Question

Orbit OSCE’s
1

1. Identify the condition

2. What are the different types
3. Mention the sequelae
4. Management
Question

Answers - 1
1. LE Bell’s palsy with paralytic ectropion of lower lid

2. UMN palsy (forehead is spared ) and LMN palsy

3. Long term sequelae – persisting weakness ,contractures, facial

spasms, synkinesis ,decreased tearing, crocodile tears

4. Management
• Temporary – lubricating eye drops/ointment, moisture
chamber, botulinum toxin, temporary tarsorraphy
• Permanent – lid loading, permanent tarsorraphy, lower lid
support and canthal tendon suspension
Question

A 10 year old boy presented with swelling around the left eye,
redness associated with pain and restricted ocular movements
since 3 days.

1. Identify the condition

2. What is the most common cause in children
3. Causative organisms
4. What are the complications associated with this condition
Question

Answers- 2
1. Orbital cellulitis of LE

2. Ethmoid sinusitis, it spreads through the thin lamina

payraceae

3. Streptococcus pneumonia, Staphylococcus aureus,

Streptococcus pyogenes and H influenza

4. Complications –
Ocular complications -optic neuropathy, exposure
keratopathy, raised IOP, endophthalmitis, CRAO, CRVO
Subperiosteal abscess
Intracranial complications- meningitis, brain abscess and
cavernous sinus thrombosis
Question

1. Write the imaging findings

2. This condition is most commonly associated with
3. Clinical features
Question

Answers -3

1. T2W MRI axial view showing fusiform dilatation and

kinking of the optic nerve in both eyes suggestive of
optic nerve glioma

2. Type 1 neurofibromatosis

3. Loss of vision, proptosis, optic atrophy in later stages

Question

1. Identify the condition with detailed imaging findings

2. Give 5 differential diagnosis for leucocoria
3. Findings on histopathology
4. Name the portion of the brain involved along with
terminology
Question

Answers -4
1. T2W MRI axial view showing an Irregular hypointense
lesion ( in relation to vitreous) in the RE most likely
retinoblastoma of RE

2. DD for leucocoria
• Persistent hyperplastic primary vitreous
• Retinoblastoma
• Endophthalmitis
• Retinal detachment
• Toxocariasis
• Coat’s disease
• Retinopathy of prematurity
• Astrocytic hamartoma

3. The tumour is composed of small basophilic cells with

large hyperchromatic nuclei and scanty cytoplasm.
Varying degrees of differentiation are characterized by
the formation of rosettes
• Flexner – Wintersteiner rosettes
• Homer – Wright rosettes
• Fleurettes

4. Pinealoblastoma- trilateral retinoblastoma

Question

1. Identify the condition

2. Clinical features
3. Causes of loss of vision in this condition
Question

Answers -5

1. Coronal CT showing enlarged superior rectus , medial rectus and

inferior rectus in both orbits. Axial scan in the mid axial plane
showing bilateral enlarged medial rectus with sparing of the
tendon and causing crowding at the apex- most likely diagnosis is
Thyroid related orbitopathy of both eyes

2. Periorbital edema ,chemosis ,congestion, lid retraction ,proptosis,

compressive optic neuropathy ,ocular movement restriction,
exposure keratopathy

3. Causes of vision loss

Exposure keratopathy leading to corneal ulceration

Optic nerve compression
Glaucomatous optic neuropathy
Posterior subcapsular cataract
Macular edema
Question
6

1. Write down the imaging findings

2. Identify the condition
3. Why is imaging indicated in this condition
Question

Answers -6

1. This is a T1W MRI axial view showing a well

defined lesion in the lateral aspect of left orbit
causing proptosis of the left eye and which has a
fat fluid level within the lesion

2. Dermoid cyst of left orbit

3. To rule out intracranial extension

Question

A 40 yr old male presented with non tender swelling in the outer

aspect of the right eye from 6 months

1. Describe the imaging picture

2. What is the condition
3. what are the features which differentiates it from its counterpart
Question

Answers -7
1. The CT scan on the left side high axial view shows a well
defined heterogenous lesion lying lateral to the eyeball and
causing bony remodeling of the underlying bone. The right
coronal scan shows a heterogenous lesion in the
superotemporal quadrant of the right orbit

2. Pleomorphic adenoma of the lacrimal gland of the right eye

3. It gives rise to painless, slowly progressive proptosis usually of

more than a year’s duration , on palpation - smooth non tender
firm mass in the superotemporal quadrant , there’s no
destruction of the surrounding bone
Question

1. Identify the procedure done in this patient

2. What are the two methods
3. What are the materials used
4. Things to look for before the procedure is done
Question

Answers -8

1. LE Frontalis sling

2. Crawford’s technique and Fox pentagon technique

3. Autogenous materials
• Fascia lata, temporalis fascia
Non autogenous
➢ Integrable eg Mersilene mesh, Gortex
➢ Non integrable eg –Supramid or prolene suture, silicone rod etc

4. Bell’s phenomenon, Corneal sensation

Question

A 50 yr old female presented with painless prominence of RE

since 6 months. Vision in the RE was normal and there was no
restriction of ocular movements

1. What is the above imaging and describe the findings

2. What is the diagnosis
3. What is the adjunct used in this imaging to better delineate the
lesion
Question

Answers -9
1. It is a MRI of orbit and brain axial view showing a well
defined isointense lesion in the intraconal space displacing
the optic nerve medially on T1W image, hyperintense on
T2W image with fat suppression and homogenously
enhancing on T1W image with contrast and fat suppression

2. Cavernous hemangioma of RE

3. Contrast agent- Gadolinium

Question

10

1. Identify the condition

2. What are the various etiologies?
3. What is the management of this condition?
Question

Answers-10

1. Cicatricial ectropion of left eye lower lid

2. Etiologies
• Trauma- mechanical, thermal, chemical, radiation
• Actinic dermatitis
• Herpes zoster dermatitis
• Basal cell carcinoma
• Lamellar ichthyosis
• Iatrogenic, eg post blepharoplasty

3. Management
• Medical – ocular lubricants, digital massage of scar, 5- FU
injection into the scar
• Surgical – Z plasty, V-Y plasty, skin graft
Question

11

A 50 yr old male with bilateral proptosis and diminuition of vision

and restricted ocular movements in the RE since 6 months

1. What is the probable diagnosis

2. What are the causes of bilateral proptosis
3. What is the cause for restricted ocular movements
4. What are Sallmann’s folds
Question

Answers -11

1. Bilateral active thyroid eye disease

2. Causes of bilateral proptosis

• Thyroid orbitopathy
• Developmental anomalies of skull
• Osteopathies
• Frontoethmoidal mucocele
• Angioneurotic edema
• Cavernous sinus thrombosis
• Lymphoma
• Chloromas
• Malignancy of nasopharynx
• Metastatic neuroblastoma

3. Edema or fibrosis of the extraocular muscle

4. These are choroidal folds seen in the macula in case of

retrobulbar mass
Question

12

1. Identify the histopathological specimen

2. Commonest site of occurrence and why?
3. What are the signs of lid malignancy?
Question

Answers -12

1. Lobules of cells with pale foamy vacuolated lipid containing

cytoplasm and large hyperchromatic nuclei suggestive of
sebaceous gland carcinoma

2. It is more common in the upper lid where the meibomian glands

are more numerous

3. Signs of lid malignancy

• Destructions of lid architecture
• Ulceration of lid margins
• Loss of eyelashes
• Distortion of eyelid margin
• Ectropion/retraction (secondary to lid growth or skin contracture)
• Increasing pigmentation of eyelid margins
• Palpebral pre auricular lymph nodes
• Dilated blood vessels
Question

13

1. Identify the histopathological specimen

2. Commonest site of occurrence

3. What are the clinical subtypes?

4. What is the classical finding on HPE ?

Question

Answers -13

1. Squamous cell carcinoma

2. It is more common in the lower eyelid

3. Clinical subtypes
• Nodular
• Ulcerating
• Cutaneous horn

4. Keratin pearls
Question

14

1. Identify the histopathological specimen

2. Commonest site of occurrence

3. What are the clinical subtypes

Question

Answers -14

1. Basal cell carcinoma

2. It most frequently occurs in the lower lid

3. Subtypes
• Nodular
• Noduloulcerative
• Sclerosing
Question 15

1. Identify the condition

2. Signs in the lid
3. Complications
4. Treatment of this condition
Question

Answers -15
1. Blepharochalasis BE

2. Recurrent bouts of inflammation and edema causes wrinkled,

redundant, discoloured, thinned eyelid skin laced by tortuous
vessels. The wrinkled skin has the appearance of tissue paper

3. Complications – ptosis, lacrimal gland prolapse

4. Blepharoplasty in the quiescent stage though recurrence is

common
Question

16

1. What is this investigation?

2. Describe the imaging findings
3. What is it’s benign counterpart
4. Treatment
Question

Answers -16
1. It is a CT film

2. A plain CT coronal view showing an ill defined heterodense

lesion in the superior aspect of the right orbit pushing the
globe downwards and eroding the roof of the orbit most likely
lacrimal gland carcinoma

3. Pleomorphic adenoma of lacrimal gland

4. Treatment involves excision of the tumour and adjacent

tissues. Extensive tumours may require orbital exenteration or
midfacial resection. Radiotherapy may prolong life and reduce
pain
Question
17

1. Identify the CT findings

2. What are the clinical features?
3. What are the points to decide for surgery?
4. What are the ocular features of blunt trauma?
Question

Answers -17
1. It is plain CT film coronal view showing fracture of the medial wall of the
right orbit , fracture of the floor of right orbit with orbital fat prolapse
and herniation of inferior rectus showing the characteristic tear drop
sign with most likely hemosinus in the ethmoid and maxillary sinus

2. Periocular edema, ecchymosis, subcutaneous emphysema, ocular

movement restriction, crepitus, subconjunctival haemorrhage, binocular
diplopia, enophthalmos, infraorbital anaesthesia

3. Indications for surgery

• White eyed bow out fracture needs repair within 24 hrs
• Diplopia with limitation of upgaze within 300 of the primary position
with a positive forced duction test 7-10 days after injury and with
radiological confirmation of a fracture of the orbital floor
• Enophthalmos >2mm and that is cosmetically unacceptable to the
patient
• Large fracture involving atleast half of the orbital floor particularly when
associated with large medial wall fracture

4.Ocular features of blunt trauma

• Cornea- abrasion, acute corneal edema,
• Anterior chamber – iritis, hyphaema
• Pupil – sphincter tears, iridodialysis, angle recession
• Lens – cataract, subluxation or dislocation
• Globe rupture
• Fundus – vitreous haemorrhage, commotion retinae, choroidal rupture,
retinal breaks, macular hole, retinal detachment
• Traumatic optic neuropathy
Question

18

1. Identify this condition

2. Probable clinical presentation
3. What is the treatment?
Question

Answers- 18

1. Bilateral frontoethmoid mucocele

2. Diplopia , proptosis ( down and out), nasal manifestations such as

obstruction, discharge and congestion of mucosa

3. FESS
Question

19

1. Describe the CT findings

2. Identify the condition
3. What are the ocular features associated with this condition
4. What is the mode of inheritance
Question

Answers-19

1. It is a plain CT film, axial view showing proptosis and distortion of

the left globe, an ill defined, heterodense lesion in the preseptal
region of the left eye and absent greater wing of sphenoid on the
left side

2. Neurofibromatosis

3. Ocular features
• Eyelid plexiform neurofibroma
• Orbital – optic nerve glioma, other orbital neural tumors eg
shwanomma, plexiform neurofibroma and meningioma, spheno
orbital encephalocele due to absence of greater wing of sphenoid
• Iris – Lisch nodules, congenital ectropion uveae
• Prominent corneal nerves
• Fundus – choroidal naevi, congenital hypertrophy of RPE,
myelinated nerve fibres , combined hamartoma of the retina and
RPE , retinal capillary hemangioma

4. Autosomal dominant
Question

20

1. Identify the finding

2. Give the names of the radiolucent counterparts
3. What is the parameter used to grade radiodensity?
4. What is the characteristic feature seen in the above CT ?
Question

Answers-20

1. Intraocular foreign body RE

2. Plastic

3. Hounsefield units

4. Backshadowing
Question

21

A 10 yr old boy came with c/o increase in proptosis of right eye while
bending down

1. What is the imaging done

2. Identify the condition
3. What is the maneuver done to elicit this finding
Question

Answers -21
1. CT Orbit

2. Multiple, oval shaped, contrast-enhancing masses are present

in the right orbit. The masses enlarge with valsalva and are
consistent with a diagnosis of orbital varix.

3. Valsalva maneuvre
Question

22

A 4 month old baby brought with complaints of watering in the RE since

birth

1. What is the probable diagnosis

2. What are the differential diagnosis
3. What is the treatment in this age group
4. When do we intervene
Question

Answers -22
1. RE congenital nasolacrimal duct obstruction

2. Other DD
• Punctal agenesis/stenosis
• Congenital glaucoma
• Keratitis
• Trichiasis
• Corneal abrasion
• Foreign body in the eye

3. Crigler’s massage

4. After the age of 1 year

Question

23

1. What is the diagnosis

2. What is the characteristic appearance in this condition called

3. Which is the most common site of involvement

4. Which is the most common type subtype

Question

Answers -23
1. Lymphoma of RE

2. Salmon patch appearance

3. Superolateral quadrant of orbit

4. Extranodal marginal zone lymphoma

Question

24

1. What is the pathogenesis of this lesion

2. What is the common masquerader of this lesion
3. What is the common site of involvement
Question

Answers-24
1. It is a sterile chronic granulomatous inflammatory lesion of
the meibomian or sometimes Zeis glands caused by retained
sebaceous secretion
2. Sebaceous gland carcinoma
3. Upper lid as the meibomian glands are more numerous in
the upper lid
Question
25

1. Describe the imaging

2. What is the diagnosis
3. What are the clinical features
Question

Answers -25
1. This is a plain CT film axial view showing mild proptosis of
the left eye and enlarged lacrimal gland with stranding of
preseptal soft tissue suggestive of inflammatory edema

2. Dacryoadenitis of LE

3. Painful firm erythematous mass with edema in the lateral

part of upper lid with S shaped ptosis sometimes
associated with dry eye