Introduction:

Asprimarycareproviders,itisimportantforoptometriststorecognizewhenlaboratorytestingisbeneficial
tothepatientandtounderstandtheimplicationsoforderinglaboratorytests.Inorderforatesttobetruly
beneficial,itmustimproveorservetomaintainthepatientsqualityoflife.Testsmaybediagnosticin
natureandthushelpidentifyatreatableocularorsystemicconditionwhichresultsinthepatientobtaining
theneededtreatment.Diagnostictestsmayalsoidentifyaconditionwhichaltersthetreatmentplanand
resultsinthepatientbeingmonitoredmorecloselyorholdinganincreasedawarenessofwarningsignsof
moreseriousconditions.Laboratorytestsshouldnotbeordered,withoutdiscretion.Additionaltests
shouldbechosendeliberatelyandthepretestprobability(aroughestimateofhowlikelythepatientisto
havetheconditionPRIORtoconductingthetest)shouldbecarefullyconsideredtominimizethenumberof
falsepositiveswhichmayleadtounnecessarytreatmentand/oremotionaldistressforthepatient.
Laboratorytestsshouldnottaketheplaceofthephysicaleyeexam;rather,athoroughexamshouldbe
complementedbylaboratorytesting.Thefollowingtestsareimportantandusefulinoptometricpractice,
andarevaluableinevaluatingapatientinbothaprobabilisticandprognosticmanner.Thesetestswere
chosenbecauseoftheirdiagnosticpower,reliability,versatilityandaccuracy.Diagnostictestsaremade
evenmorepowerfulbyutilizingthemproperlyasoneofmanytoolsincludingthepatienthistoryand
objectiveexamwhichworktogethertogenerateadiagnosis.

TestOne:Completebloodcountwithdifferential(CBCwithdiff)
Althoughitlackssensitivity,acompletebloodcountwithdifferentialbroadlyassessesthehealthofa
patientinacostconsciousway.ACBCincludesananalysisofthreemajorcomponentsoftheblood:red
bloodcells,whitebloodcells,andplatelets.Redbloodcellsarecriticaltooneoftheprimaryfunctionsof
bloodoxygentransporttotissues.Whitebloodcellsareimportantinthebodysimmuneresponsewhich
maybemountedinresponsetoaforeigninvaderorsometimesittargetsthebodysowntissuesinan
autoimmuneresponse.Plateletsfunctionintheclottingcascade.Anabnormalityofanyofthese
componentsmaycauseocularmanifestations.ACBCcanidentifyaspecificconditionsuchas
leukocytosis(anabnormallyhighWBCcount)thatmayhelpdirectfuturetestingforconditionswhich
causeWBCabnormalities.Conditionssuchasacuteandchronicleukemias,rheumatoidarthritis,and
tuberculosismaycauseelevatedWBCcounts.Somemedicationssuchascorticosteroidscanalsoelevate
theWBCcount.AnemiaresultsfromadecreasednumberofRBCs,andcanstemfromvariousetiologies
includingdeficienciesofvitaminsorironandmisshapenredbloodcellsasinsicklecellanemia.ACBC
withdifferentialisalsousefulinanalyzingtheresultsofothertestssuchastheerythrocytesedimentation
rate(ESR)inapatientwithsuspectedgiantcellarteritis(GCA)asdiscussedlaterinthismodule.

ComponentsofaCBCwithDifferential

Redbloodcells
Whitebloodcells
Platelets
Component
Definition
Plateletcount
Numberofthrombocytesincubicmillimeterofblood
Meanplateletvolume
Averagevolumeofplatelets

WHEN:
ThereareafewspecificocularsignswhichwarrantaCBCwithdifferentialalthoughaCBCcanbean
appropriateintroductorytesttoestablishbaselinesinpatientswithoutspecificocularsigns.Belowisanon
exhaustivelist:

Unexplainedretinalhemorrhages
Cottonwoolspotsintheabsenceofknownsystemicdisease
Vitreoushemorrhageintheabsenceofknownsystemicdisease
Recurrentsubconjunctivalhemorrhages
Inconjunctionwithmostotherbloodtests(asareference)

TestTwo:ComprehensiveMetabolicPanel(CMP)
Thecomprehensivemetabolicpanelisacombinationoffourteenscreeningtestswhichassessfunctionof
majororganssuchastheliverandkidneyaswellasmoregeneralindicesincludingproteinlevelsand
electrolytes.ThebasicmetabolicpaneldiffersfromtheCMPconsistsofseventestsanddoesnotcontain
liverenzymeanalysis.
Test
Function
Albumin(Serum)
Proteinproducedbytheliver,abundantintheseru
Liverenzymeabnormallevelsmaybeduetoliver
AlkalinePhosphatase
abnormalities
AlanineAminotransferase(ALT)
Liverenzymealteredlevelsmayindicateliverd
AspartateAminotransferase(AST)
Enzymepresentintheheartandliver,indicatesliv
BloodUreaNitrogen(BUN)
Assesseskidneyandliverfunctioncanalsoindic
Importantinfunctionofnerves,muscles,bonesan
Calcium
bloodclotting
Chloride
Activeinregulatingthebodysfluidbalanceandm
CarbonDioxide(Total)
MaintainsproperpH
Indicateskidneyfunctionbecausecreatinineisaw
Creatinine
themuscleswhichisfilteredoutbythekidneys
GlucoseTest
Assessingforhypoglycemiaorhyperglycemiawh
Importantinmaintainingheartrhythmandotherm
PotassiumTest
incellmetabolism
Sodium
Importantinthefunctionofnervesandmuscles
TotalBilirubin
Wasteproductoftheliver,indicatesliverdysfunc
TotalProtein
Measuresthetotalamountofserumproteins

WHEN:
Acomprehensivemetabolicpanelmaybeusefulwhencollagenvasculardisordersaresuspected.Liver
andkideyfunctionareassessedbytheCMP,andthiscanbeusefultooptometristsasdysfunctionofthese
majororganscanhaveocularimplications.Theglucosetestmayaidindiagnosisofdiabetesorindicate
diabeticcontrol.

TestThree:ThyroidTesting
Recognizingtheneedforthryoidfunctiontestingcanbeverybeneficialtopatientsbecauseitcanresultin
thediagnosisofatreatablesystemicdisease.Thyroidtestingconsistsofananalysisofthreemajor
componentswhichworkinsynergytoregulatethyroidhormonelevels:thyroidstimulatinghormone
(TSH),serumfreeT3andfreeT4,andserumtotalT3andT4.TSHisreleasedfromtheanteriorpituitary
andhelpsmodulatethelevelsoffreeT3andT4.TSHisconsideredthemostaccurateindicatorofthyroid
function.Currentthyroidtestinghasadetectionlimitof0.01mU/L,whichismuchmoreaccuratethan
previoustestswhichhadadetectionlimitof0.10mU/L1.Overall,thyroidtestingisconductedtoassess
thyroidfunctionorevaluatetheefficacyoftreatmentforhypothroidismorhyperthyroidism.Themost
commontypesofthyroiddysfunctionarehypothyroidismandhyperthyroidismwhicharemostfrequently
causedbyautoimmunedisorderssuchasGravesdiseaseandHashimotosthroiditis.

Thyroiddysfunctionmaybeevidencedbyprominentocularfeaturesthatcanbedetectedbyoptometrists.
Thefollowingisalistofocularsignsrelatedtothyroiddysregulation2:
Dalrymplessign:commonlyknownasthestare,thissignreferstothelidretraction
commonlyseeninpatientswithGravesdisease
VonGraefessign:anocularsignofGravesdiseaseinwhichtheupperliglagsbehindthe
rotationoftheglobeindowngaze
Kocherssign:anocularsignwhichcouldbeconsideredthecounterparttoVonGraefes
signbecauseitinvolveslidretractiononupgazewhichismorerapidthantherotationoftheglobe
upward
Superiorlimbickeratoconjunctivitis:Aconditionconsistingofinflammationinthesuperior
aspectoflimbalinterfaceandisoftenrelatedtothyoidissues
Proptosis:AforwarddisplacementoftheglobewhichmayoccurinGravesdiseasedueto
theproliferationoforbitalfibroblastswhichpushtheglobeanteriorly
Extraocularmusclerestriction:mayresultfromthedepositionofextramaterialswithinthe
bodyoftheEOMS,thusreducingmobilityinconjunctionwithproptosis.Thismaycausethe
patienttonoticesymptomssuchasdiplopiafromthesubtleocularmisalignment.
Lagophthalmos:aninabilitytofullyclosethelids,resultinginpotentialcornealdessication
andpossiblycausingsymptomssuchasdryness,itching,orburning.
Opticnervecompression:ThisseverecomplicationmayresultfromtheenlargedEOMs
expandingwithintheorbitandplacingadditionalpressureonthesusceptibleopticnerve.Orbital
decompressionisapotentialtreatmentoptiontohelpreducethepressureontheopticnerveand
spareitsdelicatefibers.

NormalValues:
TSH:.34mIU/L
TotalT4:4.512.6g/dL
FreeT4:.71.8ng/dL
FreeT3:.2.5ng/dL
*Normalvaluesvarybetweenlaboratories.ValueslistedarefromtheNationalEndocrineandMetobolic
DiseaseInfromationService

TestFour:ELISA/WesternBlot
ThemostcommonmethodofdetectingtheHIVismeasuringthelevelsofantibodiesthebodyproducesin
reponsetothevirus.TherearetwomaincategoriesofHIVtestingarethestandardtestandthemore
recentlyintroducedrapidscreeningtest.Thebenefitsoftherapidscreeningtestisthatitprovidesresults
withinminutesandiscostefficientwhilemaintainingaccuracy.Thesensitivityoftherapidscreeningis
between99.1%and99.7%,whileitsspecificityisbetween99.6%and99.9%(comparabletoELISA) 3.The
standardenzymelinkedimmunoassayscreeningassay(ELISAorEIA)isthemostpopularscreeningtest
forHIVinfectionand,ifpositive,itsresultsareconfirmedwithaWesternblot.ELISAisverysensitive
andextremelyspecificbutitmaygenerateafalsenegativeresultifthetestisadministeredintheperiod
betweentransmissionandseroconversion.ELISAhastheabilitytodetectantibodiestotheHIVvirus
whichiswhyitwillonlybepositivefollowingtheimmuneresponsetothevirus.Itisimportanttoidentify
thosepatientswithHIVinfectiontominimizeaccidentaltransmissionifthepatientisunawarehe/sheis
HIVpositive.ELISAdoesnotdetectthelevelofviralparticles.IftheELISAisposititive,itisfollowed
byaWesternblotandadeterminationoftheviralload.TheWesternblotis99.3%sensitiveand99.7%
specific4.IftheELISAisnegative,nofurthertestingistypicallyconductedatthattime.

WHEN:

HIVinfectionshouldbeconsideredwhenthereareunexplainedretinalfindingsoropportunisticinfections
inapatientwhowouldnotbeataheightenedriskforsuchinfectionsnormally.Specificocularfindings
whichmayindicatetheneedforHIVtestingsareasfollows:
Retinalhemorrhages
Cottonwoolspots
Opportunisticinfections
oHerpesfamily(herpeszoster,herpessimplex,etc.)
Unexplainedinflammationintheeyeaffectingvirtuallyanystructure
oMolluscumcontagium,uveitis,retinitis,Kaposissarcoma

TestFive:ESR(ModifiedWestergren)andCRP
Erthrocytesedimentationrate(ESR)andCreactiveprotein(CRP)aretestswhichdetectmarkersof
inflammation.TheESRisrelativelysensitivebutlacksspecificity.ConditionswhichelevatetheESR
includesystemiclupuserythematous,pregnancy,inflammatoryboweldisease,rheumatoidarthritis,and
giantcellarteritis.TheESRisbasedontheprinciplethattheproteincontentinbloodincreasesinresponse
toinflammation.ThisalterationpromotestheclumpingofRBCstogether.TheESRismeasuredinmm/hr
becausesitquantifiesthedistancethatRBCfallinathintesttube(aWestergrentube)overtheperiodofan
hour.HigherlevelsofinflammationyieldfasterratesofsedimentationbecausetheclumpsofRBCfall
fasterthanindividualRBCs.CRPisaanacutephaseproteinproducedinresponsetoinflammationwhich
risesfasterandfallsmorerapidlythetheESR.CRPmaybeelevatedfollowingtissuedamagesuchasa
myocardialinfarcationortoamoreophthalmiccenteredconditionsuchasgiantcellarteritis(CRP).Inthe
worldofoptometry,theESRandCRPshouldtypicallybeorderedsimultaneouslywhenconsidering
differentialdiagnosesprognostically.ESRandCRParethemosteffectiveatdetectingGCA;whentaken
incombinationtheyare99%sensitiveand97%specific5.Orderedindiscriminately,thesetestsmaynotbe
verypowerful,butwhenthereisareasonablesuspicionforGCA,theduoofthesetestsislikelytoresultin
anaccuratediagnosis.BothofthesetestsshouldbeconductedwithaCBCbecauseifthenumberorsizeof
RBCsissubstantiallydifferentfromthenormsthattheESRisbasedon,theESRresultbecomesunreliable
aswell.
Normalvalues:
Males:Age/2(mm/hr)
Females:(Age+10)/2(mm/hr)
WHEN:
ESRandCRPshouldbeperformedurgentlywhenoftenwhenthereisanincreasedsuspicionforGCA.
ThetypicalpatientwithGCAisover65,maycomplainofaheadache,neckpainorjawclaudication,fever
orweightloss.OcularsignsofGCAmayincludeaunilaterallyswollennerve,reducedvision,artery
occlusions,orlesscommonly,nervepalsies.5

TestSix:HbA1c
TheHbA1cisarelativelysimpletest,butitdoesprovidevaluableinformationfortheoptometrist.The
HbA1cmeasurestheamountofglycatedhemoglobinintheblood.GlucoseattachestoRBCsviaatwo
stepreactionwhenthereisanexcessofglucoseinthebloodstream.6Thefirsthalfofthereaction,the
formationananaldimine,isreversible.TheHbA1cactuallymeasurestheproductofthesecond,
irreversiblehalfofthereactiontheketoamine.TheglucoseremainspermanentlyattachedtotheRBCs,
thusthelevelofglycatedhemoglobinreflectsthebloodglucosecontroloftheprevious23monthsandis
largelyunaffectedbyshorttermbloodglucosefluctuations.TheaveragelifespanofaRBCis90days,so
theA1cservesasarelativelylongtermindicatorofbloodsugarlevels.Althoughindividualbloodglucose
levelsprovideonlyasnapshotofwhatishappeningwithinthebody,withlittleindicationofwhatcame
beforeorfollowedafter,theA1cprovidesamorereliablemeasureofdiabeticcontrol.Conditionssuchas
anemiaorkidneyfailuremayconfoundtheresultsofHbA1ctestingsotheseconditionsshouldbe
identifiedpriortoconductingthistest.Theestimatedaverageglucose(eAG)canbecalculatedfromthe
A1cresultwiththefollowingequation7:

eAG(mg/dl)=(28.7*HbA1c)46.7
HbA1c
eAG(mg/dl)
5
97
6
126
7
154
8
183
9
212
10
240
11
269
12
298
13
326
14
355
15
384
16
413

AccordingtothetheAmericanDiabetesAssociationnormativevaluesforaHbA1cofanondiabetic
personaretypicallybetween4and6%.ApatientwithdiabetesshouldideallymaintainaHbA1cvalueof
7%orless.
WhyisthisimportanttoO.D.s?TheDiabetesControlandComplicationsTrial(DCCT)showeda
reductioninmicrovascularcomplicationswithalowerHbA1c8.Otherthantheobviousriskofdiabetic
retinopathy,HbA1clevelsprovideanindicationofrefractivestabilityvaluableinformationforthe
refractioncomponentoftheeyeexam.
WHEN:
HbA1cisespeciallyusefulinpatientswhohavenotreceivedadequatehealthcareandthustheoptometrist
canactasagatewaytohelpthesepatientsestablishentryintothehealthcaresystem.Diabetesshouldbeon
thelistofdifferentialsforpatientswithintraretinalhemorrhages,exudates,cottonwoolspots,ormacular
edemaofunknownorigin.Ifapatienthasexperiencedalargerefractiveshift,diabeticchangeswithinthe
lensmaybetheculprit.HbA1cisareliablescreeningtoolforpatientsinwhomvasculardiseaseis
suspected.

TestSeven:LipidProfile
Alipidprofileprovidesinformationaboutthelevelsoftriglyceridesandcholesterolinthebody.These
insolublelipidsmustbeattachedtospecificproteins,lipoproteins,inordertomoveeasilywithintheblood
stream.Lowdensityliproteins(LDL)areresponsibleforthebulkofcholesteroltransportwhile
triglyceridesaretypicallycarriedbyverylowdensitylipoproteins(VLDL).Typicallylevelsoftotal
cholesterolandhighdensitylipoproteinsaremeasured,andtheotherlevelsareestimatedfromthesedirect
quantifications.TheVLDLlevelisestimatedbydividingthetriglyceridelevelbyfive 9.Byanalyzingthe
levelsoflipidswithinthebloodstream,itiseasiertoascertainthepotentialhelathhazardsthatmayaffect
thepatient.Thelipidprofilehasfourmaincomponents:
HighDensityLipoproteins(HDL)
LowDensityLipoproteins(LDL)
VeryLowDensityLipoproteins(VLDL)
Triglycerides
Component
Normalvalues
Men:4050mg/dL
HighDensityLipoproteins(HDL)
Women:5060mg/dL
>60mg/dL=optimal
130159mg/dL=borderlinehigh
LowDensityLipoproteins(LDL)
>160mg/dL=high

Triglycerides

<100mg/dL=optimal
<150mg/dL=normal
Lessthan200mg/dL

Totalcholesterol
NormalvaluesaccordingtoAmericanHeartAssociationstandards

WHEN:Alipidprofilemaybeusefultoevaluatethesystemichealthrisksofapatientwhohasaretinal
arteryocclusionorsymptomsofalteredperfusiontotheeyeincludingamaurosisfugax.Midperipheral
hemorrhageswhichmaybeindicativeofocularischemicsyndromealsoprovideastimulusforlipid
testing.Veinocclusionsalsocanalsobeevidenceoftheneedforlipidtesting.Thepresenceofcorneal
arcusinapatientwhowouldnototherwisebeexpectedtohavethiscornealfinding,suchasthoseunder40
yearsold,shouldraisethesuspicionofhyperlipidemia.

TestEight:ChestXRay
Althoughtherearebloodtestswhichcanassessthelevelofriskforsarcoidosis,achestxrayprovides
confirmationofthediagnosisofsarcoid.AchestXraycanalsobeutilizedintheevaluationofHorners
syndrome.AfterdiagosisofHornerssyndrome,itisimportanttoconsiderpotentialetiologiesina
prognosticway.APancoasttumorattheapexofthelungcandamagethepreganglionicsympatheticfibers,
resultinginHornerssyndrome.Tuberculosis,althoughrelativelyrareintheU.S.,canalsobedectedviaa
chestxray.Allthreeoftheseconditions,sarcoid,Hornerssyndrome,andtuberculosiscanhaveocular
manifestations.SarcoidandTBarebothgranulomatousdiseaseswhichcanpromotegranulomaformation
throughouttheeye.IntheiristhesegranulomascanmanifestasKoeppeorBusaccanodules.Bothofthese
conditionsmayalsocauseabilateral,granulomatousuveitis.Hornerssyndromeisusuallyevidencedbya
triadofsigns:ptosis,anhydrosis,andmiosisontheaffectedside.AlthoughcongenitalHornerssyndrome
doesnotrequireachestxray,thisimagingisappropriateinpatientswithacquiredHorners.Chestxrays
arealsorelativelycostefficientandaremuchcheaperthancomputedtomography(CT)scansandhavethe
benefitofexposingpatientsto100500timeslessradiationthanaCTscan 10.Patientswithsarcoidwith
develophilaradenopathyonachestxray,andtwothirdsofpatientswilldevelopanterioruveitis 11.
WHEN:Patientswithsarcoidmaypresentwithanterioruveitisalongwithrespiratorysymptomsorthey
maybeasymptomatic.SarcoidismostcommoninAfricanAmericanfemalesofages2040years.Vessel
sheathingintheperipheralretinamayalsobeindicativeofsarcoid.
Achestxrayshouldalsobeorderedwhenapatientpresentswithanacquiredonsetondiminished
sympatheticflowunilaterallytoruletheprognosticallytroublingdiagnosisoflungcancer.Tuberculosis
canmanifestocularlyinseveraldifferentways.Cellsoropacitiesinthevitreousmaybeanocular
manifestationofTBwhichmaypresentwithaconcurrentchorioditisoropticneuropathy.Apatientwitha
chronicuveitis,particularlyofagranulomatousnature,isagoodcandidateforachestxraybecausethe
ocularinflammationcouldbegeneratedbysarcoidorTB,bothofwhichalsoaffectthelungs.

Recurrentbilateraluveitiswithorwithoutrespiratorysymptoms
Irisnodulesvisibleonslitlampwithconcurrentrespiratorysymptoms
Unilateralmiosisandptosis

TestNine:MagneticResonanceImaging(MRI)
AnMRIoftheorbitscandetectseveralconditionswhichmayhavenotablesystemicimplications.MRIs
aretypicallybestatimagingsofttissueswhileCTscansprovidethebestvisualizationofbonystructures
andblood.MRIutilizesmagneticfieldsandradiowavestocreateathreedimensionalimagewithout
exposingthepatienttoionizingradiationlikeaCTorxray.Duetotheinvolvementofamagneticfieldin
MRIscans,patientswithaknownorsuspectedmetallicforeignbodyshouldnotbeimagedwiththis
modality.MRIsaretypicallymuchmoreexpensiveandaremoretimeintensivethanCTscans.Tumors
withintheorbitoralongtheopticnervesuchasaneuromaormeningiomaareoftenvisualizedwellwithan
MRI.OneofthemostimportantrolesoftheMRIinoptometricpracticeistoaidinuncoveringthe

etiologyofopticneuritis,withmultiplesclerosisbeingtheprimarysuspect.Brainlesionscharacteristicof
MScanbediagnosedwithMRIs.MostpatientswithMSwillsufferfromopticneuritisatsomepoint
duringthecourseoftheirdisease,andtheoccurrenceofopticneuritisisassociatedwithanincreasedrisk
ofdevelopingMS11.AnMRIcanalsodetecttheeffectsofGravesdiseaseontheorbit.Themusclebelly
oftheextraocularmuscles,visualizedbyanMRI,becomesenlargedsecondarytodisorderlyfibroblasts
whichalterthenormalarrangmentofthefibers.MRIscanbeorderedwithorwithoutcontrast,butusually
theuseofcontrastispreferrediftherearenocontraindicationstoitsuse.AT1weightedMRIprovidesa
betterimageoftheanatomicdetail,whereasaT2imageisoftenbetteratdetectingpathology. 12
WHEN:
ProptosisoftheeyeisoftenanindicationforMRIimaging.Someofthemostworrisomeculpritsof
proptosissuchasaspaceoccupyinglesioncanbediagnosedviaMRI.Evidenceofopticnervehead
compression,suchasasymmetricalopticnerveheadappearance,couldalsoprovidecauseforanMRI.Ifa
patientexhibitssymptomspotentiallyindicativeofretrobulbaropticneuritis,suchaspainoneye
movement,unilaterallyblurredvisionordesaturatedcolorvision,anMRIcanassesstheriskofMS.In
patientswithsuspectedidiopathicintracranialhypertension(IIH)thathavethetypicalocularfindingof
papilledema,anMRIshouldbeconductedbeforealumbarpuncture(LP)topreventtheriskofuncal
herniation.UnexplainedvisualfielddefectscanwarrantanMRIifnoothercauseisreadilyapparentand
thedefectisrepeatable.Homonymousvisualfielddefectsindicatepathologyposteriortotheopticchiasm
canbedetectedbyMRI.OtherindicationsforMRIincludeunilaterallowtensionglaucomaand
unexplainedopticnervepallorespeciallyifitisprogressiveinnature.

Cranialnervepalsyinapatientwithnoknownvasculardisease
Newonsetofdiplopiawithassociatedneurologicalsymptomssuchasdizzinesorheadache
Opticdiscedemaorpallorwithoutknownetiology
Unilaterallowtensionglaucoma
PainoneyemovementwithassociatedAPDorreducedacuity

TestTen:ComputerAxialTomography(CTscans)
CTscanshavewidespreadutilityinimagingthebody,andtheeyeisnoexception.CTscansdorequire
ionizingraditiontoproduceanimage,sothesescansshouldnotbeorderedindiscriminately.Contrastdyes
maybeincludedtogenerateanoptimalimageortospecificallyhighlightthedistinctionbetweenvarious
tissues.ACTscanoftenprovidesbetterresolutionthanatraditionalxrayandismoreversatileinthe
typesofpathologyitcandetect.CTiscommonlyusedintheERduetothespeedofthescananditsability
toidentifypotentiallylifethreateningconditionslikehemorrhaging.
WHEN:
CTscansareoptimalforimagingtheorbitsofpatientswhohaveahistoryofpenetratingoculartraumaor
thepossibilityofanintraocularforeignbody.Inpatientswhoaresuspectforanopenglobe,theCTis
reliableinimagingthearchitectureoftheposteriorsclera,thusaidinginthediagnosisofanoccultopen
globe.13TheCTcanalsobebeneficialinanotherformoftrauma,orbitalfracture.Blunttraumatothe
globeincreasesthepressurewithinthealreadytightlycompressedorbit,andtheglobehasnoreadyavenue
ofrelocation.Theweakestareaoftheorbitisthefloor,sotheglobefollowsthepathofleastresistance
downwardandfracturestheorbitalfloor.CTscanscanreadilyidentifytheseinferiorfractures,aswellas
evaulatedtheintegrityoftheparanasalsinusesthatsurroundtheorbitwhichmayalsobecompromisedin
anorbitalfracture.Potentialsignsthatcanbeindicativeofanorbitalfractureincludegazerestriction
(specificallyonupgazeastheinferiorrectusmaybeentrapped)ordiplopiaandpainwhenactivatingthe
extraocularmuscles.AcuteorbitaltraumaistypicallybestimagedwithaCTduetothepossibilityor
orbitalfractureorhemorrhage.
SpaceoccupyinglesionswithintheglobecanalsobedetectedbyCTeventhoughCTisnotasefficientin
imagingsofttissuegrowthsasMRI.CTcanalsobeusedtoevaluatetheintegrityoftheEOMsin
conditionssuchasGravesdisease.
Differentiatingpreseptalcellulitisfromorbitalcellulitisisanimportantclinicaldecisionforoptometrists.
Preseptalcellulitisrepresentsinflammationofthesofttissuesanteriortotheorbitalseptum,whileorbital

cellulitisconsistsofinflammationwithinthesofttissueoftheorbitbutstilldoesnotaffecttheintraocular
contents.ACTscancanlocalizethesiteofinflammationtopreseptalorpostseptal,adistinctionthatmay
bedifficultfrompatienthistoryandgrossphyscialexamination.Thepresenceofanafferentpupillary
defect,decreasedvisualacuity,fever,and/orextraocularmusclerestrictionincreasestheriskoforbital
cellulitisandimagingshouldbeordered.
Ingeneral,aCToftheorbitswithandwithoutcontrastmaybeappropriatewhenthepatienthaseyepain
(inassociationwithothersymptoms/signs),doublevisionofunknownetiologyoracranialnervepalsy.
Acuteorbitaltrauma,especiallyifthepatienthasdiplopiaorfacialnumbness
Unilateralred,swolleneyeinapatientsuspiciousfororbitalcellulitis(concurrentfever,
EOMrestriction,reducedacuity,and/orAPD)
Unilateralproptosis
Historyoftraumawhichcouldhaveresultedinanintraocularforeginbody
COST
Thecostofadditionaltestingshouldalwaysbeaconsiderationtoreduceunnecessarycostsforpatientsand
thehealthcaresystemingeneral.Listedbelowareapproximatecostsofthetestsdiscussedinthis
document:
Test/Procedure
Approximatecost
CBCwithdifferential
$3050
Comprehensivemetabolicpanel
$3060
Thyroidtesting
$5080
ELISA/Westernblot
>$100
ESR/CRP
$100(total)
HbA1c
$3050
Lipidprofile
$2550
Chestxray
$4050
MRI(orbits)
$20004000(variesgreatly)
CTscan(orbits)
$6002000(variesgreatly)
Mostpriceestimateswerebasedonhttp://www.healthcarebluebook.com14

Conclusion:
Therearemanycommonlyorderedtestswhichdidnotmakethislist,andthatiscertainlynottoimplythat
thosetestsarenotvaluableorshouldnotbeordered.Angiotensinconvertingenzyme(ACE),antinuclear
antibody(ANA),rheumatoidfactor(RF),rapidplasmaregain(RPR),fluorescenttreponemalantibody
absorption(FTABS),humanleukocyteantigenB27(HLAB27)noneofthesetestswereincludedin
thisdiscussionbuteachonecanbevaluableintherightcircumstances.Manypatientswithsarcoidwillnot
testpositivewiththeACEtest,soitisaratherspecifictestthatissomewhatlackingindiagnosticpower.
ANAandRFarecommontests,butanabnormalresultdoesnotdirectlyleadtoadiagnosisortreatmentof
aspecificcondition.Inoneanalysis,thesensitivityofANAwas100%wasthespecificitywasonly86%.15
RFtypicallyhasalowpositivepredictivevalue,soapositiveresultonthetestisnotstrongevidencethat
thepatientactuallyhasrheumatoidarthritis.16Testingforsyphilisisplaguedbyfalsepositives,soitshould
onlybeorderedwhenotherpatientfactorsindicateahighriskofthedisease.HLAB27isasensitivetest,
butitisntspecific.ApositivetestforHLAB27doesnotgenerateadiagnosisanddoesnotnecessarily
indicatethatanypathologyispresence.ItistruethatmostpeoplewithconditionssuchasCrohnsdisease
andankylosingspondylitishavetheHLAB27allele,butmanypeoplewiththeHLAB27allelenever
developtheseconditionssoitisnotextremelypredictiveofsystemicdisease11.
ACE:Measurestheamountofangiotensinconvertingenzymeintheblood.Itisusefulinthe
diagnosisofsarcoid,butmayalsobeelevatedinleprosy,tuberculosis,andactivehistoplasmosis.
ANA:Detectsthepresenceofantibodiestonormalproteinsanditusuallyorderedwhen
autoimmunediseaseissuspected.Itaidsinthediagnosisofconditionssuchaslupus,scleroderma,
Sjogrenssyndromeandautoimmunehepatitis.ApositiveANAtestinisolationisnotdiagnostic
foranyonecondition,andupto155ofthenormalpopulationmayhaveapositiveANA.

RF:DetectsthelevelofRFantibodyintheblood.ThistestisnonspecificbutRFantibody
levelsaremostoftenelevatedinrheumatoidarthritisandSjogrenssyndromebutcanalsobe
elevatedinsarcoidosis.
RPR:Screeningtestforsyphilisthat,ifpositive,mustbeconfirmedbytheFTAABS.This
testcanalsobeutilizedtomonitorhowwelltreatmentisworking.
FTAABS:DetectsantibodiestotheorganismTreponemapallidumwhichisresponsiblefor
syphiliticinfection.Itisaconfirmatorytestforsyphilisbasedonthetechniqueofindirect
antibodyfluorescence.
HLAB27:Utilizedinthediagnosisofmanydiseaseswhichareinflammatoryinnature
includingbutnotlimitedtoankylosingspondylitis,reactivearthritis,andinflammatorybowel
diseasesuchasCrohnsdiseaseandulcerativecolitis