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Apr 11, 2023
PROPTOSISchildren
Dr. Yousaf JamalFCPS Resident
Ophthalmology UnitHayatabad Medical Complex
06-03-2010
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CONTENTS
• Recap• Causes in children• Differentiating features• Common causes discussion• Summary• Take home message• MCQs
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Recap
• Causes of Proptosis• Common causes in adults• Examination of proptosis
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CONTENTS
• Recap• Causes in children• Differentiating features• Common causes discussion• Summary• Take home message• MCQs
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Causes in children
• Orbital cellulitis• Dermoid cyst• Capillary
hemangioma• Optic nerve
glioma• Rhabdomyosarco
ma
• Retinoblastoma • Leukemia• Lymphangioma
• Metastasis – Metastatic
neuroblastoma– Ewing's sarcoma
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CONTENTS
• Recap• Causes in children• Differentiating features• Common causes discussion• Summary• Take home message• MCQs
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CAPILLARY HEMANGIOMA
ORBITAL LYMPHANGIOMA
Pathology Vascular hemartoma Isolated vascular hemartoma
Demographics
Infant, commonest benign orbital tumor in childhood, spontaneous involution
Early childhood
Associated Visceral, nasopharyngeal hemangioma, kasabach-merit syndrome
-
Presentation Nonaxial, +ve Valsalva, superficial/deep
Nonaxial, -ve Valsalva, acute episodes of spontaneous hemorrhage, may be superficial/deep
Radiology Intra/extraconal mass, poorly defined
Low density cyst-like mass, enlargement of bony orbit
Tx Observation, surgery Guarded prognosis, surgery, drainage
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ON GLIOMA ON MENINGIOMA
Pathology Fusiform enlargement of ON, origin - glial tissues, meninges show reactive hyperplasia, dura is normal
Tubular enlargement of ON, origin-meninges, psammoma bodies
Demographics
Young girls (2-6yrs) Late middle aged woman
Associated NF-1 (20-40%) -
Presentation
Axial, VA decreases early, EOM normal, optociliary shunts - uncommon
Axial, gaze evoked amaurosis, EOM impaired, optociliary shunts
Radiology Fusiform enlargement, isodense to bone
Tubular enlargement, hyperdense, ON sheath enhancement
Tx Conservative, surgical, radiotherapy
Conservative, radiotherapy, surgery
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RHABDOMYOSARCOMA
ORBITAL CELLULITIS
Pathology Undifferentiated mesenchymal cells, most common primary orbital malignancy of childhood
Infection of soft tissues behind the septum
Demographics
Boys > girls (avg 7 yrs), Commonest cause of proptosis in children, adults also affected
Associated Cervical L. nodes involved Usually after trauma, sinus related
Presentation Nonaxial, painful, unilateral, rapid onset, swollen bluish lids, nose bleed, Ptosis, chemosis
Painful, lids edema with reddish color, Ptosis, malaise, fever, life threatening, VA impaired, Ophthalmoplegia,
Radiology Moderately well-defined homogenous mass, Bony destruction
CT-(orbit, sinuses, brain): diffuse orbital infiltrate, sinus opacity, proptosisMRI for cavernous sinus thrombosis.
Tx Radiotherapy, chemotherapy, Exenteration for resistant cases
Medical, surgical
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CONTENTS
• Recap• Causes in children• Differentiating features• Common causes discussion• Summary• Take home message• MCQs
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ORBITAL CELLULITIS
• Bacterial orbital cellulitis – life-threatening
• Infection of soft tissues behind septum• More common in children• Organisms
– S. pneumoniae– S. aureus– S. pyogenes– H. influenzae
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Etiology
• Sinus-related– Ethmoidal (90%)
• Extension of preseptal cellulitis
• Local spread– Dacryocystitis– Facial cellulitis– Dental infections
• Systemic bacteremia
• Post-trauma– Penetrating septum
(48-72 hrs)– Retained foreign body
• Post-surgical– Lacrimal– Orbital– Retinal
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Presentation…
• Malaise• Fever• Pain• Visual impairment• Tender, warm, red periorbital edema• Proptosis
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… Presentation
• Painful Ophthalmoplegia• Chemosis• Headache• Rhinorrhea• Elevated IOP
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Courtesy: Medline
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Courtesy: Medline
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Work-up
• Hx• Examination• Vital signs record• WBC/blood culture• Lumbar puncture• CT orbit• MRI
– For cavernous sinus thrombosis
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Complications
• Ocular– Exposure
keratopathy– Raised IOP– CRVO,CRAO– Endopthalmitis– Optic neuropathy
• Intracranial– Meningitis (2%)– Brain abscess– Cavernous sinus
thrombosis (1%)
• Orbital abscess• Subperiosteal
abscess
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Treatment
MEDICAL…• Hospital admission + ENT consultation• I.V. antibiotics
– Ceftazidime, Cefotaxime, Ceftriaxone– Flucloxacillin – Vancomycin– Ampicillin-Sulbactam– Piperacillin-Tazobactam– Ciprofloxacin/Levofloxacin
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• Metronidazole• Nasal decongestant
– Phenylephrine – Oxymetazoline
• Antibiotic eye ointment
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SURGICAL…
• Indications– Decreasing vision– Afferent pupillary defect– No response to antibiotics in 48-72 hrs– Orbital/Subperiosteal abscess– Atypical picture…..Needs biopsy
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• Canthotomy/Cantholysis in emergency• Surgical drainage of fluid • Orbital surgery + sinusotomy• For fungal
– Debridement– Exenteration
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Doses
• Ceftazidime (Fortum®)– Adults=1-2g/8hr I.V.– Pediatric
• Neonates=30mg/kg IV• 1 month-12 years=30-50mg/kg IV
• Ceftriaxone (Rocephin®)– Adults=2g/12hr IV– Pediatric
• 20-50mg/kg/day IV
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• Cefotaxime (Claforan®)– Adults=1-2g/10ml/4hr IV in 3-5 min
(max=12g/day)– Pediatric
• 0-1 week=50mg/kg/12hr IV• 1-4weeks=50mg/kg/8hr IV• 1month-12years=50-80mg/kg/day IV in 4-6 doses
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• Vancomycin (Vancocin®)– Adults=1g/12hr IV (over 1 hour with rate <
10mg/min at concentration <5mg/ml)– Pediatric
• Infants & neonates=15mg/kg loading
• Ciprofloxacin– In > 17 years age=400mg/12hr IV
• Levofloxacin– In > 17 years age=750mg/6hr IV
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• Ampicillin-Sulbactam (Unasyn®)– Adults=3g/6hr IV– Children=300mg/kg/day 4 divided doses
• Piperacillin-Tazobactam (Zosyn®)– Adults=4.5g/8hr IV– Children=240mg Piperacillin
component/kg/day 3 divided doses
• Metronidazole (Flagyl®)– 500mg/6-8hr IV
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Tx combinations
• Metronidazole to all• Vancomycin + Ceftriaxone (3rd gen
ceph)– Allergy to penicillin
• Fluoroquinolone– Allergy to penicillin + cephalosporins
• Vancomycin + Ampicillin-Sulbactam or Piperacillin-Tazobactam– For MRSA
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Follow-up
• Daily monitor– Symptoms– Temperature– Visual acuity– Ocular motility– Proptosis– Cornea– IOP– Retina and optic nerve
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• Change to oral to complete 14 days course if– Afebrile for 48 hours
• Oral Drugs– Amoxicillin-clavulanate (Augmentin®)
• Adults=500mg TDS• Children=20-40mg/kg/day 3 divided doses
– Cefaclor (Ceclor®)• Adults=500mg TDS• Children=20-40mg/kg/day 3 divided doses
– Metronidazole
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DERMOID CYST
• A choristoma, found adjacent to suture lines
• Connected to periorbita by fibrovascular tissue
• Contain…– Keratinized stratified squamous epithelium
– Blood vessels, fat, collagen, sebaceous glands, and hair follicles
– a tan oily liquid to a white or yellow substance
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Presentation…
• Mostly in children• Mostly…Superotemporal aspect of orbit• A painless mass• Slowly growing• Usually < 1 cm in diameter, non-tender
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… Presentation
• Globe displacement• Inflammation if ruptures• May
– Compress optic nerve – Diplopia
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Courtesy: Medline
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Courtesy: Medline
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Work-up
CT/MRI
– Indicated if posterior extent not palpated– Cystic appearance– Well circumscribed lesion
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Courtesy: eyetext.org
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Courtesy: eyetext.org
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Treatment
Surgical• Excision in Toto
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CAPILLARY HEMANGIOMA
• Most common orbital tumor of infancy• Benign endothelial cells neoplasms• Absent usually at birth• Rapid growth in infancy• Involution later on
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Pathophysiology
• Thought … of placental origin• 02 phases of growth
– Proliferative• Rapid growth…8-18 months• Increase in no. of endothelial & mast cells
(stimulus for vessel growth)
– Involutional• 30-50% involute by 5 yrs• 75% by 7 yrs
Kavanagh EC, Heran MK, Peleg A, et al. Imaging of the natural history of an orbital capillary hemangioma. Orbit. Mar 2006;25(1):69-72
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Mortality/Morbidity
• Kasabach-Merritt syndrome – Coagulopathy, thrombocytopenia– large visceral / Nasopharyngeal
hemangiomas– DIC may occur, high output CCF– Mortality…30-50%
• Ophthalmic morbidity – Space occupying– Amblyopia
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Presentation
• F:M…3:1• 1-2% in neonates• All develop by 6 months• Typically…red spot growing in size in
Periorbital area• Inability to open lids• Bulging of the eye
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Classified as…
1. Cutaneous2. Purely preseptal3. Preseptal with extraconal element4. Combination of preseptal, extraconal and
intraconal
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Signs
• Usually…superonasal, brow or lid lesion• Typically blanches with pressure• Ptosis & proptosis if posterior extension• Visual loss• Preseptal…Dark blue or purple• Enlarge & change color while crying
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Work-up
CT– poorly circumscribed mass with no bony
erosion – Homogenous enhancing lesion
MRI– hypointense to fat on T1-weighted &
hyperintense on T2-weighted scans US & Doppler
– For anatomic relations & extent
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Treatment
Medical • Observation• Steroids
– Clobetasol propionate cream – Injectable steroid formulations – Systemic corticosteroids are used for
amblyogenic lesions
• Interferon alfa-2a – Resistant to steroid treatment
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Surgery• Laser surgery
– carbon dioxide laser – Argon laser – Nd:YAG laser
• Primary excision
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OPTIC NERVE GLIOMA
• Most common primary tumor of ON– In children…mostly benign– In adults…Aggressive glioma
• WHO classify it as– Grade I astrocytomas (pilocytic
astrocytomas) bcz slow growing & tend not to metastasize
• Generalized hyperplasia of glial cells in the nerve to complete disorganization
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• 10-38% of pediatric pts with ON glioma have NF-1
• Bilateral ON gliomas…almost pathognomonic for NF-1
Listernick R, Charrow J, Greenwald MJ, et al. Optic gliomas in children with neurofibromatosis type 1. J Pediatr. May 1989;114(5):788-92.
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Presentation…
• ON gliomas are…*– 4% of orbital tumors– 4% of intracranial gliomas– 2% of intracranial tumors – 2/3rd of all primary optic nerve tumors
• 20% gliomas extend to the optic chiasm or beyond into the optic radiations & aggressive
* Hollander MD, FitzPatrick M, O''Connor SG, et al. Optic gliomas. Radiol Clin North Am. Jan 1999;37(1):59-71.
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… Presentation…
• F>M• In pediatrics
– Median age…5 yrs – 80% pts present before age 15
• In adults– 22-79 yrs with a mean age of 52 yrs
Hollander MD, FitzPatrick M, O''Connor SG, et al. Optic gliomas. Radiol Clin North Am. Jan 1999;37(1):59-71.
Millar WS, Tartaglino LM, Sergott RC, et al. MR of malignant optic glioma of adulthood. AJNR Am J Neuroradiol. Sep 1995;16(8):1673-6.
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… Presentation
• Painless proptosis with inferior dystopia• Decreased vision• Nystagmus• Changes in appetite or sleep• Large lesion can obstruct 3rd ventricle &
ICP• Optic atrophy• Opticociliary collaterals• CRVO
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Work-up
CT• Diffuse Fusiform enlargement of the
optic nerveMRI
• T1-weighted images– Isointense to hypointense
• T2-weighted images– Isointense to hyperintense
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Treatment
• Not required if– Not growing– Good vision– No cosmetic blemish
• Surgical excision– Large & growing lesions– Confined to orbit
• Radiotherapy + chemotherapy– Intracranial extension
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EMBRYONAL SARCOMA
• Most common primary orbital malignancy of childhood
• Origin…undifferentiated mesenchymal cells
• Called Rhabdomyosarcoma if differentiate into striated muscle
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Presentation…
• Usually first decade (average…7yrs)• Boys > girls• Proptosis
– Rapid (days to weeks)– Unilateral– Painful– Non-axial
• Mimics orbital cellulitis
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… Presentation…
• Swollen lids but bluish appearance• Ptosis • Location
– Superonasal– Retro bulbar– Superior– Inferior
• Chemosis• Sinuses involvement & nose bleeds
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… Presentation
• Other findings– Disc edema– Choroidal folds– Decreased vision – Cervical lymph nodes involvement
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Courtesy: medline
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Courtesy: medline
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Work-up
USG• Relatively well-circumscribed mass• Low-medium amplitude echoes
CT & MRI• Moderately well-defined homogenous mass• Bony destruction
Biopsy Systemic investigations
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Treatment
• Referred to pediatric oncologist• Radiotherapy• Chemotherapy• Surgery
– Exenteration for recurrent & resistant cases
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LYMPHANGIOMA
• Introduction – Non-Neoplastic– Non-functional– Abortive– Vascular malformation
• Hemodynamically isolated• Bleeding into lumen…chocolate cysts
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Presentation…
• Early childhood (average=5-6 yrs)• Multiple bluish soft masses • Upper nasal quadrant• Cystic conjunctival component• Proptosis
– Due to spontaneous hemorrhage– Painful – Axial/non-axial
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… Presentation
• Worsened by RTI• Palatal involvement• Ptosis• Restricted eye movements• Optic nerve compression• Papilledema• Secondary glaucoma
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Work-up
CT• Multilobulated cystic mass within the
orbit and/or intralesional calcificationsMRI
• Hemorrhagic cyst…Hyperintense• Fluid level
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Treatment
• Conservative • Partial surgical
resection of the major cyst
• Needle aspiration• CO2 laser
• Cryotherapy
• Intralesional injection of sclerosing agents– sodium tetradecyl
sulfate (Sotradecol®)
– OK-432 (Picibanil®)
• local radiotherapy
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• Sodium tetradecyl sulfate (Sotradecol®)• An anionic surface-active agent used for its wetting
properties in industry and used in medicine as an irritant and sclerosing agent for hemorrhoids and varicose veins
• $259.00
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• OK-432 (Picibanil®)• lyophilized preparation of a low-virulence strain of S.
pyogenes (S. hemolyticus), inactivated by heating with penicillin G. It has been proposed as a noncytotoxic antineoplastic agent because of its immune system-stimulating activity.
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CONTENTS
• Recap• Causes in children• Differentiating features• Common causes discussion• Summary• Take home message• MCQs
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PROPTOSIS
Lid edemaSinus diseaseRestricted motilityPain/TenderLid traumaFever
Little/no inflammationOrbital lesionYoung child/adultSlow growingLocated near bone sutures
ORBITAL CELLULITIS Dermoid cyst
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PROPTOSIS
Child (5 yrs)Upper nasal quadrant massPainfulFew episodes of proptosisWorsened by RTIMRI shows fluid levels
Child (7-8yrs)Hx of nose bleedsBluish color lids
UnilateralLymph node involved
Painful
ORBITAL LYMPHANGIOMA Rhabdomyosarcoma
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CONTENTS
• Recap• Causes in children• Differentiating features• Common causes discussion• Summary• Take home message• MCQs
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TAKE HOME MESSAGE
• Proptosis in children may be – Benign as … Dermoid– Malignant as … Rhabdomyosarcoma
• Thorough Hx & clinical approach• Pediatric ophthalmologist & oncologist
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MCQs
1. A 1-month old infant presents with a purplish, spongy eyelid mass. Most likely diagnosis:
a. Rhabdomyosarcomab. Neurofibromac. Dermoid cystd. Capillary hemangiomae. Metastatic Ewing sarcoma
Ans. d
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2. In the evaluation of child with unilateral Proptosis, which assumption is true?
a. Cavernous hemangioma is the most common cause of unilateral Proptosis in children
b. Thyroid ophthalmopathy is the most common cause of unilateral Proptosis in children
c. Neurofibroma is the malignant tumor that most commonly produce Proptosis in children
d. ON meningioma are more common than gliomas in childrene. None of the above
Ans: e
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3. The management of Rhabdomyosarcoma of the orbit usually involves
a. Lumbar puncture to rule out CNS Metsb. Exenterationc. Enucleation & orbital radiationd. Systemic chemotherapy & orbital radiatione. Radical neck dissection if cervical L. nodes are
involved
Ans: d
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4. All of the following are true regarding optic nerve tumors except:
a. ON gliomas in children are associated with NF-1b. ON meningioma in children are associated with NF-2c. Radiation therapy is an accepted therapy for ON
sheath meningiomad. ON gliomas of childhood can be malignant
Ans: d
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FOR MCQs 5-8
5. An 11-year old girl presents with acute, unilateral, left-sided periocular pain, Proptosis and double vision. Which condition would NOT be included in D. Dx?
a. Cavernous hemangiomab. Sinusitis with orbital abscessc. Traumatic retrobulbar hemorrhaged. Orbital Lymphangioma
Ans: a
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…Continued…6. 24 hrs later & without any treatment, the pain
has resolved. Periocular ecchymosis develops, & the double vision stabilized. MRI shows cystic mass & layered hemorrhage. Most likely Dx based on clinical Hx & MRI findings is:
a. Rhabdomyosarcomab. Capillary hemangiomac. Orbital abscessd. Lymphangioma
Ans: d
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…Continued…
7. If the patient was losing vision bcz of this process, you would consider:
a. Intravenous antibioticsb. Open surgery to excise the lesion in its entiretyc. CT-guided drainage of encysted bloodd. Biopsy of the lesion to establish Dx
Ans: c
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…Continued
8. The disease process is an example of :a. The most common cause of proptosis in childrenb. The most common primary orbital malignancy in
childrenc. A tumor that may enlarge with upper RTId. An orbital vascular lesion that will involute after
intralesional corticosteroids
Ans: c
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9. Which one of the following is the most common primary malignancy of the orbit in children?
a. Neuroblastomab. Rhabdomyosarcomac. Ewing’s sarcomad. None of the above
Ans: b
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10. what is the most common cause of unilateral childhood proptosis?
A. capillary hemangiomaB. Thyroid related orbitopathyC. Orbital hemorrhageD. Orbital cellulitis
Ans: D
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11. In orbital cellulitis, which of the following is false:
a. Common cause of proptosis in childrenb. Seen due to infection spread from surrounding sinusitisc. Commonly bilaterald. Can cause cavernous sinus thrombosis
Ans: c
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12. Most common organism causing orbital cellulitis in children < 5 yrs:
a. Pneumococcib. Staph aureusc. Strep pyogenesd. H. influenzae
Ans: d
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13. ON glioma includes following:a. Usually seen in 1st decade of lifeb. Can be seen either in the intraorbital or intracranial
part of optic nervec. Generally causes painless, bilateral proptosisd. Proptosis is axial, non-Pulsatile & irreducible
1. a+b+c 2. a+b+c+d 3. a+b+d 4. a+c+d
Ans: 3
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14. A young child presents with sudden loss of vision & proptosis of right eye. On examination, the direct pupillary reflex is absent but consensual pupillary reflex is present. He is having:
a. ON gliomab. ON meningiomac. Retinoblastomad. ON angiomae. Capillary hemangioma
Ans: a
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Apr 11, 2023
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Lecture• Dr. Gulzada
– Red eyes
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