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Similar to Diseases of orbit and globe [compatibility mode]
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Diseases of orbit and globe [compatibility mode]
- 1. 11/21/2016 1 THE “BULGING” EYE Ron Ofri, DVM, PhD, DECVO Koret School of Veterinary Medicine Hebrew University of Jerusalem, ISRAEL DEFINITION PROPTOSIS • Forward displacement out of orbit EXOPHTHALMOS • Forward movement in the orbit DISTINGUISHING FEATURE? • Position of eyelids relative to equator DEFINITION
- 2. 11/21/2016 2 TRAUMATIC OCULAR PROPTOSIS WHO HAS BETTER PROGNOSIS? 1. DOG 2. CAT 10 DAYS LATER
- 3. 11/21/2016 3 FELINE PROGNOSIS 18 cats with ocular proptosis: • Enucleation 12/18 • Euthanasia 4/18 • Blind eye 2/18 • Vision 0/18 Gilger et al. Traumatic ocular proptoses in dogs and cats: 84 cases. JAVMA 1995 10 DAYS LATER Lateral strabismus likely CANINE PROGNOSIS 66 dogs with ocular proptosis: • Enucleation 18/66 • Euthanasia 4/66 • Blind 26/66 • Visual 18/66 Gilger et al. Traumatic ocular proptoses in dogs and cats: 84 cases. JAVMA 1995
- 4. 11/21/2016 4 “DOCTOR, CAN YOU SAVE THE EYE?” CAT Probably not. Only 2/18 (blind) eyes saved DOG • Save vision 18/66 • Cosmetic salvage of blind eye 26/66 WHO HAS BETTER PROGNOSIS? PROGNOSTIC INDICATORS. I. NUMBER OF EXTRAOCULAR MUSCLES TORN • An indicator of extent of trauma • Intraocular blood supply comprised Three torn muscles or more: • Blind eye • Grave prognosis for saving eye Two torn muscles: • Guarded prognosis
- 5. 11/21/2016 5 PROGNOSTIC INDICATORS. I. NUMBER OF EXTRAOCULAR MUSCLES TORN • Fair prognosis if one muscle torn • Medial rectus is shortest Lateral strabismus likely PROGNOSTIC INDICATORS. I. HOW TO TREAT THE LATERAL STRABISMUS? • Immediate repair Challenging • Permanent medial canthoplasty (later) Reduces risk of repeat prolapse • Let it pigment PROGNOSTIC INDICATORS. II. ADDITIONAL TRAUMA • Trauma to the body • Trauma to the skull Consider neurological exam & radiography
- 6. 11/21/2016 6 THINGS TO CONSIDER • Fractures Look for pain, facial asymmetry, strabismus, exophthalmos/enophthalmos… PROGNOSTIC INDICATORS. II. ADDITIONAL TRAUMA • Immediate trauma to the eye Corneal/scleral perforation and rupture Hyphema and/or posterior segment hemorrhage Lens luxation Retinal detachment Avulsion of optic nerve
- 7. 11/21/2016 7 PROGNOSTIC INDICATORS. II. • Duration of prolapse Instruct by phone to keep globe moist PROGNOSTIC INDICATORS. II. TRAUMA TO THE EYE USEFUL TESTS • Comprehensive ocular examination • Pupillary light reflex Direct and/or indirect Resting pupil size not indicative • Ultrasound (in cases of hyphema) r/o retinal detachment, lens luxation… PROGNOSTIC INDICATORS SUMMARY • Species & breed • Number of torn muscles • Trauma to body & skull • Trauma to eye Duration! • Results of PLR, ultrasound
- 8. 11/21/2016 8 TREATMENT • Can always enucleate later… • Attempt to replace: General anesthesia, clean globe May pull lids out with sutures or hooks May facilitate replacement with lateral canthotomy Slatter’s Fundamentals of Veterinary Ophthalmology. DJ Maggs, PE Miller, R Ofri TREATMENT TEMPORARY TARSORRHAPHY • Simple interrupted or horizontal mattress • 2-0 to 4-0 nylon • Tension relieving stents • Careful placement on margin • May place underlying 3rd lid flap • May leave medial opening for Rx Slatter’s Fundamentals of Veterinary Ophthalmology. DJ Maggs, PE Miller, R Ofri
- 9. 11/21/2016 9 POST OPERATIVE CARE • Elizabethean collar • Cold compresses • Topical/systemic therapy Antibiotics & steroids Topical atropine • Remove sutures sequentially, depending on lagophthalmos • Topical steroids, antibiotics and/or artificial tears, depending on state of cornea LONG-TERM COMPLICATIONS • Strabismus • Exposure keratitis, pigmentary keratitis Corneal denervation Dry eye • Uveitis, glaucoma, cataract, lens luxation, retinal detachment… Phthisis bulbi Blindness IS IT A CASE OF EXOPHTHALMOS OR BUPHTHALMOS? Ron Ofri, DVM, PhD, DECVO Koret School of Veterinary Medicine Hebrew University of Jerusalem, ISRAEL
- 10. 11/21/2016 10 DEFINITIONS EXOPHTHALMOS • Normal eye pushed forward in the orbit Retrobulbar process BUPHTHALMOS • Enlarged eye in a normal position Due to elevated IOP (glaucoma) WHICH IS A CASE OF GLAUCOMA? WHICH IS A CASE OF EXOPHTHALMOS? 2 1 HOW CAN WE KNOW? IS IT UNILATERAL OR BILATERAL? • Glaucoma may be unilateral or bilateral • Exophthalmos is usually unilateral WHAT IS THE POSITION OF THE 3RD LID? • It is normal in glaucoma • It is elevated in exophthalmos
- 11. 11/21/2016 11 SO WHAT’S WRONG HERE? HOW CAN WE KNOW? • Examine the patient laterally Excess conjunctiva visible in exophthalmos • Examine the patient from above to detect forward displacement HOW CAN WE KNOW? SOUNDS STRANGE, BUT TRUE… • Estimate the corneal curvature • Retropulsion test
- 12. 11/21/2016 12 HOW CAN WE KNOW? THE “GOLDEN STANDARD” GLAUCOMA: Measure IOP (tonometry) HOW CAN WE KNOW? THE “GOLDEN STANDARD” EXOPHTHALMOS: Image retrobulbar area HOW CAN WE KNOW? ADDITIONAL CLINICAL SIGNS GLAUCOMA: numerous clinical signs EXOPHTHALMOS: Signs depend on the retrobulbar disease • Is it a retrobulbar tumor? • Is it a retrobulbar abscess? Boroffka SAEB, Vebruggen AM, et al. Assessment of ultrasonography and computed tomography of unilateral orbital disease in dogs. JAVMA 2007.
- 13. 11/21/2016 13 SUMMARY OF COMMON SIGNS FOR RETROBULBAR DISEASE • Exophthalmos • Unilateral disease • Protruding 3rd eyelid • Periocular/orbital swelling • Resistance to retropulsion • Signs of systemic disease possible May depend on type and stage of tumor • Vision may be affected if ON involved DISTINGUISHING BETWEEN RETROBULBAR ABSCESS AND TUMOR THE “GOLD STANDARD” Ultrasound-guided FNA ETIOLOGY OF RETROBULBAR ABSCESS Bacterial infection usually due to dental disease or foreign body Hematogenous infection and spread from nasal sinus described No growth, anaerobic growth or fungal isolation also possible
- 14. 11/21/2016 14 RETROBULBAR ABSCESS. I. SIGNS • Acute onset • Pain on opening the mouth Anorexia • Swelling/fistula of oral mucosa Behind last upper molar RETROBULBAR ABSCESS II. TREATMENT • Intubate patient • Incision of mucosa • Create draining tract Use CLOSED hemostat US guidance? • C & S, cytology • Flush with saline/antibiotics • Systemic antibiotics • Soft food RETROBULBAR TUMOR I. SIGNS • Slow progression • Non-painful • Older patients • Signs of local extension Deviated globe Nasal discharge CNS signs May be seen ophthalmoscopically
- 15. 11/21/2016 15 RETROBULBAR TUMOR II. TREATMENT • Most tumors are malignant • Examine for metastasis • Depending on stage: Refer for orbitotomy Exenteration Surgery may be combined with chemo, radiation… • Grave prognosis