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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
278
CHAP TER9 The cheek andorbit
The prognosis is good if treated early. Optic neuropathy and vascular
occlusions carry poor visual prognosis. Cavernous sinus thrombosis has
poor prognosis (see E Chapter 3).
In children, a rhabdomyosarcoma can mimic orbital cellulitis.
Orbital cellulitis can lead to meningitis, brain abscess, cavernous sinus
thrombosis, septic shock, and death. It is vital for it to be diagnosed and
managed promptly.
cSinusitis
Sinusitis may present in many ways and may be confused with atypical facial pain, dental infections, orbital infections, osteomyelitis, or a
tumour. The majority of infections are related to an initial rhinitis (as
rhinosinusitis), but some can arise secondarily to dental infections in the
upper teeth. Untreated sinusitis can spread to involve all four sinuses
(maxillar y, ethmoid, frontal, and sphenoid) sometimes referred to as
pansinusitis. This is a potentially life- and sight- threatening condition. See
Figure9.7.
Sinusitis often arises following an URTI. Blockage of the draining ostia,
paralysis of the cilia, and stagnation of secretions within the sinus predisposes to superadded infection. Any sinus can be aected, but the
maxillary and ethmoid sinuses are the more common. Dental infections
involving the upper teeth can also cause maxillar y sinusitis. The roots of
the molar and premolar teeth are sometimes separated from the sinus
mucosa only by ‘wafer- thin’ bone, or dehisced bone. Infection within the
pulp chamber can therefore pass through the tip (apex) of the root into
the sinus relatively easily. The absence of toothache does not r ule out
dental causes.
Figure9.7 The sinu ses of the face . kowal ska- a rt/ istock phot o.
cAcute maxillary sinusitis
This is commonly caused by upper respiratory commensals (pneumococci, staphylococci, streptococci, and anaerobes), or untreated upper
dental infections. There is often some predisposing obstruction to the
opening of the middle meatus, preventing the sinus from draining freely.
This results in stagnation and then infection.
Clinically thereis:
• Systemicupset
• Severe cheek pain, worse on bending
• Swelling over thecheek
• Numbness of thecheek
• Mobile upper teeth, which are tender to percussion (in severe cases).
Patients usually present with unilater al swelling of the face, sometimes
referred to as a ‘fat face’. Untreated, sinusitis can result in bacteraemia,
or even septicaemia. The latter can occasionally lead to septicshock.
Usually the FBC will show an increased WCC. Blood cultures and a
raised ESR may indicate the presence of bacteraemia or septicaemia.
Radiographically there is r adio - opacity of the involved sinus on an occipitomental view. CT scan is required to assess the extent of infection.
Infec ted large dental cyst s should also be considered. If these are not
identied a sinus washout will not remove all thepus.
Closure of the eyelids from swelling should be taken seriously— the eye
should be assessed and the patient often needs to be admitted.
bChronic maxillary sinusitis
An underlying cause should be considered (dental disease, cystic brosis,
or Kar tagener’s syndrome). Symptoms are similar to the acute infection
but much less in severity. CT and MRI scans are useful diagnostic tests,
although a high percentage of asymptomatic people have ‘abnormal’
scans. Diagnosis and treatment is therefore on clinical grounds.
cAcute frontal sinusitis
(See E Chapter 3.) This is potentially serious due to the risk of intr acranial infection. Patients complain of front al headache, which is tender to
percussion. Untreated, the infection can spread intr acranially or involve
theorbit.
cAcute ethmoid sinusitis
(See E Chapter 7.) This usually occurs in association with other sinus
infections. Patients complain of deep- seated pain and throbbing deep to
the bridge of the nose. The medial orbital walls are paper thin, so orbital
cellulitis can rapidly develop.
Management ofsinusitis
Antibiotics and, in some ca ses, sinus washout with drainage using functional endoscopic sinus surgery. Ephedrine nasal drops and menthol
inhalations may help reduce congestion and improve sinus drainage.
Consider screening for diabetes and other causes of immunosuppression. Symptoms requiring urgent assessment or referral include:
• Pyrexia
• Headache
SINUSITIS
279
280
CHAP TER9 The cheek andorbit
• Swollen eyelids
• Blur redvision
• Signicant malaise.
These patients probably need to be admitted for IV antibiotics and close
observation.
cFungal sinusitis
The most common fungus is Aspergillus. Microsporidia can also infect the
sinuses. This may occur in otherwise healthy individuals. However, look
for underlying causes of immunosuppression. The infection is seen as an
opacity on X- ray or CT. Surgical debridement may be required.
bThyroid eye disease
Thyroid eye disease ( TED) is frequently termed Graves’ ophthalmopathy and is part of an autoimmune process that can aect the orbital and
periorbital tissue, the thyroid gland (hyperthyroidism), and rarely pre
tibial skin. An antibody- mediated reaction with lymphocytic inltration
of the orbital tissues results in an increa se in volume of the orbital contents. This involves both the extraocular muscles and fat. This can cause
bilateral or unilateral proptosis. Patients present with irritation around
the eye, painful eye movement s, a red eye, and, if severe, decreased
vision. There is lid retraction, proptosis, chemosis, periorbital oedema,
and altered ocular mobility. Initially an acute or subacute stage can make
the dierential diagnosis of orbital cellulitis dicult. In the latter there
is usually a fever. Untreated, TED can cause vision- threatening exposure keratopathy, diplopia, and compressive optic neuropathy. Look for
systemic features of hyperthyroidism. TED can also occur in euthyroid
state. Investigations include thyroid function tests (thyroid- stimulating
hormone, T3, and T4 levels) and thyroid autoantibodies.
Management
Ocular irritation without inammation can be managed with articial
tear supplements. Mild ocular surface inammation can be managed with
topical steroids. Acute severe TED that can compromise optic nerve
function should be referred urgently to ophthalmology urgently for
management with IV methylprednisolone. Surgical decompression of the
orbits is rarely indicated acutely.
bDiplopia (double vision)
Diplopia occurs when one or both eyes are either moved out of alignment (by displacement of a fr acture or by an orbital ma ss/ swelling),
or they lose their ability to move precisely together (either because of
nerve/ muscle weakness, or mechanical restriction). This is called binocular diplopia. Less commonly, diplopia may occur secondary to a problem within just one of the globes. This is called monocular diplopia.
Binocular diplopia is a common complaint following injuries to the
orbit/ eye, but in most cases it is temporar y and secondary to swelling/
DIPLOPIA (DOUBLE VISION)
bruising around the extraocular eye muscles. Nevertheless, it can also be
a symptom of signicant orbital or globe injury, and in some cases requires
surgical repair (see E ‘Orbital fractures (isolated)’, pp. 267–9). Diplopia
can also occur in other non- traumatic conditions, notably tumours, and
therefore needs careful evaluation.
Causes ofdiplopia
These include ophthalmologic, traumatic, infectious, autoimmune, neurological, and neoplastic causes:
• Alcohol intoxication
• Fractures to the zygoma/ orbit/ NOE/ skull
• CN III, IV, VIinjury
• Orbital/ extraocular eye muscles, swelling/ bruising
• Orbital myositis
• Tumours
• Migraine
• Neurological disease(MS)
• Sinusitis
• Orbital abscess
• Graves’ disease
• Strabismus
• Globe disorders.
Investigations
In gross cases, conrmation of diplopia may be possible by clinical
examination of eye movements and looking at the corneal light reex.
However, in more subtle cases diplopia may only be apparent at the
extremes of eye moments. All cases require an orthoptic assessment.
Diplopia associated with proptosis is worrying and requires an urgent
CT (to look for a space- occupying orbital lesion). Other investigations
are guided by the history (notably of trauma, or the presence of visual
impairment, and/ or pain). Progressive, persistent, or signicant diplopia requires urgent referral to either ophthalmology or maxillofacial,
depending on local protocol.
Management
This is dependent on the underlyingcause.
281
Chapter10
283
The eye and eyelids
Common presentations 284
Common problems and their causes 284
Essential questions 287
Examination of the eye and eyelids 288
Useful investigations 293
Ocular/ eyelid injuries 294
Penetrating/ perforating globe injuries 294
Blunt injuries 296
Eyelid lacerations 299
Chemical injuries 302
The red eye 302
Glaucoma 303
Keratitis 305
Iritis/ uveitis 306
Scleritis and episcleritis 307
Foreign bodies 307
Contact lens- related problems 309
Loss of vision 310
Eyelid problems 314
Watery eyes 315
284
CHAP TER10 The eye and eyelids
Common presentations
Common presentations for the eye and eyelids:
• Black eye (periorbital haematoma)
• Double vision (see E Chapter 9, pp. 280 –1)
• Dryeyes
• Foreign body sensation
• Injuries
• Loss of vision (painful)
• Loss of vision (painless)
• Painfuleye
• Proptosis (see E Chapter 9, p. 273)
• Red eye (painful)
• Red eye (painless)
• Swollen (puy) eyelids.
Common problems and theircauses
Black eye (periorbital haematoma)
Common
• Trauma to the eye, nose, or forehead
• Basal skull fr acture (especially if bilater al) — racooneyes
• Recent surgical procedures to the eye orface.
Uncommon
• Pre- septal or orbital cellulitis
• In children— non- accidental injuries.
Rare
• Tumours, e.g. rhabdomyosarcoma, neuroblastoma (in children).
Dryeyes
Common
• Ageing
• Blepharitis
• Meibomian gland dysfunction
• Rheumatoid arthritis
• Sjögren’s syndrome
• Drugs, e.g. diuretics, tricyclic antidepressant drugs,
antihypertensives, beta- blockers.
Uncommon
• Wegener’s granulomatosis
• Systemic lupus erythematosus(SLE)
• Congenital alacrima
• Lacrimal gland ablation
• Sarcoidosis
• Tumours
• Post- radiation brosis.
COMMON PROBLEMS AND THEIRCAUSES
Foreign body sensation
Common
• Gr i t / d u s t
• Hairs
• Eyelashes
• Corneal scratch
• Dryeyes.
Uncommon
• Glass
• High- velocity objects
• Cornealulcer.
Injuries
Common
• Foreignbodies
• Corneal abrasions
• Arceye.
Uncommon
• Rupturedglobe
• Penetrating/ perforating
• Eyelid lacerations
• Chemicalburns.
Loss ofvision (painful)
Common
• Acute angle- closure glaucoma(AACG)
• Uveitis— especially posterior and intermediate uveitis
• Cornealulcers
• Scleritis— especially posterior scleritis
• Orbital cellulitis
• Herpes zoster ophthalmicus.
Uncommon
• Arteritic anterior ischaemic optic neuropathy— temporal arteritis
• Optic neuritis
• Chemicalburns
• Blunt and penetrating oculartr auma
• Retrobulbar haemorrhage
• Endophthalmitis— exogenous and endogenous.
285
286
CHAP TER10 The eye and eyelids
Loss ofvision (painless)
Common
• Amaurosis fugax— TIA of the opticnerve
• Retinal artery/ vein occlusion
• Retinal detachment
• Vitreous haemorrhage
• Age- related macular degeneration (gradualonset)
• Cataract (gradualonset)
• Non- arteritic ischaemic optic neuropathy
• Advanced glaucoma (gradual onset).
Uncommon
• Neurological diseases— occipital cortex strokes, lesion involving the
visual pathways:optic tract, chiasm, lateral geniculate nucleus, cortex.
Painfuleye
Common
• All the causes listed under painful loss ofvision
• Corneal abrasion
• Foreignbodies
• Conjunctivitis
• Contact lens problems
• Blepharitis
• Dryeyes
• Glaucoma
• Infective keratitis
• Chalazion
• Cluster headache/ migraine
• Sinusitis.
Uncommon
• Iritis/ uveitis
• Optic neuritis
• Scleritis.
Red eye (painful)
Common
• Acute conjunctivitis— viral, bacterial, allergic
• Keratitis (bacterial/ viral), e.g. herpes simplex, herpeszoster
• Keratitis marginal
• Corneal abrasion
• Corneal foreignbody
• Subtarsal foreignbody
• Arc eye/ ashburn
• Contact lens- related problems
• Chronic conjunctivitis— chlamydia, allergic, Molluscum contagiosum
• Angle- closure glaucoma.
Uncommon
• Anterior uveitis (iritis)
• Scleritis and episcleritis
• Atypical microbial keratitis, e.g. Acanthamoeba keratitis.
Red eye (painless)
Common
• Blepharitis
• Ectropion/ entropion
• Tric h i a sis
• Subconjunctival haemorrhage.
Uncommon
• Pterygium
• Carotico- cavernous stula.
Swollen (puy) eyelid(s)
Common
• Blepharitis
• Chalazion
• Allergic reaction
• Stye
• Oversleeping/ sleep deprivation
• Normal ageing.
Uncommon
• Cellulitis
• Tumour
• Graves’ disease
• Infectious mononucleosis
• Fluid retention— many conditions (including pregnancy)
• Diet— excesssalt
• Nephrotic syndrome
• Trichinosis— from eating raw, infectedpork
• Superior vena cava obstruction
• Cavernous sinus thrombosis.
ESSENTIAL QUESTIONS
287
Essential questions
Irrespective of the presenting complaint, a detailed history is required.
The two main symptoms to ask about are pain and visual disturbances.
Ask about the following specic symptoms.
Pain
• Onset and duration
• Gritty/ foreign body sensation
• Ache/ pain within or around theeye