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2.5Chemical burns
3.External examination:
—Check extraocular movements. Measure any
ocular misalignment with prisms .
—To examine for proptosis, Measure with a
Hertel exophthalmometer. Upper limits of normal
are approximately 12 - 14 mm . A difference
between the two eyes of more than 2 mm is
considered abnormal.
Work-Up
Synonyms:
Thyroid Eye Disease or Graves Disease
Ocular Symptoms
Early: nonspecific complaints including foreign body
sensation, redness, tearing, photophobia
Late: eyelid and orbital symptoms including
prominent eyes, persistent eyelid swelling, double
vision, “pressure” behind the eyes, and decreased
vision in one or both eyes.
Thyroid-Related Orbitopathy
Signs
Critical. 1.Retraction of the eyelids (highly specific)
2.lagophthalmus. Unilateral or bilateral axial
proptosis with resistance to retropulsion.
3.When extraocular muscles are involved, elevation
and abduction are commonly restricted .
4.Although often bilateral, unilateral or asymmetric
thyroid-related orbitopathy (TRO) is also frequently
seen. Thickening of the extraocular muscles
(inferior, medial, superior, and lateral) without
involvement of the associated tendons may be
noted on orbital imaging.
Thyroid-Related Orbitopathy
Signs
Other. Reduced frequency of blinking (stare),
chemosis, significantly elevated intraocular pressure
(especially in upgaze), superior limbic
keratoconjunctivitis,etc
Thyroid-Related Orbitopathy
Treatment
1.Smoking cessation: All patients with TRO who
smoke must be explicitly told that continued
tobacco use is especially dangerous. This
conversation should be clearly documented in the
medical record. Smokers have a higher incidence of
Graves disease and more severe orbitopathy.
2.Refer the patient to a medical internist or
endocrinologist for management of systemic thyroid
disease, if present.
Thyroid-Related Orbitopathy
Treatment
3.Treat exposure keratopathy with artificial tears
and lubricating or by taping eyelids closed at night.
4. Treat eyelid edema with cold compresses in the
morning and head elevation at night .
5. Indications for orbital decompression surgery
include: optic nerve compression; worsening or
severe exposure keratopathy despite adequate
treatment (some patients may develop infectious
corneal ulceration or melting from lagophthalmos);
uncontrollable high IOP; or cosmesis.
Thyroid-Related Orbitopathy
Follow-Up
1.Optic nerve compression requires immediate
attention.
2.Patients with advanced exposure keratopathy and
severe proptosis also require prompt attention.
3.Patients with minimal to no exposure problems
and mild to moderate proptosis are reevaluated
every 3 to 6 months. Because of the increased risk
of developing optic neuropathy, patients with
restrictive strabismus should be followed more
frequently.
Thyroid-Related Orbitopathy
Follow-Up
4.All patients with TRO are instructed to check for
color (red) desaturation once every 1 to 2 weeks,
and to return immediately with any new visual
problems.
Orbital Cellulitis
Orbital Cellulitis
Etiology
1.Direct extension from a paranasal sinus infection or
dental infection.
2.Complication of orbital trauma .
3.Complication of orbital surgery or paranasal sinus
surgery (more common).
4.Vascular extension (e.g., seeding from a systemic
bacteremia )
When a foreign body is retained, the cellulitis may
develop months after injury.
Orbital Cellulitis
Symptoms
Red eye, pain, blurred vision, double vision, eyelid
swelling, nasal congestion, sinus headache, tooth
pain.
Orbital Cellulitis
Signs
Critical. Eyelid edema, tenderness. Conjunctival
chemosis and injection, proptosis, and restricted
ocular motility with pain on attempted eye
movement are usually present. Signs of optic
neuropathy
Other. Decreased vision, optic disc edema, fever.
possible orbital abscess.
Orbital Cellulitis
Treatment
1.Admit the patient to the hospital and consult
Infectious Disease.
2.Broad-spectrum intravenous (i.v.) antibiotics to
cover Gram-positive, Gram-negative, and anaerobic
organisms are required for at least 72 hours,
followed by p.o. medication for 1 week.
Low Vision
Blindness: Introduction
blindness is a worldwide health problem,
Definition of Blindness
The World Health Organization (WHO) defines visual
impairment as shown in Table :
Categories of Visual Impairment
(Adapted from International Classification of Diseases, WHO,
1977).
Category of Visual Impairment Visual Acuity (Best Corrected)
Better worse
Low Vision 1 <0.3 ≥ 0.12
2 <0.1 ≥0.05
4 <0.02 light
perception
5 NLP