Path

• Author: E Kruger
• Year mentioned


  2022
• Source: 'This Photo by Unknown Author is licensed under CC BY-SA'
• Orbital pathology


  • Orbital disease
  • Inflammatory orbital disease
  • Infectious orbital disease
  • Orbital tumours
  • Traumatic orbital disease
  • Lacrimal gland mass/chronic dacryoadenitis
  • Miscellaneous Orbital diseases
• Orbital disease symptoms


  • Eyelid and conj oedema
  • Redness
  • Watering
  • Pain (may become worse with eye movement)
  • Increased ocular prominence
• Orbital disease symptoms


  • Sunken impression of eye
  • Double vision
  • Blurry vision
  • Pulsing sensation
• Soft tissue involvement causes

  • Proptosis
  • Enopthalmos
  • Ophthalmoplegia
  • Orbital inflammatory conditions
• Soft tissue involvement signs and symptoms

  • Eyelid and periocular oedema
  • Skin discoloration
  • Ptosis
  • Chemosis
  • Epibulbar injection
• Proptosis


  Abnormal protrution, generally applies to the eye, may indicate pathology
• Dystopia


  Displacement of globe in coronal plane due to extaconal orbital mass such as a lacrimal gland tumour
• Pseudoproptosis


  Due to facial asymmetry, enlargement of globe, lid retraction, contralateral lagopthalmos
• Measuring proptosis


  Exophthalmometer (Hertel), > 20mm indicates proptosis, difference of 2-3mm between eyes is suspicious regardless of absolute values
• Proptosis signs and symptoms

  • Symptoms similar to lid retraction, Signs: Axial, Unilateral / Bilateral, Symmetrical / asymmetrical, Frequently permanent, Severe cases might compromise lid closure, Tear disfunction and exposure, Keratopathy, corneal ulceration, infection
• Enophthalmos


  Recession of the globe within orbit, causes include congenital / traumatic orbital wall abnormalities, atrophy of orbital contents, sclerosis, pseudoenophthalmos, small or shrunken eye, ptosis, contralateral proptosis or pseudoproptosis
• Ophthalmoplegia


  Defective ocular motility, causes include orbital myositis (inflammation in muscles), restriction of muscles or tissue after orbital wall fracture, ocular motor nerve involvement
• Ptosis


  • Contralateral proptosis or pseudoproptosis
• Causes of Ophthalmoplegia


  • Orbital myositis (inflammation in muscles)
  • Restriction of muscles or tissue after orbital wall fracture
  • Ocular motor nerve involvement
• Tests for Ophthalmoplegia


  1. Forced duction test

  2. Differential IOP test

  3. Saccadic eye movements
• Forced duction test: Aneathetisia (local), Insertion of muscles grasped with forceps, Globe rotated, Restrictive: Difficulty to move the globe, Neurological: No resistance is encountered
• Differential IOP test: IOP in primary gaze, Second time with patient attempting to look direction of limited mobility, Restriction: Increase in IOP > 6 mmHg, Neurological: Increase < 6 mmHg
• Saccadic eye movement test: Restriction - normal velocity with sudden halting (stopping) of ocular movement, Neurological - reduced velocity
• Dynamic properties: Increasing venous pressure, Dependant on head position, Orbital venous abnormalities will worsen proptosis, Pulsation caused by arteriovenous communication or orbital roof defect, Mild pulsation can be detected with applanation tonometry
• Dynamic properties: A bruit, Sign found with a larger carotid-cavernous fistula, Best heard with the bell of a stethoscope and is lessened by gently compressing the ipsilateral carotid artery in the neck
• Fundus changes: Optic disc swelling, Initial feature of compressive optic neuropathy, Optic atrophy may be preceded by swelling, Causes include thyroid eye disease and optic nerve tumours
• Fundus changes: Optocilliary collaterals, Enlarged, pre-existing peripapillary capillaries, Divert blood from the central retina venous circulation to the peripapillary choroidal circulation when there is obstruction of the normal drainage channel
• Thyroid eye disease (TED): Orbital disorder that can cause bilateral or unilateral proptosis, Most common form is Graves ophthalmopathy, Found in adults
• Hyperthyroidism: Excessive secretion of thyroid hormone, Most common form called Graves disease, Autoimmune disorder- overstimulation of thyroid gland due to TSH binding to antibodies, Presents 4th to 5th decades
• Symptoms of Hyperthyroidism: Weight loss, Increased bowel f
• Most common form of hormone disorder is called Graves disease
• Graves disease is an autoimmune disorder characterized by overstimulation of the thyroid gland due to TSH binding to antibodies
• Graves disease typically presents in the 4th to 5th decades
• Symptoms of Hyperthyroidism


  • Weight loss
  • Increased bowel frequency
  • Sweating
  • Heat intolerance
  • Nervousness
  • Irritability
  • Palpitations
  • Weakness
  • Fatigue
  • Enlarged thyroid gland
• Major clinical risk factor for developing TED (Thyroid Eye Disease) is smoking
• There is a proportionate increase in risk and amount of smoking every day for developing TED
• Women are 5 times more likely than men to develop TED
• Radioactive iodine used to treat hyperthyroidism can worsen TED
• Pathogenesis of ophthalmopathy


  1. Organ-specific autoimmune reaction

  2. Antibody reacts against thyroid cells

  3. Orbital fibroblasts lead to inflammation of extraocular muscles and interstitial tissue

  4. Orbital fat and lacrimal glands with pleomorphic cellular infiltration

  5. Increased secretion of glycosaminoglycans and osmotic imbibition of water
• Pathogenesis of TED


  1. Increased volume of orbital contents, particularly muscles

  2. Muscles swell up to 8 times their normal size

  3. Secondary increase in intra-orbital pressure

  4. Optic nerve may be compressed

  5. Degeneration of muscle fibers eventually leading to fibrosis

  6. Tethering effect on involved muscle resulting in restrictive myopathy and diplopia
• Clinical features


  1. Initial stages: Inflammatory stage where eyes are red and painful, remits within 1-3 years, only 30% develop serious long-term problems

  2. Fibrotic/quiescent stage: Eyes are white, painless motility defect present
• Clinical features categorized


  • Soft tissue involvement
  • Lid retraction
  • Proptosis
  • Optic neuropathy
  • Restrictive myopathy