EXAM AND IMAGING

SECONDARY ORBITAL LESIONS Extension of nasopharyngeal carcinoma (43%), conjunctival cancer (20%), eyelid cancer (18%), and lacrimal sac tumors (9%)

‘‘S’’-SHAPED EYELID Plexiform neurofibroma, dacroadenitis, and sarcoid

SUPERONASAL ORBITAL MASSES Rhabdomyosarcoma, myocele, mucopyocele, encephalocele, neurofibroma

TOUTON GIANT CELL-CONTAINING LESIONS Erdheim-Chester, necrobiotic xanthogranuloma, juvenile xanthogranuloma. Tissue granulomas with a ring of nuclei around the periphery of the giant cell.

UMBILICATED SKIN LESIONS Keratoacanthoma, BCC, and molluscum

UNILATERAL PERIORBITAL INFLAMMATION IN A CHILD Ruptured dermoid cyst, rhabdomyosarcoma (rubor without calor), pseudotumor, leukemia, eosinophilic granuloma, and infantile cortical hyperostosis

VASCULAR NEOPLASMS Capillary hemangioma (41%), lymphangiomas (33%), and cavernous hemangioma (21%)

WELL-DIFFERENTIATED LESIONS Cavernous hemangioma, hemangiopericytoma, peripheral nerve sheath tumors, and fibrous histiocytoma

Exam and Imaging

EXAM, EYELID Record lid measurements; assess corneal protective mechanisms (ensure good blink reflex and CN V function; rule out inferior keratopathy or lagophthalmos; look for Bell’s phenomenon; check tear production with TBUT or basal secretion test or Schirmer’s). Evaluate brow, lid laxity, canthal tendons, and presence of steatoblepharon. In ptosis evaluation, check for Herring’s effect (lift the ptotic lid to see if the contralateral lid lowers), look for jaw wink, and, if new onset, rule out myasthenia and check EOM function. Document with photos, and get superior visual field (VF) evaluation for ptosis or dermatochalasis.

Brow to upper lid (BUL): measure temporally, centrally, and nasally.

Excess skin (XS): grade 1–4 for upper and lower lids.

Herniated orbital fat (HOF): grade 1–4 (two fat pads upper and three lower lid).

telecanthus is increased soft tissue distance, and hypertelorism is widened bony distance. Exorbitism is lateral bony orbital walls >90 degrees.

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50ORBIT, EYELIDS, AND OCULAR ADNEXA

Levator function (12–14 mm): most important measurement in ptosis evaluation. Perform by eliminating frontalis muscle function, then measure lid excursion as patient looks down, then up. If >10 mm, then good function; fair function: 4–8 mm, poor function: <4 mm.

Lid laxity: evaluate canthal tendons, snap back (0 normal to 3þ lax), and distraction (<6 mm of lower lid laxity is normal).

Margin to crease distance (MCD): upper lid crease height normally 7– 8 mm (males), 9–10 mm (females); increases with levator dehiscence because the crease is from the insertion of aponeurosis fibers into skin. May also measure margin to fold distance (MFD).

Vertical palpebral fissure: if >9 mm, then probably has inferior scleral show.

Margin to reflex distance 1 (MRD1): distance from upper eyelid margin to the corneal light reflection; normal 3.5–4.0 mm; if >5, suspect superior scleral show.

Margin to reflex distance 2 (MRD2): distance from lower eyelid margin to the corneal light reflection; normal 5 mm.

Inferior scleral show (0 mm)

EXAM, ORBIT Do full eyelid work-up, plus evaluate ON function (BCVA, look for APD, color plates or red top test or D-15), check stereo vision to screen for early strabismus, exophthalmometry, IOP in primary and upgaze, current DFE, and obtain VF for baseline or any visual changes.

‘‘6 P’s’’ of orbital disease:

Pain: inflammation, infection, malignancy, ischemia

Proptosis: Graves’, pseudotumor, tumor, fistula

Progression: hours—trauma, infection, hemorrhage; days— previous plus inflammation, metastatic cancer; weeks—all previous plus neoplasia, vascular, cystic lesions

Palpation: masses may cause resistance to retropulsion

Pulsation: arteriovenous fistulas or cerebrospinal fluid pulsations

Periorbital changes: salmon patch in lymphoma, erythema with inflammation, etc.

Blowout fractures: do ptosis work-up, plus evaluate motility, hypophthalmos, diplopic VF, forced ductions and generations.

Thyroid: do ptosis work-up, plus evaluate motility, diplopic VF, Humphrey visual field (HVF), color plates, pupils, manifest refraction if patient is not 20/20, tonometry in primary and upgaze, and exophthalmometry.

EXAM, TEARING Look at lids, anterior segment, and secretory tests such as TBUT (if no anesthetic >15 seconds is normal, determined by goblet cell and oil function) and basal secretion test or Schirmer’s I (with anesthetic, >10 mm of wetting at 5 minutes is normal). Lacrimal drainage tests include:

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Dye disappearance test (DDT): excretory test; test is positive if there is significant dye present in the tear film 5 minutes after fluorescein was instilled.

Jones I (primary dye test): excretory test to determine if tears are passing into nose under normal physiological conditions. Use 2% fluorescein drop in eye and a topical decongestant/anesthetic in nose; place cotton fluff in inferior meatus. If after 5 minutes no fluorescein is recovered, there may be a functional block (but also negative result in 20–30% of normals). Test is positive if dye is recovered in nose. May also use light to look in nose after 10 minutes, or use Calgy swab or have patient blow nose. Gives same information as DDT.

Jones II (secondary dye test): nonphysiologic test to determine if dye has entered the lacrimal sac. After DDT or Jones I, irrigate through the punctum with saline; recovery of dye in nose indicates lower lacrimal system obstruction. If clear fluid is recovered, obstruction is before the lacrimal sac.

Jones III: assesses functioning of surgical osteotomy; test is positive if dye is recovered in nose of a post-dacryocystorhinostomy (DCR) or conjunctivodacryocystorhinostomy (CJDCR) patient.

Probe to evaluate upper system, not the nasolacrimal duct (NLD), except in children.

Irrigation: 3 cc of saline injected with blunt canula; have patient lean forward, feel sac, and look in nose or have patient report swallowing of fluid.

Dacryocystography (DCG): nonphysiologic Jones II test using radiopaque dye, then x-ray; can show size and filling defects within sac.

Dacryoscintigraphy: physiologic test imaging the flow of technetium dye placed in the inferior fornix.

EXOPHTHALMOMETRY Hertel exophthalmometry (upper limits of normal: black males 25 mm, black females 24 mm, white males 22 mm, and white females 21 mm); Naugel exophthalmometry measures from superior and inferior rim (useful after decompression surgery or zygomatic complex fracture), and Luedde exophthalmometry uses ruler (useful with children).

FINE NEEDLE ASPIRATION Limited usefulness and never use for cystic orbital masses or lacrimal gland tumors.

ORBITAL TRAUMA (MNEMONIC: TICS) Tetanus, intravenous antibiotics (e.g., Ancef ), computed tomography (CT) thin cuts (3 mm) axial and coronal, and shield for suspected open globe are usually appropriate interventions by emergency personnel while awaiting eye evaluation.

RADIOLOGICAL IMAGING (Fig. 2–9 shows basic orbital structures of the right orbit seen with axial CT images)

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52 ORBIT, EYELIDS, AND OCULAR ADNEXA

Figure 2–9 Serial diagrams of the right orbit, superior view, showing the basic orbital structures that may be seen on axial CT images.

CT is the imaging of choice in orbital trauma and gives excellent bony detail.

Magnetic resonance imaging (MRI) is never the initial imaging modality in trauma or in unconscious patients without adequate history. On MRI, vitreous is dark in T1 and bright in T2 (mnemonic: water is white); orbital fat is bright in T1 and dark in T2.

Plane x-ray films, especially Waters views, give limited views of the bony orbit and may help localize metallic foreign bodies when CT is not available.

ULTRASOUND A-scan ¼ amplitude mode, 8 MHz. B-scan ¼ brightness mode, 10 MHz (can only see about 25 mm into the anterior orbit). Standardized A-scan is an acoustic biopsy (99% sensitive for melanoma, 90% for metastatic cancer).

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