A Matter of Millimeters

3/28/2016

PATIENT INFORMATION A MATTER OF • 57 WM • POH • (+) trauma OS MILLIMETERS • PMH • Hyponatremia • Hyperglycemia • Chronic low back pain ALANNA O’KEEFE – MARCH 29TH, 2016

PATIENT INFORMATION EXAM INFORMATION

• CC – “my eye sticks out”, “friends were worried” • BCVA: 20/20 OU • (-) pain, diplopia, pulsatile exophthalmos, bruit • Refraction • No thyroid problems • OD: -4.75 -1.25 x 040 • (+) occasional FBS, redness • OS: -2.75 -2.25 X 150 • EOMS: Limitation OS • VF: clear OU • Exophthalmometry • Base: 100 mm • OD: 14 mm • OS: 21 mm

http://www.jcytol.org/showbackIssue.asp?issn=0970-9371;year=2008;volume=25;issue=2

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EXAM INFORMATION PLAN

• Observation • Exophthalmos • Incomplete lid closure OS • CT • IOP • CTA • 16 mmHg OU • Lens • AMD • 1+ NS • Preservision and Amsler grid • Optic Nerve • Cataracts • OD: .15 • Monitor yearly • OS: .25 • CMA with Presbyopia • Vitreous • Asteroid hyalosis OD • SRx •Macula • Soft coalesced drusen OU

CLINICAL MANIFESTATIONS EXOPHTHALMOS OVERVIEW

• Exophthalmos • Proptosis • Bruit • Exophthalmos • Chemosis • Specific • Arterialized corkscrew conjunctival vessels • Thyroid-Associated Ophthalmopathy • Diplopia • Glaucoma

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MEASUREMENT HERTEL EXOPHTHALMOMETER

• Exophthalmometry • Hertel exophthalmometer • Base measurement • Used for future measurements • Exophthalmos measurement • Accuracy • Patient fixation • Positioning • Worm’s-eye view

https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDA x8jfULsh0VAdAsNSU!/?ActiveNumber=1&ActivePopup=1&StepPos=510&contentUrl=%2Fsrg%2Fpopup%2Fadditional_material%2F92%2F X70-examination.enl.jsp&popupStyle=diagnosis&printPopup=true&soloState=true

ALTERNATIVES ALTERNATIVES

• Luedde Exophthalmometer • Naugle exophthalmometer • Distance from corneal apex to orbital rim • Relative difference between each eye • Transparent ruler • Above and below superior and inferior orbital rims • Forehead • Cheek bones • Indications • Asymmetry of lateral orbital rims • Congenital • Orbital fracture • Previous surgery • Lateral orbitotomy

http://archive.constantcontact.com/fs014/1107938791324/archive/1110930109840.html

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NAUGLE EXOPHTHALMOMETER NORMATIVE VALUES

• Agree to disagree • Multiple sources with varying ranges. • Normal Range : 11mm – 24mm • Ethnicity • Asian: 18 mm • Caucasian: 20 mm • African American: 24 mm • Sex • More prominent in men. • Asymmetry • Greater than 2mm abnormal • Age • Increase as we age https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDA x8jfULsh0VAdAsNSU!/?ActiveNumber=1&ActivePopup=1&StepPos=511&contentUrl=%2Fsrg%2Fpopup%2Fadditional_material%2F92%2F X70-examination.enl.jsp&popupStyle=diagnosis&printPopup=true&soloState=true

DIFFERENTIAL DIAGNOSES HISTORY OF PRESENT ILLNESS

• Tumor • Onset/Course • Vascular Abnormality • Days to weeks • Inflammatory • Months to years • Trauma • Old photographs • Symptoms • Thyroid-Associated Ophthalmopathy • Pain, diplopia, changes in vision • Pseudoproptosis • Systemic Disease • Enlarged globe • Thyroid • Asymmetrical orbital size • Cancer • Asymmetric palpebral fissures • Ear, Nose, or Throat abnormalities • EOM weakness/paralysis • Prior injury • Contralateral enophthalmos

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ESSENTIAL EXAM ELEMENTS - SIGNS • Globe Displacement ESSENTIAL EXAM ELEMENTS – SIGNS • Axial displacement • Nonaxial displacement • Red Flags • Bilateral • Eye pain or diplopia on EOMs • Unilateral • Severe headache • Periorbital Changes • Loss of vision or visual field

http://www.eyecancer.com/conditions/21/lymphoma-of-the- conjunctiva • Fever • Pulsating proptosis

http://www.kellogg.umich.edu/theeyeshaveit/red- pdfs.journals.lww.com eye/arteriovenous-fistula.html

SPECIAL TESTING BLOODWORK

• Exophthalmometry • Thyroid Function Testing • Eyelids • Thyroid-Stimulating Hormone (TSH) • Palpation • Ultrasensitive • Orbit, Thyroid, Regional lymph nodes • Presumptive diagnosis • Pulse or thrill • Thyroxine (T4) • Auscultation • Confirmation • Valsalva • Triiodothyronine (T3) • CN testing • Ordered if T4 is normal • VF testing • 5% of patients that are hyperthyroid will have normal T4 levels

http://www.ncbi.nlm.nih.gov/books/NBK289/

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BLOODWORK IMAGING TSH Free T4 Free or Total T3 Probable Interpretation • Computed Tomography (CT) High Normal Normal Mild (subclinical) hypothyroidism • Magnetic Resonance Imaging (MRI)

High Low Low or normal Hypothyroidism • T1 –weighted Low Normal Normal Mild (subclinical) • Best anatomical detail of orbit hyperthyroidism Low High or normal High or normal Hyperthyroidism • T2 –weighted Low Low or normal Low or normal Non-thyroidal illness; • Gadolinium pituitary (secondary) • Contrast agent hypothyroidism Normal High High Thyroid hormone • Fat Suppression resistance syndrome (mutation in the thyroid hormone receptor decreases thyroid hormone function)

IMAGING TREATMENT

CT MRI • Lubrication • Spatial resolution • Soft tissue definition • Lid taping • Cheap • Subacute trauma • Close monitoring/time • Referral • Quick • Orbital apex • Surgery • Bone or calcification • Simultaneous imaging • Acute of multiple planes trauma/hemorrhage • OK for ferromagnetic metallic FB

6 3/28/2016

TAO TREATMENT GUIDE PATIENT INFORMATION

• 50 year old AAF • Medical History • Headaches • Hypertension • Sinus pain • Sleep apnea • Hypothyroidism • Thyroidectomy

Indian J Ophthalmol. 2012 Mar-Apr; 60(2): 87–93. doi: 10.4103/0301-4738.94048

PATIENT INFORMATION CONT. INITIAL VISIT – EXAM FINDINGS

• Va • Ocular History sc • OD – 20/20 • Reading glasses • OS – 20/25 • Current Medications • EOMS – FROM OU, (+) pain, (-) diplopia • Exophthalmometry • Synthroid 0.125 mg • Base 105 mm • Hydrochlorothiazide • OD – 27mm • Clonidine • OS – 26 mm • IOP – 16 OU • Lexapro • Decreased tear meniscus OU • OTC sinus medications • Mild Injection OU • Optic Nerves 0.4 OU, (-)swelling, pallor OU

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INITIAL VISIT - MANAGEMENT IMAGING RESULTS

• Dry Eye Symptoms OD > OS • CT • Artificial tears preservative free OU • Ovoid hyperdense mass right orbit • Exophthalmos OD • 1.0 cm X 0.5 cm • CT scheduled • Located upper – inner quadrant of intraconal • RTC if pressure/pain increases, vision decreases space • RTC for full exam

CT IMAGE MRI

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MRI MRI

MRI