Ocular Examination

The ocular examination should include the best corrected visual acuity and intraocular pressure applana-tion in the primary position and in different vertical and horizontal gazes. A neuro-ophthalmologic examination, including motor and sensory functions, pupillary examination, contrast sensitivity, color vision assessment, confrontation visual fields, and central visual acuity with an Amsler grid should also be done (see Chapter 7).

During biomicroscopy, the integrity of the corneal and conjunctival epithelium should be checked as well as the conjunctival and subconjunctival blood vessels for dilatation, fusiform distension, tortuosity, and congestion. Chemosis of varying degrees is also a common finding in orbital tumor patients (Figure 6.1).

Fully dilated indirect ophthalmoscopy should be performed on every patient because many orbital diseases cause a wide variety of funduscopic changes, which may provide clues regarding the location, size, and the nature of the orbital pathology.4 The major fun-dal manifestations of a space-occupying mass in the orbit include chorioretinal folds, retinal vascular changes, and optic disk edema and/or atrophy (Table 6.1).

Chorioretinal folds appear as a series of delicate striae, which are most often present in the posterior pole (Figure 6.2). Lines are usually parallel, but rarely they may radiate haphazardly to all directions.5 Although chorioretinal folds are most commonly seen with orbital tumors, they are also seen with muco-celes and other types of cysts and also in cases of orbital injury.6-9 Most chorioretinal folds are without symptoms and do not affect visual acuity.

The etiopathogenesis of chorioretinal folds is not known, but they are most likely due to the compression of the globe by a space-occupying lesion in the orbit.10 However, the compression theory fails to explain the process fully, since in some cases folds are

FIGURE 6.1. (A) Congestion of the conjunctiva with tortuous vessels in an orbital tumor. (B) Marked chronic chemosis in a pro-ptotic orbit with long-standing optic nerve meningioma.

Orbital Tumor

FIGURE 6.2. Fundus photograph showing horizontally aligned choroidal striae in a patient with intraconal cavernous hemangioma.

FIGURE 6.1. (A) Congestion of the conjunctiva with tortuous vessels in an orbital tumor. (B) Marked chronic chemosis in a pro-ptotic orbit with long-standing optic nerve meningioma.

present without scleral indentation, and in other patients, rapidly expanding orbital tumors lead to scleral indentation without chorioretinal folds.11 There is no clear relationship between the size of the space-occupying lesion and the extent or direction of the chorioretinal folds. Furthermore, the position of the chorioretinal striae is not a very dependable finding on which to localize the compressing orbital lesion.5 Although choroidal folds have a typical appearance on fluorescein angiography, appearing as alternating light and dark lines, this test is not helpful in adding anything to the clinical workup of a patient in the presence of chorioretinal folds. The folds usually regress

FIGURE 6.2. Fundus photograph showing horizontally aligned choroidal striae in a patient with intraconal cavernous hemangioma.

after treatment of the associated orbital pathology.12 However, they may persist many months or even years after the exclusion of the primary orbital disease.

Congestion and increased tortuosity of retinal veins is another significant finding secondary to space-occupying mass lesions of the orbit, which occur more commonly with masses located in midorbit, causing stasis through the vortex veins. The diameters of engorged retinal veins are best measured and compared with the fellow eye by means of fluorescein angiography.

Disk edema, optic nerve atrophy, and, occasionally, optociliary shunt vessels13-15 are other findings that should be noted during the funduscopic examination of the orbit harboring a space-occupying lesion (Figures 6.3, 6.4, and 6.5). Optociliary vessels are venous shunts that develop to carry blood from the retinal vasculature to the juxtapapillary choroidal circulation when the retinal venous return at the optic nerve head is blocked secondary to optic nerve tumors and other pathology.16 Therefore, "retinochoroidal venous shunt" is a better name for these collateral vessels, which usually develop in meningioma, and, rarely, in optic nerve glioma, central retinal vein oc

TABLE 6.1. Funduscopic Changes That May Be Seen Secondary to Orbital Disease.

Retinal vascular

Optic disk edema

Chorioretinal folds

Retinal detachment

abnormalities

and atrophy

Optociliary shunts

Primary and secondary

Primary and secondary

Primary and secondary

Optic nerve meningioma

Optic nerve meningioma

tumors

tumors

tumors

Optic nerve glioma

Optic nerve glioma

Metastatic tumors

Metastatic tumors

Metastatic tumors

Intraconal hemangiomas

Cavernous hemangioma

Choroidal tumors

Choroidal tumors

Choroidal tumors

nerve tumors

Orbital vascular

Specific inflammation

Trauma

Trauma

Dermoid cyst

Hamartomas

Pseudotumor

Cavernous sinus

Mucocele

Glaucoma

Mucocele and cysts

thrombosis

Fibrous dysplasia

High myopia

Hyperopia

Wegener's granulomatosis,

sarcoidosis

Hypotony

Phycomycoses

Scleritis, uveitis

Postradiation

Retinal detachment

treatment

Scleral buckle

Juxtapapillary Hemangioma
FIGURE 6.3. Papilledema in a patient with sphenoid ridge meningioma.

clusion, juxtapapillary tumors, or cysts. As opposed to choroidal folds and vascular changes, optic disk changes are better seen by means of direct ophthalmoscope or a contact lens. Optic nerve changes and other neuro-ophthalmologic features are detailed in Chapter 7.

The funduscopic examination of the orbit patient is also important to detect posttreatment changes secondary to surgical complications, radiation therapy, chemotherapy, and second primary malignancies.4'17'18

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