• 47yo male presents with a 1 month history swelling over right lower lid and medial canthal region. He had 7 previous less severe episodes all of which recovered with oral antibiotics.

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Dacryocystitis

• Inflammation of the lacrimal sac

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Pathophysiology

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Idiopathic Inflammatory Stenosis

(Primary Acquired) Secondary Acquired

Infection

Inflammation

Neoplasm

Mechanical obstruction

Trauma

Obstruction of nasolacrimal duct

Stagnation of tears and infection

Increased Age

Female

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History to ask

• Epiphora

• Previous similar episodes

• History of trauma to medial canthal region

• History of systemic disease:

– Lymphoma / Neoplasms

– Granulomatosis with polyangiitis (Wegener’s Granulomatosis)

– Sarcoidosis 27

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Clinical findings

• Pain, redness and oedema

• Pus expressed from punctum

• Fistula may be present if sac ruptures through skin

• Conjunctival injection and preseptal cellulitis

• Can progress to orbital cellulitis

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To note

• Not all masses in medial canthal area arise from lacrimal sac

– Ruptured dermoid cyst

– Acute skin infection

– Acute ethmoiditis

• Swellings below the medial canthal tendon are typical of dacryocystitis

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To note

• Signs in favour of a lacrimal sac tumor include:

– Mass above medial canthal ligament

– Telangiectasia in the skin overlying the mass

– Serosanguinous discharge or bloody reflux with atraumatic irrigation

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Dacryocystitis

• Management

– Oral antibiotics (commonly gram positive)

– May require percutaneous drainage of abscess, small risk of fistula formation

– Imaging (CT orbits and Sinuses) may be required if atypical findings

– Dacryocystorhinostomy (DCR) few weeks after acute infection resolves

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Dacryocystorhinostomy

• Can be performed externally or endoscopically

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Scenario 4

• 50yo Chinese male, smoker, with a known history of Grave’s disease presented with a 20 year history of “prominent eyes”. He now complains of a 1 week history of L>R eye redness and tightness with left eye blurring of vision.

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Thyroid Eye Disease (TED)

• Diagnosed if eyelid retraction occurs with:

– Thyroid dysfunction or;

– Exophthalmos or;

– Optic nerve dysfunction or;

– Restrictive myopathy

If no eyelid retraction present, then TED can be diagnosed if

exophthalmos, optic nerve dysfunction or restrictive myopathy is associated with thyroid dysfunction

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Bartley GB, Gorman CA. Diagnostic criteria for Graves' ophthalmopathy. American journal of ophthalmology

1995;119:792-5.

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Thyroid Eye Disease (TED) • Affects 25 -50% of patients with Graves disease, of

which 5% have severe involvement

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Development or Progression of TED

Ancestry Caucasians > Asians

Active or Passive Smoking

Radioactive Iodine Therapy

Thyroid Dysfunction

Gender Women – more frequent Men – more severe

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Extraocular signs

• Proptosis

• Lid signs

– Lid retraction

– Lid lag

– Lid swelling

– Lid erythema

• Restrictive Myopathy

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Intraocular

• Anterior segment

– Conjunctival injection and chemosis

– Superior limbic keratoconjunctivitis

– Exposure keratopathy

– Glaucoma

• Posterior segment

– Optic neuropathy

– Choroidal folds 37

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Clinical assessment of patients with TED

• Clinical Activity

– CAS (Clinical Activity Score)

– VISA (Vision, Inflammation, Strabismus, Appearance)

• Clinical Severity

– NOSPECS (No signs and symptoms, Only signs, Soft tissue involvement, Proptosis, EOM involvement, Corneal involvement, Sight loss)

– EUGOGO (European Group on Graves’ Orbitopathy

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Clinical Activity Score (First visit)

1. Ocular pain at rest

2. Ocular pain on attempted up, side or down gaze

3. Eyelid erythema

4. Eyelid swelling

5. Conjunctival injection

6. Chemosis of the conjunctiva

7. Chemosis of the caruncle

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≥3/7 indicates active disease

Mourits MP, Prummel MF, Wiersinga WM, Koornneef L. Clinical activity score as a guide in the management of patients with

Graves' ophthalmopathy. Clinical endocrinology 1997;47:9-14.

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Clinical Activity Score (Repeat visits) • Ocular pain at rest

• Ocular pain on attempted up, side or down gaze

• Eyelid erythema

• Eyelid swelling

• Conjunctival injection

• Chemosis of the conjunctiva

• Chemosis of the caruncle

• Plus (during a period of 1 – 3 months): – Increase in proptosis by ≥ 2mm

– Decrease in eye movement in any direction by ≥ 5°

– Decrease in best corrected visual acuity by ≥ one line on the Snellen chart

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≥4/10 indicates active disease

Mourits MP, Prummel MF, Wiersinga WM, Koornneef L. Clinical activity score as a guide in the management of patients with

Graves' ophthalmopathy. Clinical endocrinology 1997;47:9-14.

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Severity of TED (EUGOGO)

• Classified into:

1) Mild TED

– <2mm eyelid retraction

– Mild soft tissue involvement

– <3 mm exophthalmos

– Transient or no diplopia

– Corneal exposure responsive to lubrication

41 Bartalena L, Baldeschi L, Dickinson A, et al. Consensus statement of the European Group on Graves' orbitopathy (EUGOGO)

on management of GO. European journal of endocrinology 2008;158:273-85.

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Severity of TED (EUGOGO)

2) Moderate-to-severe TED

– ≥ 2mm Moderate or severe eyelid retraction

– Moderate or severe soft tissue involvement

– ≥ 3mm exophthalmos

– Inconstant or constant diplopia

3) Sight-threatening (or very severe) TED

– Dysthyroid optic neuropathy

– Corneal breakdown

42 Bartalena L, Baldeschi L, Dickinson A, et al. Consensus statement of the European Group on Graves' orbitopathy (EUGOGO)

on management of GO. European journal of endocrinology 2008;158:273-85.

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Management of TED

43 Bartalena L, Baldeschi L, Dickinson A, et al. Consensus statement of the European Group on Graves' orbitopathy (EUGOGO)

on management of GO. European journal of endocrinology 2008;158:273-85.

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References 1. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital

complications in acute sinusitis. The Laryngoscope 1970;80:1414-28.

2. Gerstenblith AT, Rabinowitz MP. The Wills eye manual : office and emergency room diagnosis and treatment of eye disease. 6th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2012.

3. Kanski JJ. Clinical ophthalmology : a systematic approach. 6th ed. Edinburgh ; New York: Butterworth-Heinemann/Elsevier; 2007.

4. American Academy of Ophthalmology. Orbit, eyelids, and lacrimal system, 2010-2011. San Francisco, Calif.: American Academy of Ophthalmology; 2010.

5. Bartley GB, Gorman CA. Diagnostic criteria for Graves' ophthalmopathy. American journal of ophthalmology 1995;119:792-5.

6. Mourits MP, Prummel MF, Wiersinga WM, Koornneef L. Clinical activity score as a guide in the management of patients with Graves' ophthalmopathy. Clinical endocrinology 1997;47:9-14.

7. Bartalena L, Baldeschi L, Dickinson A, et al. Consensus statement of the European Group on Graves' orbitopathy (EUGOGO) on management of GO. European journal of endocrinology 2008;158:273-85.

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