Ocular Disease Iii - Orbital Dz

Front 1

6 P's of orbital dz?

Back 1

Pain
Progression
Proptosis
Palpation
Pulsation
Periorbital changes

Front 2

Fast progression of orbital dz leads you to believe...

Back 2

rabdomyosarcoma/infection

Front 3

Your pt's proptotic eye goes down and in - you suspect...

Back 3

lacrimal gland lesion

Front 4

When your patient's eyes are proptotic and they complain of diplopia, you must first ask...

Back 4

"do you see two DISTINCT images?"

Helps determine if refractive

Front 5

A pulsating eye leads you to believe...

Back 5

vascular issue e.g. fistula

Front 6

Positive retropulsion means...

Back 6

you push on the eye and it doesn't give

Front 7

Mean exophthalmometry protrusion in white men?

Back 7

16.5 mm

Front 8

Mean exophthalmometry protrusion in white women?

Back 8

15.4 mm

Front 9

Mean exophthalmometry protrusion in black men?

Back 9

18.5 mm

Front 10

Mean exophthalmometry protrusion in black women?

Back 10

17.8 mm

Front 11

Mean exophthalmometry protrusion in asian men?

Back 11

16 mm

Front 12

Mean exophthalmometry protrusion in asian women?

Back 12

16 mm

Front 13

This EOM is the first to go in grave's...

Back 13

IR

Front 14

Corkscrew vessels is a sign of ___ in orbital dz

Back 14

arteriovenous fistula

Front 15

Between MRD1 and MRD2, which is more diagnostic?

Back 15

MRD1 b/c MRD2 more variable

Front 16

What is a "thrill"?

Back 16

the vibration felt due to a hardened artery

Front 17

What is crepitous?

Back 17

Air cracking out of orbit/skin, sign of suborbital or subdermal emphysema

Front 18

Suborbital emphysema is...

Back 18

a sign of break in a cranial sinus (e.g. ethmoid), evident when do valsalva - air enters in sinus and causes proptosis. Due to abnormal communication b/w ethmoid and retrobulbar space

Front 19

Subdermal emphysema is...

Back 19

a sign of abnormal communication between subdermal space and retrobulbar space - lid "blows up" when do valsalva

Front 20

What kind of X-ray would you order for orbital dz?

Back 20

Caldwell Waters - checks for every orbital bone

Front 21

What types of ultrasound would be useful for vascular tumors and thyroid dz?

Back 21

A & B scan

Front 22

T/F - CAT scans are useful for vascular tumors.

Back 22

False - does not pick up BVs that well

Front 23

T/F - CAT scans are not useful for EOMs and the orbital wall.

Back 23

False - CAT scans are useful for these structures, but not the best for vascular structures e.g. vascular tumors

Front 24

MRIs are useful for what types of structures?

Back 24

Vascular structures e.g. vascular tumors

Front 25

Difference b/w T1 and T2 MRIs?

Back 25

T1 = water (i.e. vitreous) is dark T2 = water is white

Front 26

What is congenital anophthalmos? Tx?

Back 26

no orbit; Tx = socket expansion and prosthesis

Front 27

What is goldenhar syndrome?

Back 27

aka Craniofacial cleft syndrome; dermoid at inferotemporal limbus, preauricular skin tags, vertebral skeletal defects, eyelid colobomas

Front 28

What is Crouzon syndrome?

Back 28

"squished frog/tadpole appearance" - basically flattened face; exophthalmos due to shallow orbits, receeded cheekbones, strab, nystag, optic atrophy, craniosynotosis (coronal sutures)

Front 29

DDx preseptal vs orbital cellulitis?

Back 29

Preseptal = no pain on motion, normal EOMs, no fever

Front 30

What does Dr. S mean by "marching" in orbital cellulitis?

Back 30

redness tends to go further away from center, an indication of spreading/progress

Front 31

Main DDx symptom of orbital cellulitis vs orbital tumor?

Back 31

Sudden onset of "pushing on back of my eye" = orbital cellulitis

Gradual = orbital tumor

Front 32

Common cause of orbital cellulitis?

Back 32

acute sinusitis

Front 33

T/F - VAs can be decr in orbital cellulitis?

Back 33

True

Front 34

Most common congested sinus in orbital cellulitis?

Back 34

ethmoid/maxillary

Front 35

T/F - Anorexia is assoc w/ orbital cellulitis

Back 35

True

Front 36

Tx orbital cellulitis in children?

Back 36

Admit to hospital; options:
- Vancomycin IV or Nafcilin IV + Ceftriaxone IV
- If allergic to penicillin/cephalosporin give Vancomycin IV or Clindamycin IV + Gentamycin IV

Front 37

Oral meds appropriate for orbital cellulitis?

Back 37

Yes, but only after pt responds to IV Tx

Front 38

Tx preseptal cellulitis?

Back 38

Options:
- Amox/clav (Augmentin)
- Cefaclor
- If allergic to penicillin, use Trimethprim/Sulfamethoxazole (Bactrim), Trimethoprim
- If allergic to sulfa, use Erythromycin, Zithromax, or Clarthromycin

Front 39

You should order [this lab test] to DDx Pseudotumor IOIS vs [this orbital dz]. How do you know it's Pseudotumor IOIS?

Back 39

CAT scan, DDx vs Thyroid.

Pseudotumor = BOTH muscles and tendons inflamed

Thyroid = only muscles inflamed (not tendons)

Front 40

Pseudotumor IOIS main complaint?

Back 40

Orbital pain

Front 41

Tolosa-Hunt sydrome is a form of this orbital dz.

Back 41

Pseudotumor IOIS

Front 42

What does IOIS stand for in Pseudotumor IOIS?

Back 42

Idiopathic Orbital Inflammatory Syndrome

Front 43

Pseudotumor IOIS has this sign that is different from Orbital cellulitis, and it is caused secondary to trabeculitis.

Back 43

Incr IOP

Front 44

What cranial nerve is affected in Pseudotumor IOIS? How?

Back 44

Decr sensation of CN V

Front 45

T/F - Possible to see optic disc edema in Pseudotumor IOIS

Back 45

True

Front 46

Your 34 yo pt comes in with a painful unilateral proptotic globe, restricted EOMs, eyelid erythema and edema, and intense conj injection. Your pt's temperature is normal. You suspect...

Back 46

Pseudotumor IOIS (normal temp, no fever in adults)

Front 47

Tx Pseudotumor IOIS?

Back 47

Steroid (prednisone), anti-ulcer med (rantidine), low dose radiation if steroids fail, or as adj Tx; immunosupp Tx if above fail

Front 48

What are Choriostomas?

Back 48

when primordial tissues fuse, dermoid/epidermoid tissue is trapped b/w suture of bone and create "skin tags". More commonly external vs internal

Front 49

Most common benign choriostoma?

Back 49

dermoid cyst

Front 50

These cystic tumors can have hair

Back 50

dermoids + epidermoids (orbital/periorbital)

Front 51

Epidermoids arise from this tissue in development...

Back 51

ectoderm

Front 52

Dermoids arise from this tissue in development...

Back 52

ecto/mesodermal

Front 53

Your pt presents with a flesh colored bump on the brow ridge. On palpation you feel a small round "ball" that moves freely inside. There is no inflammation. You suspect...

Back 53

dermoid/epidermoid (cystic tumor)

Front 54

Lipodermoids usually show up on...

Back 54

the conjunctiva

Front 55

Most common benign vascular tumor in children?

Back 55

Capillary hemangiomas (strawberry nevus)

Front 56

T/F - Capillary hemangiomas occur after birth.

Back 56

True - first several mos after birth (not at birth)

Front 57

T/F - Capillary hemangiomas will blanch if pushed.

Back 57

True

Front 58

Tx Capillary hemangiomas?

Back 58

Steroid IV (betamethasone and triamcinolone), but can depigment eye and incr IOP.

can also just monitor b/c can resolve over time on its own

Front 59

This tumor is often assoc w/ neurofibromatosis

Back 59

ON glioma

Front 60

ON glioma demographic?

Back 60

Females 2-6 yrs (Females 3x > males)

Front 61

T/F - ON gliomas are rapid growing and benign.

Back 61

False - slow growing and benign (not metastatic but can take vision)

Front 62

Lisch nodules and cafe au-lait spots on a child are very diagnostic of...

Back 62

ON gliomas

Front 63

What are lisch nodules?

Back 63

small brown elevations on iris, diagnostic of ON glioma

Front 64

You want to check the VF of your 3 yo female pt, who you suspect ON glioma, but you know the responses will be poor. What is an alternative?

Back 64

Multifocal ERG

Front 65

ON Giloma Tx?

Back 65

If VA good, NOT surgery. Surgery only if VA loss or severe proptosis

Under 5 yo = chemo
Over 5 yo = radiation of ONH

Front 66

This tumor must be ruled out in cases of sudden unilateral proptosis in young children...

Back 66

Rabdomyosarcoma

Front 67

Most common malignant tumor of orbit in kids?

Back 67

Rabdomyosarcoma

Front 68

Why is Rabdomyosarcoma so serious?

Back 68

Can metastasize

Front 69

Enlarged lymph nodes at the neck/underarms, bruised eyelids (that won't go away) with a Hx of nosebleeds in a child makes you think...

Back 69

Rabdomyosarcoma

Front 70

Why is a chest and bone x-ray indicated for Rabdomyosarcoma?

Back 70

look for metastasis

Front 71

T/F - Main demographic of Rabdomyosarcoma is children.

Back 71

True

Front 72

T/F - Males are more likely to get capillary hemangiomas.

Back 72

False - equal to females

Front 73

The main difference in etiology of orbital cellulitis in adults vs kids is...

Back 73

kids = assoc w/ polyps, allergies

Front 74

What is Red Man Syndrome?

Back 74

Side effect of vancomycin, a Tx for orbital cellulitis

Front 75

Cavernous hemangioma demographic?

Back 75

middle aged women

Front 76

T/F - Cavernous hemangioma tends to be slow growing.

Back 76

True - 4 yrs from signs to dx (avg)

Front 77

Where can you find Cavernous hemangiomas?

Back 77

Muscle cone

Front 78

T/F - Cavernous hemangiomas are vascular

Back 78

True

Front 79

T/F - Cavernous hemangioma has (+) retropulsion

Back 79

True

Front 80

Your pt has decreased VAs due to increased hyperopia, (+) retropulsion, axial proptosis, choroidal folds, disc edema. Orbital T2 MRI is hyperintense. CT scan reveals intracanal lesion. Dx?

Back 80

Cavernous hemangioma

Front 81

What artery is involved in a low flow, low pressure fistula? What demographic?

Back 81

Meningiohypophyseal a.

Post-menopause females

Front 82

Your 60 yo female pt hears a whooshing sound when sleeping on her side. You note that the globe is not pulsating. Dx?

Back 82

Fistula at meningiohypophyseal a.

Front 83

High flow fistula demographic and cause?

Back 83

Young male, trauma; ICA fistula in cavernous sinus

Front 84

T/F - You do not see incr IOP in arteriovenous fistulas.

Back 84

False - there is incr IOP, in high flow

Front 85

Orbital bruit with pulsatile proptosis are key indicators of...

Back 85

high flow arteriovenous fistula

Front 86

What type(s) of palsies occur in high flow arteriovenous fistulas? Low flow?

Back 86

High flow = 3rd/6th palsy

Low flow = 6th palsy

Front 87

T/F - You see engorged episcleral veins only in high flow arteriovenous fistulas.

Back 87

False - seen both in high and low flow

Front 88

Cavernous hemangioma appearance on MRI T1 and T2?

Back 88

T1 = hypointense
T2 = hyperintense

Remember tumor is vascular

Front 89

Typical VF defect on cavernous hemangioma?

Back 89

Variable - ON is choked at muscle cone

Front 90

On orbital CT scan or MRI, you see this highly diagnostic sign on arteriovenous fistulas.

Back 90

Enlargement of sup ophthalmic vein

Front 91

Tx high flow arteriovenous fistula? Low flow?

Back 91

High = surgery
Low flow = most resolve on own (60%)

Front 92

Lacrimal gland tumors include these types...

Back 92

Pleomorphic adenoma, pleomorphic adenocarcinoma, cylindroma

Front 93

S-shaped lid is a sign of this tumor.

Back 93

Lacrimal gland tumor

Front 94

Lacrimal gland tumor demographic?

Back 94

males slightly more vs females

2nd-5th decade, 4th decade highest

Front 95

T/F - Lacrimal gland tumor progression is rapid.

Back 95

False - slow (Sx for 12 mos)

Front 96

What type of Lacrimal gland tumor has a 50% survival at 5 yrs?

Back 96

cylindrome type

Front 97

Most common cancers in women? Men?

Back 97

Women = breast & lung
Men = lung & prostrate

Front 98

Chemo/radiotherapy for cancer often results in this ocular Sx.

Back 98

Dry eye

Front 99

Breast cancer has its highest risk of metastasis during...

Back 99

First 2 years

Front 100

What is the most important factor in Dx orbital tumor secondary to metastatic breast cancer?

Back 100

Hx of cancer

Front 101

Radiation retinopathy involves...

Back 101

closing of microvasculature therefore see multiple CWS

Front 102

T/F - Orbital ultrasound is indicated for metastatic tumors to the orbit.

Back 102

False - not a solid mass (diffuse) therefore not diagnostic

Front 103

T/F - Anisocoria is commonly found in blowout fractures of the orbit.

Back 103

True - parasymp damage

Front 104

What EOM is usually affected in orbital blowout fractures?

Back 104

IR (orbital floor break so IR gets trapped)

Front 105

T/F - Proptosis occurs with blowout fractures.

Back 105

False - enophthalmos (orbital floor drops so globe pulls back)

Thus also can see ptosis

Front 106

#1 place of orbital trauma? #2?

Back 106

#1 = home, #2 = street/highway

Front 107

Orbital trauma almost always occurs in (males/females)?

Back 107

males

Front 108

Top occupation of orbital trauma

Back 108

construction

Front 109

Top activity leading to orbital trauma?

Back 109

hammering

Front 110

Orbital trauma usually results in what kind of VAs?

Back 110

Hand motion

Front 111

Orbital trauma usually (sharp/blunt) objects?

Back 111

blunt

Front 112

% not wearing eye protection in orbital trauma?

Back 112

80

Front 113

Afrin is indicated for orbital trauma because...

Back 113

(nasal decongestant) so pt won't blow nose (valsalva can push sinus contents into orbit)

Front 114

If the AC is not well-formed in orbital trauma, what test should you do?

Back 114

Seidel test to make sure no leakage

Front 115

T/F - Orbital floor blowout fracture is an ocular emergency that must get surgery STAT

Back 115

False - not necessarily an emergency, want swelling to subside first

Surgical repair of orbit at day 7-14 if persistent diplopia or large fracture of bone present

Front 116

T/F - Orbital roof blowout fracture is an ocular emergency that must get surgery STAT

Back 116

True - possible CSF leakage

Front 117

If your pt talks about any Hx of flying FBs and complains of pain (whether active or subsided), MUST do this test...

Back 117

Orbital X-ray

Front 118

Wood and vegatative matter are tolerated (poorly/fairly well/well) as a foreign body.

Back 118

poorly

Front 119

Copper alloys, brass, bronze are tolerated (poorly/fairly well/well) as a foreign body.

Back 119

fairly well

Front 120

Lead is tolerated (poorly/fairly well/well) as a foreign body.

Back 120

well

Front 121

Steel is tolerated (poorly/fairly well/well) as a foreign body.

Back 121

well

Front 122

Stone is tolerated (poorly/fairly well/well) as a foreign body.

Back 122

well

Front 123

T/F - Topical antibiotics are indicated for intraorbital foreign bodies.

Back 123

False - systemic e.g. cefazolin