Differentials
Common
Involutional changes
History
use of forehead muscles to see clearly and improve peripheral vision; worsening of peripheral vision over the course of the day; brow ache and/or headache common later in the day
Exam
facial soft-tissue laxity with brow position below superior orbital rim; horizontal forehead furrows common; suspect sequelae of peripheral facial nerve (cranial nerve VII) palsy if unilateral
1st investigation
- none:
clinical diagnosis
Other investigations
Prolapsed orbital fat
History
progressive, nonerythematous, nontender upper and lower eyelid prominence
Exam
diffuse and focal prominence of the upper and lower eyelids, may vary with extraocular movement; smooth yellow tissue visible beneath tenon capsule on the lateral aspect of the globe; smooth, nontender, pale-colored masses on temporal aspect of the eye; bilateral common
1st investigation
- no initial test:
clinical diagnosis
Other investigations
Dermatochalasis
History
heavy feeling around the eyes, brow ache, eyelashes visible especially on upgaze; progressively diminished superior visual field
Exam
redundancy of upper eyelid skin; skin often thin with visible subcutaneous telangiectasias, orbital fat prolapse frequent
1st investigation
- no initial test:
clinical diagnosis
Other investigations
Congenital myogenic ptosis
History
ptosis, unilateral or bilateral
Exam
chin-up head position, reduced levator function, decreased supraduction (upward rotation of the eye), poor eyelid crease, poor eyelid closure, and poor eyelid excursion in downgaze
1st investigation
- none:
clinical diagnosis
Other investigations
Thyroid eye disease
History
progressive pain and discomfort around the eye; dry eye or foreign body sensation, double vision, production of tears or light sensitivity; decreased vision requires urgent ophthalmologic consultation
Exam
eyelid retraction and swelling, exophthalmos, extraocular muscle restriction, globe malposition, decreased vision and/or relative afferent pupillary defect, unilateral or bilateral
1st investigation
Previous eye-related surgery or implant
History
eyelid malposition following orbital fracture repair, previous gold weight eyelid implants for paralytic lagophthalmos or a scleral buckle for retinal detachment repair, extraocular muscle surgery for strabismus, filtering and shunting surgery for glaucoma; progressive symptoms
Exam
eyelid ptosis or retraction, unilateral or bilateral; depending on the nature of the implant, variable measurements of eyelid position and motility; surgical anatomic changes with associated implanted hardware
1st investigation
- forced duction testing:
restriction and limitation of ocular movement
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Other investigations
- CT of orbits:
malpositioned or migrated implantable device
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Chalazion
History
blepharitis and ocular rosacea are frequently associated; dry eye and foreign body sensation are common; production of tears and pain may be variable
Exam
local or diffuse erythema; moderately firm nodule palpable over eyelid; circumscribed nodular swelling with meibomian gland inspissation (mucus plug of duct); fluorescein staining may show rapid tear break-up time; recurrent, chronic, or multiple lesions may require ophthalmologic consultation
1st investigation
- eyelid biopsy:
chronic granulomatous inflammation
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Other investigations
Stye (hordeolum)
History
acute and subacute swelling of the eyelid margin; variable pain; occasionally frank purulent discharge
Exam
focal or diffuse eyelid swelling with overlying erythema, typically tender to palpation; frequently peaked to skin surface with purulent drainage; progressive, worsening periorbital edema and erythema with ocular symptomatology requires urgent ophthalmologic evaluation
1st investigation
- eyelid culture:
positive for normal skin flora in majority of cases
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Other investigations
- CT of orbits:
orbital abscess formation with adjacent soft-tissue stranding may represent cellulitis
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Uveitis
History
ocular pain and discomfort with redness and photophobia; pain with extraocular movement and flashes are not uncommon; variable onset of symptoms; correlate with constitutional symptoms in possible systemic disease
Exam
decreased vision; conjunctival injection; anterior chamber cell and flare; hypopyon; vitreous haze and retinal and optic nerve edema are common with posterior disease; presence of profoundly decreased vision or a relative afferent pupillary defect requires urgent ophthalmologic evaluation
1st investigation
- CBC with differential:
leukocytosis
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Orbital cellulitis
History
acute and chronic sinusitis (>90%), recent dental procedure, systemic and intracranial infection, immunocompromised, recent eye and orbital surgery, trauma with and without foreign body
Exam
decreased vision; strabismus and diplopia variable; pain with extraocular movement, proptosis, chemosis, fever; relative afferent pupillary defect requires urgent ophthalmologic consultation
1st investigation
Other investigations
Orbital inflammatory syndrome
History
acute or insidious onset of eye pain, eyelid swelling and eye redness; double vision; previous episodes; systemic symptoms (headache, lethargy, nausea, vomiting)
Exam
eyelid edema and erythema; ptosis variable; pain with extraocular movements; chemosis, proptosis, strabismus and diplopia; decreased visual acuity, visual field defects, relative afferent pupillary defect; must differentiate from orbital cellulitis
1st investigation
- CT of orbits with contrast or MRI:
lacrimal gland enlargement (most common), extraocular muscle thickening involving tendons (contrast to thyroid eye disease), fat-stranding
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Other investigations
- Hertel exophthalmometry:
elevated (>20 mm) or normal
More - visual field assessment:
visual field constriction, scotomas
More - B-scan ultrasound:
posterior sclera and tendon capsule edema
More - CBC with differential:
leukocytosis, eosinophilia
More - serum erythrocyte sedimentation rate:
elevated
More - serum antinuclear antibodies:
abnormal
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Eyelid tumors
History
middle-aged to older adult, fair complexion, history of prolonged sun exposure, Northern European descent; cigarette smoking, previous skin cancers, immunosuppressed patients (particularly post-transplant patients)
Exam
upper eyelid lesions with ptosis; firm, raised, pearly nodule; adjacent telangiectasias; central ulceration, lash loss, disruption of normal eyelid architecture; entropion and ectropion variable, strabismus and diplopia variable; prominent keratinization suggests squamous cell carcinoma, multicentric lesions with yellow appearance suggest sebaceous cell carcinoma, darkly pigmented lesions suggest melanoma; must check preauricular and submandibular lymph nodes
1st investigation
- Hertel exophthalmometry:
unilateral proptosis
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Orbital tumors
History
acute and insidious proptosis; eyelid asymmetry, recent changes in refractive error, decreased vision, variable double vision; previous malignancies suggest metastatic spread
Exam
eyelid ptosis and retraction, decreased visual acuity; color vision and visual field defects variable; proptosis, strabismus and diplopia, conjunctival vascular dilatation, relative afferent pupillary defect
1st investigation
- CT of head, orbits with and without contrast:
tumor (diffuse and encapsulated), bony changes (remodeling and hyperostosis), soft-tissue involvement, optic nerve impingement
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Other investigations
- Hertel exophthalmometry:
unilateral proptosis
More - visual field assessment:
visual field constriction, scotomas
More - MRI of orbits with and without contrast:
posterior tumors, optic nerve involvement
More - forced duction and generation testing:
extraocular muscle restriction and paresis
More - retinoscopy:
hyperopic shift
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Chronic progressive external ophthalmoplegia (CPEO)
History
slowly progressive limitation of eye movements with drooping of eyelids; cardiac arrhythmias and maternal inheritance suggest Kearns-Sayre syndrome; later onset with difficulty eating and swallowing with French-Canadian ancestry suggests oculopharyngeal dystrophy
Exam
bilaterally symmetric limitation of extraocular movement, ptosis, generalized weakness; diplopia uncommon
1st investigation
- ECG:
conduction abnormalities
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Other investigations
Stroke
History
typically middle-aged or older adult, acute onset of vision loss (central and peripheral), facial and peripheral weakness, slurred speech, ataxia, numbness and tingling; incomplete resolution of symptoms, extent of ophthalmologic symptoms depends on carotid versus vertebrobasilar circulation
Exam
visual acuity decreased, visual field defects variable, ptosis secondary to generalized facial weakness or involvement of cranial nerve nuclei; strabismus and diplopia variable
1st investigation
- non-contrast CT of head:
territory of infarction or hemorrhage
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Eyelid foreign body
History
unilateral, focal eyelid swelling following trauma or surgery; redness, tenderness, and discharge depending on nature of foreign body
Exam
focal eyelid lesion with possible erosion through skin; edema, erythema, tenderness, and variable discharge, common with vegetable matter, less common with surgical materials
1st investigation
- CT of orbits:
location and size of foreign body
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Other investigations
Eyelid laceration
History
men more than women; decreased vision, difficulty and/or inability in moving eyelids; diplopia variable
Exam
decreased visual acuity, mild to severe ptosis, strabismus, variable diplopia; orbital fat prolapsed from wound; decreased vision or relative afferent pupillary defect requires urgent ophthalmologic consultation
1st investigation
- Berke levator function:
decreased levator function (<10 mm), significant asymmetry
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Uncommon
Blepharophimosis
History
facial anomalies present from birth, family members with similar facial features; eyes appear disproportionately small, difficulty opening eyes
Exam
significant upper eyelid ptosis, wide intercanthal separation (telecanthus); medial eyelid skin fold extending from lower to upper eyelid (epicanthus inversus)
1st investigation
- no initial test:
clinical diagnosis
Other investigations
Myasthenia gravis
History
fluctuating eyelid position and diplopia over time, symptoms worse in evening and after exertion; systemic symptoms (e.g., difficulty eating, breathing, speaking, movement)
Exam
variable measurements of eyelid position and motility; variable field of diplopia; fatigability with prolonged upgaze; dyspnea, dysphagia are potentially life-threatening and require prompt evaluation
1st investigation
- acetylcholine receptor antibody test:
presence of binding, blocking, or modulating antibodies; presence of antimuscle-specific kinase (MuSK) antibodies
More - serum thyroid function tests:
abnormal function and regulation
More - serum antinuclear antibodies:
autoimmune activation
More - CT of chest:
anterior mediastinal mass indicating thymoma
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Multiple sclerosis
History
women more than men; young and middle-aged; eye symptoms (pain with movement, blurred vision, decreased peripheral vision); prior and coincident neurologic symptoms
Exam
decreased vision, diplopia, visual field defects, variable optic disk edema, relative afferent pupillary defect; must evaluate for ataxia, bowel, and bladder dysfunction, and peripheral weakness
1st investigation
- MRI of brain:
disseminated white matter plaques
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Other investigations
- lumbar puncture:
elevated IgG with oligoclonal bands
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Blepharochalasis
History
adolescent or young adult with repeated episodes of painless eyelid swelling; unilateral or bilateral; may have history of preceding physical and emotional stress or allergy
Exam
nonerythematous eyelid edema with thinning and redundancy of the skin, superficial telangiectasias, blepharoptosis, orbital fat and lacrimal gland prolapse
1st investigation
- CT of orbits:
anterior orbital soft-tissue swelling without abscess formation
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Other investigations
Giant cell arteritis
History
older adult with history of a temporal headache, vision loss, and variable ocular or orbital discomfort; fatigue, lethargy, loss of appetite, and weight loss
Exam
jaw claudication, ptosis, palpable tenderness along the course of the superficial temporal artery and lack of pulsation of this artery; vision loss may be significant, symptoms may develop in the contralateral eye; urgent ophthalmologic evaluation is required
1st investigation
- erythrocyte sedimentation rate (ESR):
elevated
More - C-reactive protein (CRP):
elevated
More - CBC:
patients with giant cell arteritis may have a normochromic, normocytic anemia with a normal WBC count and elevated platelet count; mild leukocytosis may occur
More - vascular ultrasonography:
mural inflammatory changes
More - temporal artery biopsy:
histopathology typically shows granulomatous inflammation
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Other investigations
- high-resolution MRI:
mural inflammation or luminal changes of cranial or extracranial arteries
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Preseptal cellulitis
History
recent penetrating trauma to the skin; cutaneous source of infection, sinusitis, infected chalazion; production of tears or mucopurulent discharge, insect bite
Exam
eyelid edema and warmth, cutaneous infection; production of tears, decreased vision or any ocular symptoms suggest orbital involvement
1st investigation
Other investigations
Globe malposition
History
previous ocular and eye muscle surgery and/or congenital anomaly; diplopia or decreased visual acuity variable; trauma variable; if progressive, correlate with systemic symptoms
Exam
hypertropia, enophthalmos, anophthalmos (congenital absence of ocular tissue), phthisis bulbi (atrophy, degeneration of a blind eye), or a superior sulcus deformity
1st investigation
- forced duction testing:
restriction and limitation of ocular movement
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Benign essential blepharospasm (BEB)
History
women more than men; middle-aged, increased involuntary blinking, must differentiate from severe dry eye syndrome
Exam
involuntary, episodic contractions involving the orbicularis oculi, procerus, and corrugator muscles; visual acuity variable
1st investigation
- Schirmer testing:
<10 mm in 5 minutes
More
Other investigations
Third nerve palsy
History
history of hypertension, diabetes mellitus, arteriosclerotic disease; older adult, significant eyelid droop, double vision, pain variable; younger patient, pupillary dysfunction, multiple cranial nerve palsies; requires urgent evaluation
Exam
significant ptosis, strabismus, diplopia, mild to severe orbital pain; relative afferent pupillary defect; requires urgent neurologic consultation
Other investigations
- CT angiography:
aneurysm of the internal carotid or posterior communicating artery
More - magnetic resonance angiography:
aneurysm of the internal carotid or posterior communicating artery
More - carotid angiography:
aneurysm of the internal carotid or posterior communicating artery
More - CT of orbits and brain:
tumor, infection, trauma, inflammation
More - MRI of orbits and brain:
tumor, infection, trauma, inflammation
More - serum angiotensin-converting enzyme and lysozyme:
elevated in neurosarcoidosis
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Horner syndrome
History
mild unilateral eyelid droop; eye appears smaller, pupil asymmetry; inability to sweat variable, headache may be associated with intermittent associated neurologic symptoms, requires neurologic consultation; cough, hemoptysis, and neck swelling suggest oncologic etiology
Exam
mild to moderate unilateral ptosis, ipsilateral pupillary miosis; facial anhidrosis variable, iris heterochromia in congenital cases; decreased visual acuity and/or ocular dysmotility with strabismus demands further investigation
1st investigation
- cocaine test:
minimal to no improvement of miosis
More
Other investigations
- hydroxyamphetamine/tropicamide ophthalmic test:
minimal to complete resolution of miosis
More - CT of the chest:
mass lesion in apex of lung, previous chest surgery, thoracic aortic aneurysms
More - MRI of brain and neck:
lesions of the brainstem and upper cervical spinal cord, tumors, cervical disk disease, changes of the internal carotid artery or cavernous sinus
More - carotid angiography:
aneurysm of the internal carotid or posterior communicating artery
More
Transection of levator muscle or aponeurosis
History
lacerations or contusive trauma to the eyelid; history of eyelid surgery
Exam
herniation of orbital fat from an eyelid laceration with or without decreased vision, inability to elevate the upper eyelid
1st investigation
- Berke levator function:
decreased levator function (<10 mm), significant asymmetry
Other investigations
Orbital and facial fracture
History
men more than women; trauma to orbital and intracranial structures and adjacent paranasal sinuses, decreased visual acuity, pain and discomfort on attempted eye movement; diplopia variable; systemic symptoms (e.g., nausea, vomiting, headache, loss of consciousness)
Exam
drooped and retracted eyelid, decreased vision, incomitant strabismus, ptosis, subconjunctival hemorrhage, hyphema; relative afferent pupillary defect requires evaluation for globe rupture, retinal detachment, and traumatic optic neuropathy
1st investigation
- CT of orbits:
fracture, foreign body, extraocular muscle entrapment
More
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