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
          • serum thyroid stimulating hormone:

            low, normal, or elevated

            More
          • serum free T4:

            elevated, normal, or low

            More
          • Hertel exophthalmometry:

            elevated (>20 mm) or normal

            More
          Other investigations
          • visual field assessment:

            constriction of peripheral isopters, scotomas variable

            More
          • MRI or CT of orbits:

            extraocular muscle enlargement sparing tendons, increased volume of retro-orbital fat, globe proptosis

            More

          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

            More
          Other investigations
          • CT of orbits:

            malpositioned or migrated implantable device

            More

          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

            More
          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

              More
            Other investigations
            • CT of orbits:

              orbital abscess formation with adjacent soft-tissue stranding may represent cellulitis

              More

            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

              More
            Other investigations
            • fluorescent treponemal antibody absorption (FTA-ABS):

              current or previous syphilis infection

              More
            • serum direct fluorescent antibody testing (DFA-TP):

              current or previous syphilis infection

              More
            • serum Treponema pallidum antibody:

              current or previous syphilis infection

              More

            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
            • CBC with differential:

              leukocytosis

              More
            • blood cultures:

              identification of pathogen

              More
            • CT of orbits with contrast:

              sinusitis, abscess, foreign body

              More
            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

                More
              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

                More

              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

                More
              Other investigations
              • nasolacrimal irrigation:

                proximal and distal obstruction

                More
              • CT of orbits:

                extent of eyelid and orbital involvement, sinus lesions

                More
              • serum alanine aminotransferase, aspartate aminotransferase, gamma-GT:

                abnormal

                More

              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

                More
              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

                More

              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

                More
              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

                  More
                Other investigations
                • MRI of brain:

                  territory of infarction or hemorrhage

                  More
                • carotid duplex scan:

                  atherosclerotic carotid occlusive disease

                • transesophageal echocardiogram:

                  source of thrombi, patent foramen ovale, atrial myxoma

                • CBC:

                  abnormal

                  More
                • serum prothrombin time, PTT:

                  abnormal

                  More

                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

                  More
                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

                    More
                  Other investigations
                  • CT of orbits:

                    fracture, foreign body, extraocular muscle entrapment

                    More
                  • forced duction and generation testing:

                    extraocular muscle restriction and paresis

                    More
                  • B-scan ultrasound:

                    vitreous hemorrhage, retinal detachment, globe rupture

                    More

                  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

                      More
                    Other investigations
                    • edrophonium and prostigmine test:

                      improvement of symptoms after administration

                      More
                    • ice-pack test:

                      improvement of symptoms after placement of ice pack for several minutes

                      More
                    • electromyographic repetitive nerve stimulation:

                      decremental response

                      More

                    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

                      More
                    Other investigations
                    • lumbar puncture:

                      elevated IgG with oligoclonal bands

                      More

                    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

                      More
                    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

                        More
                      Other investigations
                      • high-resolution MRI:

                        mural inflammation or luminal changes of cranial or extracranial arteries

                        More

                      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
                      • CBC with differential:

                        leukocytosis

                        More
                      • CT of orbits with contrast:

                        sinusitis, superficial foreign body

                        More
                      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

                          More
                        Other investigations
                        • Hertel exophthalmometry:

                          asymmetry in globe position

                          More
                        • CT of orbits:

                          fracture; eyelid and orbital lesion; soft-tissue enlargement, especially extraocular muscles

                          More

                        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

                          1st investigation
                          • HbA1c:

                            elevated

                            More
                          • CBC with differential:

                            leukocytosis

                            More
                          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

                            More

                          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
                            Other investigations
                            • forced duction and generation testing:

                              extraocular muscle restriction and paresis

                              More
                            • B-scan ultrasound:

                              vitreous hemorrhage, retinal detachment, globe rupture

                              More

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