 Good morning, I'm Tom Oberg. I'm an oculofacial plastic surgeon in Salt Lake City, Utah, and today we're going to cover the basics of an orbital exam. All right, I'm Megan, Tom. Hi. Nice to meet you. All right, so we're going to start just like any regular ophthalmology exam with our Core 5 vision pressure, pupils, motility, and visual fields. Okay, so do me a favor, cover your left eye with your left hand, and I'm just making sure that she isn't cheating and that her hands totally covering her eye. If you have an occluder available, that's also an easy way to do it. Okay, so just with your right eye, tell me what the smallest line is that you can see on the chart. Very good. Okay, and now switch, and now same thing with the left eye. Good. Okay, so if a patient is able to see 2040 or better, we kind of let it go with that. If they're seeing less than 2040, excuse me, I'll use the pinhole occluder to see if there's a refractive error involved. Next thing I'm going to do is check your pupils, okay? So I have a very bright light, I apologize. So I'm going to have the patient focus at distance so that we're not inducing an accommodative reflex and creating pupillary constriction. So the gray light switch, do your best to just stay focused on the gray light switch, try not to switch to me and focus on the light. Okay, so just kind of try to focus on staring off into the distance. And like with any pupil exam, I'm looking at the eye that I'm shining the light in, but as importantly, I'm looking at the eye that I'm not shining the light in, making sure there's symmetry, no affiring pupillary defects or problems with constriction or dilation, normal pupil exam, you're doing great. All right, so now we're going to check your visual fields. So do me a favor, cover your left eye with your left hand. Same thing, I'm going to make sure that her hand is completely occluding the eye we're not testing. And then I'm going to line up so that our faces are exactly facing each other, our noses are lined up. And then I'm going to close the eye that is the mirror image of her occluded eye. Okay, Meg, now look right here at my nose. And I'm going to hold my hands up. And you're going to notice I always hold up two hands. A patient's natural tendencies, if you put up one hand, they're going to move their eye to look at that hand. And that can give you a false reading because that's sort of a way for them to cheat because they see the quick movement and they focus and then you can they see what fingers you're holding. So by holding up two hands, it kind of forces them to stay straight ahead and focused. So you're doing great. Look right at my nose and tell me how many fingers I hold up. Perfect. Okay, switch eyes for me. Okay, and same thing. Look right here at my nose. I usually give them a second to adjust to the light because that eye's been closed for a minute. Okay, keep looking right at my nose. You're doing great. How many fingers? One, two, one, two, two. Perfect. All right, very, very good. All right, next we're going to check for motility. I like to use a muscle light with my finger on it. It's just an easy target for both adults and children to follow. So Meg, do me keep your head very still and just with your eyes I want you to follow my finger. Okay, so we're checking all positions of gaze and it's okay. I'm just going to gently lift your eyelids up and so what I'm going to do here is just to make sure that they can move their eyes all the way down. I'm going to hold the upper eyelids up just so I can get a really good view. You're doing fantastic. Next thing we're going to do is is check the intraocular pressure. So whatever device you have available to you, use it. There's another good video that will be published using the Goldman Applination. If I have one available, I like to use a tonal pen, especially because as part of an orbital exam, I like to check the intraocular pressure in different positions of gaze. That's very important with things like thyroid eye disease and fractures because if an orbit's very congested or there's an entrapped muscle, the pressure will oftentimes rise in the eye when they go off of central gaze. So for example with thyroid eye disease, I always check with a patient in primary gaze and then with up gaze. And if there's a significant difference between those two, that makes me more worried about a congested orbit. Okay, so obviously put numbing drops in. We're not actually going to check Meg's pressure, but I have her look straight ahead. And then the other reason I like to use the tonal pen is because you can sneak it in between the eyelids. So even if they're coming in with a swollen eyelid because they've had a trauma, you can oftentimes still check the pressure on the cornea without having to open the eyelids up. The reason I worry about that is if they have a lot of edema in their eyelids and you open it up to check the pressure, you're going to artificially increase the orbital pressure while you're checking it. So just try that sometimes. If you have a tonal pen, you're doing a trauma eval on a swollen lid, check it with the eyes open and then check it with trying to just get into the palpial aperture. And you might be surprised at what a big jump occurs when you are mechanically elevating the eyelids. Okay. All right. The other things we're going to check with an orbital exam. I want to check to make sure that the optic nerve is functioning well. So this test is called red desaturation. Pick up the brightest, reddest object you can find. Often the tip of a phenylaphrine or a tropicomide cap, one of the red dilating caps is what works really well for me. Okay. So what color is the cap on that pen? Right. Okay. And what color is the cap on that pen? Right. Is that the same color red between both eyes? Yes. Okay. And I want you to look straight ahead at that light switch again. I'm going to bring this pen in from the side. Tell me if that pen looks any brighter or darker on one side versus the other. Okay. Good. So that's checking for red desaturation. I'm also going to check for brightness desaturation. So again, I'm going to have the patient focus ahead. So look at that light switch again for me. I'm going to shine that bright light in your eyes again. I apologize. And now I want you to tell me if is that as bright as that? Yes. Okay. If the patient's to say no, it's dim in one eye versus the other. There's a couple ways to kind of try to figure out how much loss there is. It's this objective test, but I like to say things like, okay, if her right eye is the one where she says it was dim in that eye, say, okay, if that's 100% brightness, what percentage of brightness is that? And I'll give you a number like 75% or 50%. And that's just a way subjectively to check it over time. Okay. All right. So moving on to an orbital exam, I want to check your eyes to see if one eye is farther forward than the other. Okay. So we're going to use an X-up thermometer so that we can measure for relative proptosis or enophthalmos. Okay. This works very well. If a patient has normal bony structure, this can be sort of a confusing test if they have fractures or facial deformities. But essentially what you're going to do is the curves of the X-up thermometer. I want these curves to rest right inside the lateral orbital rim. And I try to use a target of the lateral canthal angle where that comes together, where that hooks into the lateral orbital rim. That's going to be the points that I'm shooting for. Okay. This can cause a little bit of a pressure sensation for a patient. It shouldn't be sharp, but especially if they have fractures or they're swollen, it can be, it can be a challenging exam. But do your best to try to get bony contact with the X-up thermometer so that you have accurate readings. Okay. So look straight ahead for me again, Meg. I'm going to bring these guys in. Be as gentle as I can. Perfect. So you can see I'm right at those lateral canthal angles. I'm parallel to the floor. Okay. And then open up really wide for me. And then what I'm doing is lining up the two red lines that you see in there. You want to move your head into those two lines that are sitting on top of each other. That's your 18 millimeter mark. And then you're looking at where the cornea sits on the scale that you see in the prism. And as long as your red marks are aligned, you're square. Okay. So the red line doesn't mean anything except that that's what they happen to place at 18 millimeters. And you're worried about where the pupil is then sitting on that millimeter scale. If you have them available, I like to use loops because I feel I can get half millimeter increment readings from the X-up thermometer when I'm wearing my loops. Okay. And then really what's important with an X-up thermometer is that the same person is measuring it to get the same results. Okay. So I might get a different base than another doctor, but it's more important for me and my records that I keep my base the same. And then I can kind of track changes that way. Okay. All right. The next thing I want to do is gently press on your eyes. Okay. So the other in an orbital exam, you also want to check for retropulsion. Now that's really important. If you have a trauma patient, you're worried about a retro bulb or hemorrhage. You have a thyroid patient, you're worried about a congested orbit or you have any sort of an orbit of tumor. And you want to make sure that there is in congestion in the orbit. Okay. So gently close your eyes for me. And then just with my thumbs, I'm just going to gently press on the eyes. You'll be surprised at how sensitive your thumbs will be in picking up differences in pressure. And if there's a retro bulb or hemorrhage, it'll be as firm as a rock. If there's a tumor, it should be harder to press in the same thing with thyroid eye disease. It's a good base measurement and it's also a good way to track changes over time. So you didn't have any difficulties with retropulsion. So so far right now your orbital exam is perfect. All right. So moving on to sort of a fracture exam or a trauma patient, we're going to check to make sure that the bony rims are intact. Okay. So again, with my thumbs, I'm going to start at the superior orbital rims feeling for crepitus over the nasal bridge. And then I'm going to go from here to the superior orbital rims. I'm just going to move my thumbs out. I like to do it at the same time on both sides so that I can appreciate if there is a difference. A lot of times you can feel a super orbital notch or somebody will have a unique frontal zygomatic sutures that are easier to palpate. But if it's the same between both, obviously it's less concerning. I do pay special attention to the frontal zygomatic suture region because that's a weak point. And oftentimes with a ZMC or tripod type fractures, you'll feel displacement in that area. And I work around to the lateral canthus. And then I come down across the medial rim and you can just palpating and feeling for any step offs or irregularities in the contour. Okay. So that's great. I don't feel any problems there. Next thing we're going to do is check your facial sensation. Okay. So we want to look for V1, V2, V3. Make sure that those are all intact and symmetric. So I'm just going to lightly touch your skin. I want you to tell me if that feels the same on both sides. Okay. It feels the same. Good. Yes. Okay. So here I check the V1 distribution, V2, and then V3. Does that feel the same? Perfect. Okay. So far everything's looking really good. Now I want to check for facial strength to see if there was any facial nerve injuries. So lift your eyebrows as big as you can for me. Scrunch those down. Good. And now squeeze your eyes as tight as you possibly can and don't let me open them. Okay. Good. She has good healthy strength. So that's important for traumas, for strokes, and also very important when you're doing an eyelid surgery evaluation. A lot of people have had Bell's palsy and it's resolved over time by appearances. But when you check the ribicular strength, you might find that it's decreased significantly compared to the unaffected side. And that's something good to know before you do a blepharoplasty surgery to make sure you're not going to induce any leg of Bell's postoperatively. Okay. And then I want you to do me a favor. Clench your teeth like that. Does your jaw feel aligned? Okay. And you pain when you bite down on your jaw. Okay. All right. And so when I'm doing a facial fracture exam, I'm also going to check for instability or movement in the mexilla. So excuse me one second while I put on a glove. Okay. And I'm going to put my glove hand in your mouth. And I'm going to go on either side of your upper teeth. And I want to see if there's any mobility in your mid-face region. Okay. Okay. So I'm going to gently put my glove to hand inside of a patient's mouth. I'm going to go on either side of the upper teeth. And I'm just basically gently, gently wiggling the mexilla back and forth. If there's a lot of instability, you'll feel it and that will help guide your surgical decision making and also be a reminder for you to make sure that the patient follows a soft diet so that they don't induce further instability until we have a chance for the fractures to heal. Okay. So then so far everything's looking good. The one other test that we want to really do with an orbital patient, especially if there's concern for an orbital tumor and you want to see if it's vascular or not, there are two things you want to do. One, we want to listen for a brewery. So we're going to auscultate with a stethoscope. Two, we want to check for increased proptosis with valsalva type maneuvers as that will push the eye forward with the valsalva, which will help sort of lead you down one differential diagnosis path. So with the stethoscope, you're actually going to put the stethoscope over a closed eyelid and then listen. And if you hear a brewery, it's a very concerning finding and you want to get imaging as soon as possible. Okay. You can gently close your eyes for me. Perfect. And now we want to check the x-ophthalmeter post valsalva. So you want to set your base back to where it was. Here's the 101. Okay, make. Here's what I want you to do. I want you to pinch your nose and then I'm going to have you lean forward and pretend like you're blowing up a balloon or trying to make your ears pop. Basically what I want to do, I want to see your face get red. Okay. So that will mean that we're building up a lot of vascular pressure in your face. Okay. So lean over and then blow out and really bear down. Use your stomach and everything because so you see her face is turning red. That's perfect. If they'll tolerate, I'll have them do it for up to 20 seconds. I have my x-ophthalmeter ready to go and have them look straight ahead. I'm going to put it right back and I'm going to look at the eye that I'm worried about first. Okay. And look straight ahead. I want the center of that cornea right on the line, making sure I'm parallel to the floor. Good. Okay. There's no increase in proptosis or anything or change in the measurement. So you're doing great. Thank you for watching. Once again, this is Tom Oberg, ocular facial plastic surgeon in Salt Lake City. I hope you found this video helpful. All the best.