Ординатура / Офтальмология / Английские материалы / Primary Care Ophthalmology_Palay, Krachmer_2005

284 CHAPTER 14 • Orbital Disease

Canaliculitis

Symptoms

• Tearing, pain, and mucopurulent discharge are characteristic.

Signs

•Swelling and erythema are noted over the involved canaliculus (Fig. 14–9).

•Mucopurulent discharge results when digital pressure is applied over the involved canaliculus.

Etiology

•Infectious organisms that can lead to the disorder include Actinomyces species (most common) and Streptomyces species, which often are associated with stones in the canaliculus (dacryoliths).

Differential Diagnosis

Diagnostic possibilities include the following:

•Dacryocystitis

•Tumor

Treatment

•Curettage of the canaliculus is performed by an ophthalmologist to remove the stones.

•Surgical incision of the canaliculus (canaliculotomy) is performed to remove the stones.

•Nasolacrimal duct probing and irrigation confirm patency of the distal system.

FIGURE 14–9 Canaliculitis manifests with conjunctivitis, inflamed and pouting punctum, and expressible discharge from the canaliculus.

286 CHAPTER 14 • Orbital Disease

FIGURE 14–12 A patient with severe exophthalmos and orbital congestion resulting from thyroid eye disease.

•Swelling of the conjunctiva, lids, and brows is noted.

•A loss of visual acuity, visual field, and color vision occurs.

Etiology

•A thyroid abnormality can lead to ophthalmic disease.

Patient may be hyperthyroid, hypothyroid, or euthyroid when the orbital disease occurs.

Some patients have autoimmune thyroiditis (Hashimoto’s disease).

Ophthalmic disease may precede or follow glandular disease by many years.

Most commonly, ophthalmic disease develops shortly after the patient undergoes treatment for hyperthyroidism.

Differential Diagnosis

Considerations in the differential diagnosis include the following:

•Conjunctivitis

•Orbital pseudotumor

•Myasthenia gravis

•Orbital tumor

Associated Factors and Diseases

•Ophthalmopathy remains active for an average of 2 years and much longer in some patients.

Workup

•A complete battery of thyroid tests is needed.

•Careful monitoring of the patient’s thyroid status is performed if the findings on thyroid tests are normal.

•A CT scan or an MRI study is needed if the ophthalmic diagnosis is not completely confirmed (Fig. 14–13).

•A thorough ophthalmologic examination and computerized visual field testing are performed to diagnose early visual loss and other sight-threatening conditions. Visual loss is caused by compression of the apical portion of the optic nerve (compressive optic neuropathy) by enlarged extraocular muscles.

Treatment

•In mild cases, artificial tears are used for lubrication.

•In moderate to severe cases, the following considerations apply:

The head of the bed is elevated to reduce congestion.

Oral prednisone (20 to 100 mg/day) is used to treat congestion, inflammation, and compressive optic neuropathy. Unfortunately, when the dosage is reduced, the ophthalmopathy flares again quickly. Oral prednisone usually is a temporizing therapy.

Orbital irradiation is performed for congestion, inflammation, and compressive optic neuropathy. This may shorten the overall course of the disease or decrease the severity. This therapy begins working in 1 month, and it may cause radiation retinopathy.

Orbital decompression is performed for congestion, compressive optic neuropathy, and exophthalmos. Beneficial effects may be noted within days. Ocular motility disturbances may worsen. Long-term side effects include sinusitis and facial paresthesias.

Eye muscle surgery (strabismus surgery) to correct double vision is performed after the disease is quiescent.

Repair of lid retraction is performed after the disease is quiescent or during the active phase if severe exposure is present.

Follow-up

•Ophthalmologic examination is needed every 3 to 6 months during the active phase and yearly thereafter to monitor for ophthalmopathy, which may recur.

•Visual field testing is performed as needed to exclude the possibility of compressive optic neuropathy.

288 CHAPTER 14 • Orbital Disease

Orbital Pseudotumor

Symptoms

•The acute variety, in which the onset occurs over hours to a few days, is the common form and involves severe pain, proptosis, visual loss, restricted ocular motility, malaise, and fatigue.

•The subacute to chronic variety, in which the onset occurs over weeks to months, is the uncommon form.

•Symptoms experienced depend on the location and rapidity of onset. In general, the more acute the onset, the more dramatic the symptoms.

Signs

•The disorder usually is unilateral.

•See Box 14–1 for classification.

BOX 14–1 Classification of Orbital Pseudotumor

Diffuse

• Generalized orbital involvement is characteristic (Figs. 14–14 and 14–15).

FIGURE 14–14 Diffuse orbital pseudotumor. The patient was a 30-year-old man who had a 2-day history of pain, proptosis, motility restriction, and visual loss involving the right eye.

BOX 14–1 Classification of Orbital Pseudotumor (Continued)

FIGURE 14–15 An axial CT scan of the head obtained in the patient in Figure 14–14 shows diffuse orbital inflammation on the right side.

Posterior Tenonitis

•The inflammation is restricted to the posterior half of the connective tissue surrounding the globe (Tenon’s capsule) (Figs. 14–16 and 14–17).

FIGURE 14–16 Orbital pseudotumor, posterior tenonitis. The patient was an 86- year-old woman who had a 3-day history of pain, lid and conjunctival swelling, and visual loss involving the right eye.

290 CHAPTER 14 • Orbital Disease

BOX 14–1 Classification of Orbital Pseudotumor (Continued)

1

FIGURE 14–17 An axial CT scan of the head obtained in the patient in Figure 14–16 shows that the inflammation is restricted to the posterior Tenon’s capsule (1) of the right eye.

Orbital Myositis

•The inflammation is restricted to one or a few extraocular muscles (Figs. 14–18 and 14–19).

FIGURE 14–18 Orbital pseudotumor, myositis. The patient was a 30-year-old woman with a 1–week history of double vision and pain in the left eye.

1

FIGURE 14–19 An axial CT scan of the head obtained in the patient in Figure 14–18 shows orbital myositis involving the left medial rectus muscle (1).

BOX 14–1 Classification of Orbital Pseudotumor (Continued)

Dacryoadenitis

• The inflammation is restricted to the lacrimal gland (Figs. 14–20 and 14–21).

FIGURE 14–20 Orbital pseudotumor, dacryoadenitis. The patient was a 64- year-old woman with a 1–month history of pain, swelling, and erythema of the left eye unresponsive to oral antibiotics and topical corticosteroid drops.

1

FIGURE 14–21 An axial CT scan of the head obtained in the patient in Figure 14–20 shows enlargement of the left lacrimal gland (1).

Etiology

• The origin of the disorder is idiopathic.

Differential Diagnosis

Diagnostic possibilities include the following:

•Thyroid eye disease

•Specific orbital inflammation (e.g., sarcoidosis, vasculitis)

•Orbital cellulitis

•Orbital tumor

292 CHAPTER 14 • Orbital Disease

Workup

•A biopsy often is necessary, because orbital pseudotumor is a diagnosis of exclusion. Polymorphous inflammatory cell infiltrate with a variable degree of fibrosis is a characteristic finding on examination of the biopsy specimen.

•A CT scan or an MRI is indicated.

•The diagnosis of orbital pseudotumor is made when other causes of these symptoms are highly unlikely.

Treatment

•Prednisone (80 to 120 mg/day) is administered and tapered over 4 to 8 weeks. This corticosteroid regimen usually gives rapid (1 to 3 days) and permanent resolution of symptoms.

•Low-dose orbital radiation (20 to 30 Gy) is an acceptable alternative if the patient relapses after corticosteroids are tapered (uncommonly) or if the patient cannot take corticosteroids.

•Immunosuppression may be needed with cyclophosphamide (Cytoxan), azathioprine (Imuran), or cyclosporine if the patient fails to respond to corticosteroids and radiation therapy, which is a rare occurrence.

Follow-up

• The disorder rarely recurs.