Displacement of the globe in each of the three dimensions should be measured and, if there is a manifest ocular deviation, it is important to assess the position whilst in primary position (if possible), covering the eye not being assessed. Evidence of variation, either with arterial pulsation or with the Valsalva manoeuvre, should be sought and the presence of a palpable thrill or bruit recorded.
The resistance of the globe to retropulsion is hard to assess, but may be markedly increased where intraorbital pressure is raised in thyroid orbitopathy.
The size, shape, texture and fixation of an anterior orbital mass provide guidance to the likely site of origin and possible diagnosis. Tenderness suggests an acute inflammation, such as that seen with dacryoadenitis. Dermoid cysts in the supero-temporal quadrant, when mobile, are typical (Figure 10.2a); when fixed, they may simply have periosteal attachment, or they may extend through a defect in the lateral orbital wall. Fixed lesions in the supero-medial quadrant are usually frontal mucocoeles in adults, but dermoid cysts in children (Figure 10.2b) or - very rarely - an anterior encephalocoele. Soft masses causing swelling of the eyelids should be regarded as infiltrative tumours or inflammation, until otherwise proved, and a "salmon patch" subconjunctival lesion is characteristic of lymphoma (Figure 10.3).
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