Ophthalmologic Evaluation in Orbital and Lacrimal Disease

History

The location, quality, and timing of symptoms, as well as modifying factors, can aid in diagnosis and management of orbital and lacrimal disease. Review of old photographs helps to document a change in appearance.

Visual symptoms should be reviewed during the workup of both orbital and lacrimal diseases. Symptoms may include blurred vision, loss of vision, double vision, and light sensitivity. Diplopia must be clarified as either monocular or binocular. Monocular diplopia does not resolve with each eye closed; it is typically due to media opacities, such as cataract or tear film irregularities. Binocular diplopia resolves with either eye closed; it is due to misalignment of the eyes and may be due to orbital disease.

Inflammatory symptoms include the four classic symptoms of tenderness or pain (dolor), swelling (tumor), warmth (calor), and redness (rubor). Infections may present with similar findings and/or mucopurulent or purulent discharge. Because the orbit represents a compartment with vast sensory innervation passing through it, pain may occur in a variety of other orbital processes, including orbital hemorrhage and malignancy.

The timing and progression of symptoms may point to particular diagnoses. Infections (dacryocystitis, orbital cellulitis, mucormycosis) and hemorrhage (orbital hemorrhage, pituitary apoplexy) typically present acutely. Inflammations (nonspecific orbital inflammation, dacryoadenitis, myositis) and some tumors such as metastases may present subacutely. A more indolent presentation may occur with benign orbital tumors, such as cavernous malformations, lymphomas, dermoid cysts, mucoceles, or neurogenic tumors.

Tearing represents the most common symptom of lacrimal disease and may result from primary or secondary tear hypersecretion or from underdrainage of tears. Epiphora specifically relates to excess tears that overflow onto the cheek, which often implies underdrainage of tears owing to lacrimal outflow obstruction or tear pumping abnormality. Hypersecretion may occur from inflammation of the ocular surface. The most common cause of surface inflammation is keratoconjunctivitis sicca, or dry eye syndrome. Dry eye syndrome is often accompanied by burning, irritation, redness, ocular ache, foreign body sensation, blurred vision, photophobia, and mattering of eyelashes; however, tearing may be the sole symptom of dry eye. Other surface inflammations that may produce tearing include blepharitis, conjunctivitis, keratitis, allergies, Stevens-Johnson syndrome, and ocular cicatricial pemphigoid. Mechanical abrasion of the ocular surface may also result in tearing. This can occur with trichiasis, eyelid malpositions such as entropion, or tumors abutting the globe. Exacerbating factors for tearing could include wind, smoke, smog, or other environmental irritants. Lacrimal sac malignancies may present with blood-tinged tears (hemolacria), epistaxis, or a mass extending superior to the medial canthal tendon in addition to tearing. Infants with tearing should be evaluated by a pediatric ophthalmologist, as the differential diagnosis includes congenital glaucoma.

Medical History, Medications, and Allergies

The medical history should be reviewed for diseases that may affect the lacrimal system and orbit, including sinusitis or rhinitis, allergies and atopy, autoimmune disorders (in particular thyroid disease, Sjögren syndrome, sarcoidosis, granulomatosis with polyangiitis, rheumatoid arthritis, and systemic lupus erythematosus), Stevens-Johnson syndrome, ocular cicatricial pemphigoid, diabetes mellitus, history of local or systemic malignancies, and periocular trauma.

The ocular history should include previous eye surgeries or interventions. For patients with tearing, a history of punctal plug placement is particularly important. Certain ocular medications can exacerbate tearing or nasolacrimal duct obstruction (NLDO), such as topical glaucoma medications (timolol, dorzolamide, pilocarpine) and antivirals (idoxuridine, trifluridine).

Prior surgical history and interventions, including past nasal, sinus, dental, lacrimal, facial and cosmetic surgeries, history of radiation treatment, or a history of skin cancer and treatments, should be elicited.

Medication history pertinent to the orbital examination includes the use of corticosteroids or other immunosuppressants, thyroid medications, and blood thinners. For the lacrimal evaluation, pertinent medications include allergy medications, radioactive iodine 131, chemotherapy (paclitaxel, docetaxel, 5-fluorouracil, and others), and topical ocular lubricants. Dry eye syndrome can be exacerbated with antihistamines, antidepressants, antihypertensives, and oral contraceptives.

Pertinent substance history includes cocaine use (nasal septum defects) and tobacco smoking history (thyroid eye disease and other inflammatory disorders, malignancy).

The family history may play a role in some orbital and lacrimal diseases, such as thyroid eye disease, nasolacrimal duct obstruction, and certain malignancies.

Ophthalmic Examination

The ophthalmic examination must evaluate the function of myriad structures within the orbit and lacrimal system, including the visual sensory system, the oculomotor system, the globe, the somatic sensory system, the periocular structures, and the lacrimal system. The examination can localize a disease process and point to the proper imaging or other evaluation techniques.