Bệnh nhãn giáp là biểu hiện ở mắt của các bệnh liên quan tuyến giáp. Bệnh lý này có nhiều tên gọi khác nhau như bệnh Graves, bệnh nhãn giáp, bệnh lý hốc mắt của Graves hay bệnh mắt liên quan tuyến giáp.
Evaluation of Orbital Disease Symptoms, Signs and Imaging Consider God’s Wonders Job 37:14 Kenn Freedman MD PhD Topics in Orbital Disease Evaluation of Patients with Proptosis and other signs or symptoms of Orbital Disease Orbital Inflammatory Disorders Orbital Surgery Orbital Tumors Soft Tissues Extra Ocular Muscles Globe and Optic Nerve Superior Ophthalmic Vein Orbital Fat Lacrimal Gland Flickr.com Somso.de Red Swollen Eyelids Pre-septal Cellulitis Orbital Cellulitis Important Signs: - PROPTOSIS - CHEMOSIS -POOR MOVEMENT - POOR PUPIL REACTION - Loss of Vision Signs Suggesting Orbital Disease • Proptosis, and other Globe Displacements Left hypoglobus • • • • Chemosis Limited Motility Pupil Defect – e.g RAPD Eyelids Edema, Ecchymosis Lid Mass or Fullness, UL sulcus defect (asymmetry) Sometimes: Ptosis, Lid Retraction, Ectropion and Entropion • Loss of Vision • Fundus Findings: Disc edema, Vessel Congestion Lid deformity in orbital NF Example: Orbital Cellulitis Eyelid Edema- Erythema, but with; Proptosis, Chemosis, Limitations in motility as well The Six “P’s” of Orbital Disease • • • • • • Pain Progression Proptosis Palpation Pulsation Periorbital changes Adapted from: Orbital Disease, a Practical Approach Krohel G.B., Stewart, W.B and Chavis, R.M 1981 Grune and Stratton, New York PAINFUL CONDITIONS • Infectious or other inflammatory Orbital Cellulitis, Abscess Orbital Pseudotumor Thrombophlebitis • Orbital Hemorrhage, Sub-periosteal Hemorrhage • Few Neoplastic nasopharyngeal carcinoma malignant lacrimal gland tumors neural tumors at times – neurofibroma, neurilemmoma SuB-periosteal Abscess http://www.nature.com/eye/journal/v20/n10/fig Dacryops JAMA Ophthalmol 2013;131(7):929-932 doi:10.1001/jamaophthalmol.2013.1885 Dacryops Graves Ophthalmopathy Orbital Pseudotumor CT Orbits What view?, What Window? What’s Wrong??? Retrobulbar Hemorrhage • Trauma • Surgery, even post-op blepharoplasty • Lymphangioma • Retrobulbar Injection Calcifications OH Sheath meningioma Left orbital phlebolithes from a varix Boney Erosion / Destruction LG Carcinomas Recurrent Pleomorphic Adenoma Neurofibromatosis Metastatic Disease in Orbit Dermoid Cyst Sinus Mucocele Histiocytosis (e.g Eosinophilic Granuloma) Angiosarcoma Infectious: TB, Syphilis Hyperparathyroidism Gorham’s Disease Boney Growth / Change / Expansion Fibrous Dysplasia Sarcoma of the bone Metastatic Disease to the Bone Paget’s Disease CT of Orbits Calcifications Orbital Varix (Phleboliths) Optic Nerve Sheath Meningioma Ocular Tumor – e.g RB Optic Nerve Head Drusen Enlarged Extra Ocular Muscle(s) Graves Ophthalmopathy (IR ,MR >SR most common) Orbital Pseudotumor (Myositis) Post- Viral Myositis (Children) Lymphoma Metastatic Disease Primary Tumor Age Category Children Adults Orbital Tumors to Consider Rhabdomyosarcoma Neuroblastoma, Lymphangioma Capillary Hemangioma Glioma of Optic Nerve Dermoid Cyst Neurofibromas (NF1 and NF2) Cavernous Hemangioma Lymphoma or other WBC tumor Optic Nerve Sheath Meningioma Lacrimal Gland CA and other tumors Neural and Fibrous Tumors Adjacent Invasive Sinus Tumor Metastasis Granulomatous Inflammation Signs of Orbital Inflammation Orbital Cellulitis Orbital Pseudotumor – Dacryoadenitis, Myositis, Diffuse, Posterior Scleritis Graves Ophthalmopathy Orbital Lymphoma Reactive Inflammation- Trauma Systemic Disease Proptosis, Chemosis, Eyelid Edema, etc Foreign Body, Ruptured Dermoid Cyst, Adjacent Sinus Inflammation Wegener’s Granulomatosis, Sjogrens , TB, Sarcoidosis, Syphilis, IgG4-ROD Need to R/O Orbital Cellulitis / Malignancy Imaging of the Orbits Medications: e.g Biphosphonates Vascular etiologies Vasculitis (e.g GCA), CC Fistula, Cavernous Sinus Work-up could include - CT orbits + or Superior Orbital Vein Thrombosis (Sepsis, Coagulopathies, etc) 10 Inflammatory Mimicking Orbital Tumors Rhabdomyosarcoma, Lacrimal Gland Carcinoma, Lymphangioma 11 Orbital Hemorrhage TED: TFTs, TSI IOIS: CBC (Eosinophilia), ANA, IgG4, Also: ANCA, ESR, Glucose, UA, CXR, RF Testing for TB / Sarcoid + possible Orbital Biopsy Orbital Cellulitis • Infectious – often secondary to adjacent sinus infection - exceptions – e.g MRSA • Serial CT orbits to look for abscess development and possible need for surgical intervention Orbital Pseudotumor (IOIS = Idiopathic Orbital Inflammatory Syndrome) • Non- Infectious – part of the spectrum of lymphoproliferative disorders • Frequently involves Lacrimal Gland or EOM(s) • Frequently responds to corticosteroids (sometimes after treatment with antibiotics) Graves Ophthalmopathy (TED= Thyroid Eye Disease) • In addition to typical orbital inflammatory signs – look for : • Lid Retraction, Lid Lag on downgaze, Specific motility problems such as infraduction or abduction deficits and ET or HoT Carotid Cavernous Fistula (CCF) • In addition to typical orbital inflammatory signs – look and listen for : • Pulsations, Bruits, Venous Congestion I tell you the truth, unless a man is born again, he cannot see the kingdom of God John 3:3 ...Topics in Orbital Disease Evaluation of Patients with Proptosis and other signs or symptoms of Orbital Disease Orbital Inflammatory Disorders Orbital Surgery Orbital Tumors Soft Tissues Extra... Metastatic tumors - Orbital apex and cavernous sinus diseases Orbital Apex Meningioma Proptosis Graves Orbitopathy ( #1 Cause) Orbital Cellulitis Forward Displacement of the Eye Orbital Pseudotumor... Sarcoidosis, see also Orbital Inflammation Orbital Tumors, Sinus Tumors Orbital Hemorrhage- Trauma, Lymphangioma Subperiosteal Hemorrhage Orbital Trauma and Compartment Syndrome 10 11 12 Vascular Abnormality