Slit lamp bio-microscope examination of the ocular surface and the anterior and posterior segments should be performed: conjunctival chemosis may be seen in inflammatory conditions, including thyroid related ophthalmopathy, and superior limbic kerato-conjunctivitis is typically related to thyroid orbitopathy. The pathognomonic Lisch nodules of neurofibromatosis are readily apparent in the postpubertal patient (Figure 10.6). Anterior or posterior segment inflammation may accompany the orbital inflammatory syndromes as a secondary phenomenon.
With compression of the globe due to tight inferior recti in thyroid orbitopathy, the measured intra-ocular pressure is often elevated during fixation in primary gaze; a true measure of the underlying pressure is given by placing the chin forward, in front of the rest, and having the patient look in slight down-gaze. A widely-swinging pulsation of the mires during applanation tonometry suggests an arterio-venous communication affecting the orbital circulation, or transmitted dural pulsation - as with dysplasia of the sphenoid in neurofibromatosis.
Choroidal striae result from globe indentation by an orbital mass, from optic nerve meningiomas or can be idiopathic; the folds occur almost exclusively at the macula and are not related to the position of the orbital mass. Atrophy or swelling of the optic disc may be due to many causes and optico-ciliary shunt vessels develop with longstanding optic nerve compression as, for example, with optic nerve meningioma.
The regional lymph nodes should be examined for enlargement or tenderness, and the presence of widespread lymphadenopathy sought. Lymphadenopathy, particularly where due to haematological malignancy, may be associated with splenomegaly. In a patient with an orbital mass, clubbing of the fingernails may indicate underlying bronchogenic carcinoma and the changes of thyroid acropachy or pretibial myxoedema would suggest thyroid orbitopathy.
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