Periorbital and eyelid signs

Swelling is the commonest eyelid sign of orbital disease, but lid retraction, lag or incomplete closure are also very common and hallmarks of thyroid orbitopathy (Figure 10.4). An S-shaped contour of the upper lid may be associated with a number of conditions: plexiform neurofibroma of the upper eyelid,

(a)
(d)

Figure 10.4 Signs typical of dysthyroid orbitopathy: (a) bilateral proptosis and upper lid retraction; (b) lid lag, best demonstrated by asking the patient to follow a slowly descending target; (c) lagophthalmos on gentle eyelid closure; (d) festoons due to marked periorbital oedema.

if present, confirms the diagnosis of peripheral neurofibromatosis; dacryoadenitis, either acute or chronic, may be associated with inflammatory signs; tumours or infiltration of the lacrimal gland. Anterior venous anomalies give a blue hue to eyelid skin and xanthomatous lesions may present as a yellow plaque.

Corkscrew episcleral vessels suggest a low-flow dural shunt (Figure 10.5a) or, in the presence of more extreme vessels and chemosis, a small carotico-cavernous fistula and these are often associated with a raised and widely-swinging intraocular pressure. Markedly dilated, tortuous vessels with a palpable thrill or audible bruit suggest a high-flow carotico-cavernous fistula or arterio-venous malformation (Figure 10.5b). Raised

Figure 10.5 (a) Dilated episcleral veins in a patient with a low-flow dural shunt; (b) the grossly abnormal vasculature, with conjunctival chemosis, in a patient with a high-flow orbital arterio-venous malformation.

Figure 10.5 (a) Dilated episcleral veins in a patient with a low-flow dural shunt; (b) the grossly abnormal vasculature, with conjunctival chemosis, in a patient with a high-flow orbital arterio-venous malformation.

pressure in the retinal venous circulation leads to loss of the spontaneous pulsation of the central retinal vein, and the presence or absence of pulsation should be noted in both fundi.

Periocular sensory loss should be assessed, as it provides a good guide to location of the orbital disease, and loss of corneal sensation must be noted.

Examination of the nose and mouth is important: palatal varices may indicate orbital varices as a cause of spontaneous orbital haemorrhage, or the presence of a nasal mass or palatal necrosis may indicate a sino-orbital tumour or infection (such as mucormycosis).

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