PROPTOSIS          Adults    Dr. Yousaf Jamal      FCPS Resident   Ophthalmology UnitHayatabad Medical Complex       20-02...
CONTENTS• Introduction• General Causes• Clinical approach + Differentiating features• Causes in Adults• Common causes disc...
Introduction•      Proptosis *     –       Forward displacement or bulging, especially             eyeball•      Exophthal...
General Causes• Congenital                   • Acquired  – Dermoid cyst                 – Inflammatory  – Orbital teratoma...
Causes• Inflammatory   – Thyroid-related orbitopathy   – Idiopathic orbital inflammatory disease     (pseudotumor)   – Sar...
• Infectious   – Orbital cellulitis   – Subperiosteal abscess   – Gumma   – Mucormycosis• Trauma   – Orbital blow-out frac...
• Vascular  – Orbital varices  – aneurysms• Cysts  – Hydatid cyst  – Cysticercus• Sinus related  – Mucocele  – Tumors Page...
• Neoplastic  – Capillary                         – Optic nerve glioma    hemangioma                        – Optic nerve ...
Clinical approach• History• Examination• Investigation Page 9           Proptosis in Adults   Mar 25, 2013
History• Age of onset• Nature of onset  – Sudden  – Gradual• Duration  – Continuous  – Intermittent postural / valsalva  –...
• Associated symptoms  – Vision loss  – Pain  – Diplopia• Past history  – Thyroid disorder  – Malignancy      • Lungs     ...
Examination• Local examination   – Inspection   – Palpation   – Auscultation   – Tests• Systemic examination Page 12      ...
Inspection• True or pseudoproptosis ??• Laterality   – Unilateral      •    Dermoid cysts, orbital teratoma, congenital cy...
Inspection – Bilateral     •    Cranifacial synostosis, osteitis deformans, rickets     •    TED, Mickulicz’s syndrome    ...
Inspection• Direction of displacement  – Axial  – Non-axial      • Lateral      • Inferonasal      • Superior• Lid signs P...
Palpation• Orbital rims• Regional lymph nodes Page 16         Proptosis in Adults   Mar 25, 2013
Auscultation• Globe/temporal region for bruit Page 17        Proptosis in Adults   Mar 25, 2013
Other tests• Transillumination• Visual acuity• Pupillary reactions• Ocular motility• Forced duction test• Tonometry• Fundo...
Systemic examination• GPE  – For systemic disease• Thyroid evaluation• Primary neoplasm ??• Otolaryngological examination ...
Investigations       LABORATORY INVESTIGATIONS• FBC, TLC, DLC• TFTs• Casoni’s test• Urine analysis Page 20          Propto...
…Investigations                  RADIOLOGY• X-rays• CT• Orbital USG• MRI• Angiography Page 21        Proptosis in Adults  ...
Causes in Adults• Thyroid Exophthalmos• Pseudotumor• Orbital cellulitis• Trauma• Meningioma• Lymphoma• Histiocytoma• Caver...
• Osteoma• Varices• Carotid-cavernous fistula• Tumors extending from adjacent areas   – Lacrimal gland   – Sinuses   – lid...
Page 24   Proptosis in Adults   Mar 25, 2013
TED                           PSEUDOTUMOR                   LYMPHOMAPathology        Hypertrophy of EOM,           Hypocel...
CAPILLARY                     ON SHEATH                       CCF                  HEMANGIOMA                    MENINGIOM...
THYROTOXICOSIS• Autoimmune disorder• 3rd – 4th decade, F > M• 25-30% pts present TED   – Females 5 times more affected• In...
Clinical manifestations• Soft tissue involvement• Lid retraction• Proptosis• Optic neuropathy• Restrictive myopathy Page 2...
Proptosis in TED• Axial• Unilateral/bilateral• Symmetrical/asymmetrical• Complications  – Exposure keratopathy  – Corneal ...
Page 30   Proptosis in Adults   Mar 25, 2013
Work-up• Complete Hx  – Known thyroid disease  – Smoking  – Visual changes• Examination• CT orbit• Visual fields / Hess ch...
Treatment of Proptosis• General  – Lubricants  – Taping eyelids  – Cold compresses Page 32        Proptosis in Adults   Ma...
Systemic steroids• Oral prednisolone = 60-80mg/day   – Tapered over 2-8 weeks• Intravenous methylprednisolone   – 0.5g/200...
• Radiotherapy  – Alone or with steroids• Combined therapy  – Radiations + Azathioprine + steroids• Surgical decompression...
PSEUDOTUMOR• Idiopathic orbital inflammatory disease• Non-infectious, non-Neoplastic• May involve any of soft orbital tiss...
Presentation• Unilateral – adults, may be bilateral – children• 3rd – 6th decade• Acute• Painful• Periorbital swelling• Re...
• Congestive Proptosis• Ophthalmoplegia• Optic nerve dysfunction• Palpable mass Page 37       Proptosis in Adults   Mar 25...
Page 38   Proptosis in Adults   Mar 25, 2013
Work-up• Hx• Examination• CT orbit  – Ring sign (contrast)• Biopsy  – FNAC       • In persistent cases Page 39            ...
Course• Spontaneous remission• Intermittent episodes• Prolonged inflammation  – Fibrosis• Frozen orbit   – Ophthalmoplegia...
Treatment• Observation• Oral NSAIDs• Systemic steroids  – Oral prednisolone = 60-80mg/day• Radiotherapy  – If no response ...
• Anti metabolites  – If resistant to steroids and radiations      • Methotrexate      • Mycophenolate mofetil• Systemic i...
CAVERNOUS HEMANGIOMA•       Most common intraorbital tumor of adults•       3rd to 5th decade•       Mostly unilateral•   ...
• Pathophysiology  – Benign, slowly growing vascular lesions  – Increase intraorbital volume to cause proptosis• Morbidity...
Presentation• Middle aged• Slowly growing unilateral axial proptosis• Decrease in VA• Diplopia• Rarely gaze evoked amauros...
Signs• Dilated & tortuous epibulbar vessels• Other defects  – Color vision  – Visual field  – RAPD• Fundus   – Optic disc ...
Work-up                         CT – Well circumscribed, round or oval isointense mass – Usually in lateral part of muscle...
Page 48   Proptosis in Adults   Mar 25, 2013
Treatment                         Surgical• En-bloc removal• Approach      • Lateral orbitotomy…lateral lesions      • upp...
Page 50   Proptosis in Adults   Mar 25, 2013
CAROTID-CAVERNOUS FISTULA• An abnormal communication btw cavernous  and external or internal carotid arteries• Classificat...
Page 52   Proptosis in Adults   Mar 25, 2013
Direct carotid-cavernous fistula• 70-90% of all cases• Communication btw intracavernous part of  ICA & cavernous sinus• Hi...
Indirect carotid-cavernous fistula• Communication btw cavernous sinus &  meningeal branches of ICA and/or ECA• Low arteria...
Presentation• Days or weeks after head injury• Hx of surgery or systemic factors  – Triad      • Pulsatile proptosis      ...
• Epibulbar injection• Ptosis• Pulsatile proptosis with bruit• Increased IOP• Anterior segment ischemia      •    Corneal ...
Page 57   Proptosis in Adults   Mar 25, 2013
Page 58   Proptosis in Adults   Mar 25, 2013
Page 59   Proptosis in Adults   Mar 25, 2013
• Exposure keratopathy• Ophthalmoplegia• Fundus changes   – Optic disc swelling   – Venous dilatation   – Intraretinal hem...
Page 61   Proptosis in Adults   Mar 25, 2013
Work-up• CT, MRI & Orbital echo  – Enlargement of EOM  – Dilation of one or both superior ophthalmic veins  – Enlargement ...
Treatment                    Medical• Exposure keratopathy• Glaucoma• NVG Page 63      Proptosis in Adults   Mar 25, 2013
Surgery• Indication   – Post traumatic fistula   – Failure to spontaneous closure• Procedures  – Surgical repair of the da...
OPTIC NERVE SHEATH           MENINGIOMA• Arise from meningiothelial cells of arachnoid  villi, hence attached to dura mate...
Presentation• Age…6th-8th decade• F>M• Chronic, painless, progressive visual    impairment•   Usually accompanied by propt...
Signs• Classic triad   – visual loss   – optic atrophy   – optociliary shunt vessels (30%)• Restrictive motility defect *•...
Page 68   Proptosis in Adults   Mar 25, 2013
Page 69   Proptosis in Adults   Mar 25, 2013
Work-up• CT scan (with contrast)  – Fusiform appearance of ON  – Mostly at orbital apex  – Calcifications usually seen  – ...
Page 71   Proptosis in Adults   Mar 25, 2013
Treatment• Observation  – No intracranial extension and no vision loss                        Medical• Radiotherapy  – Pri...
Chemotherarpy• Unresectable, recurrent, or previously  irradiated• Combinations  –   5-fluroouracil, folate, and levamisol...
Page 74   Proptosis in Adults   Mar 25, 2013
PROPTOSIS                                   Hx                             Middle-aged woman     Rapid onset Proptosis  Un...
PROPTOSISOrbital inflammation                           Hx of traumaSudden onset/chronic                           Severe ...
TAKE HOME MESSAGE• Proptosis is alarming condition• Localized or systemic cause• Proper approach• Thorough Hx & investigat...
Page 78   Proptosis in Adults   Mar 25, 2013
MCQs1. Features of carotid-cavernous fistula include:    a. dilated superior ophthalmic vein on CT scan     b. blood in th...
2. A forty-eight year old woman presents with a  several month history of slowly progressive,  painless Proptosis and blur...
a. Findings on the scan ?Ans. Well-defined, round, intraconal massb. What is probable Dx of the scan ?Ans. Cavernous heman...
3. This is the orbital CT of a man with painless  progressive Proptosis OS Page 82        Proptosis in Adults   Mar 25, 2013
a. Findings on the scan?Ans. Enlargement of muscles without involvement of the tendinous   portionb. What is your diagnosi...
4. 54 year old man with 4 days of progressively  worsening pain and swelling around the right  eye. Page 84       Proptosi...
Q. What is the differential diagnosis?Ans. Preseptal cellulitis     orbital cellulitis     pseudotumor     malignancy     ...
5. A 30 year old woman noticed mild Proptosis    which accelerated during her pregnancy.    Lesion caused hyperopia & reti...
NEXT                      Lecture• Dr. Yousaf Jamal  – Proptosis in children                   Journal club• Dr. Naeem KTK...
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  • Lid swelling , ecchymosis n chemois suggest cellulitis, lid lag n staring suggst TED.
  • Retropulson also for pulsations..Lymphatic supply of retina??
  • Proptosis in adults

    1. 1. PROPTOSIS Adults Dr. Yousaf Jamal FCPS Resident Ophthalmology UnitHayatabad Medical Complex 20-02-2010 Mar 25, 2013
    2. 2. CONTENTS• Introduction• General Causes• Clinical approach + Differentiating features• Causes in Adults• Common causes discussion• Summary• Take home message• MCQs Page 2 Proptosis in Adults Mar 25, 2013
    3. 3. Introduction• Proptosis * – Forward displacement or bulging, especially eyeball• Exophthalmos – Abnormal protrusion of eyeball * – Proptosis secondary to endocrinological dysfunction ** * Dorland’s medical dictionary 26th edition ** Henderson JW. Orbital Tumors. 3rd ed. New York: Raven Press; 1994. Page 3 Proptosis in Adults Mar 25, 2013
    4. 4. General Causes• Congenital • Acquired – Dermoid cyst – Inflammatory – Orbital teratoma – Infectious – Congenital cystic – Trauma eyeball – Vascular – Cysts – Neoplastic Page 4 Proptosis in Adults Mar 25, 2013
    5. 5. Causes• Inflammatory – Thyroid-related orbitopathy – Idiopathic orbital inflammatory disease (pseudotumor) – Sarcoidosis – Wegener’s granulomatosis – Systemic amyloidosis – Histiocytosis Page 5 Proptosis in Adults Mar 25, 2013
    6. 6. • Infectious – Orbital cellulitis – Subperiosteal abscess – Gumma – Mucormycosis• Trauma – Orbital blow-out fracture – Retrobulbar hemorrhage – Carotid-cavernous fistula – Retained foreign body Page 6 Proptosis in Adults Mar 25, 2013
    7. 7. • Vascular – Orbital varices – aneurysms• Cysts – Hydatid cyst – Cysticercus• Sinus related – Mucocele – Tumors Page 7 Proptosis in Adults Mar 25, 2013
    8. 8. • Neoplastic – Capillary – Optic nerve glioma hemangioma – Optic nerve sheath – Cavernous meningioma hemangioma – Retinoblastoma – Rhabdomyosarcoma – osteoma – Neurofibroma – Pleomorphic lacrimal gland adenoma – Leukemia, Lymphoma – Lac. Gland – metastasis carcinoma – Lymphangioma Page 8 Proptosis in Adults Mar 25, 2013
    9. 9. Clinical approach• History• Examination• Investigation Page 9 Proptosis in Adults Mar 25, 2013
    10. 10. History• Age of onset• Nature of onset – Sudden – Gradual• Duration – Continuous – Intermittent postural / valsalva – Pulsatile Page 10 Proptosis in Adults Mar 25, 2013
    11. 11. • Associated symptoms – Vision loss – Pain – Diplopia• Past history – Thyroid disorder – Malignancy • Lungs • breasts • Prostate Page 11 Proptosis in Adults Mar 25, 2013
    12. 12. Examination• Local examination – Inspection – Palpation – Auscultation – Tests• Systemic examination Page 12 Proptosis in Adults Mar 25, 2013
    13. 13. Inspection• True or pseudoproptosis ??• Laterality – Unilateral • Dermoid cysts, orbital teratoma, congenital cystic eyeball • Orbital hemorrhage, traumatic aneurysm • Cellulitis/abscess, cavernous sinus thrombosis • TED, pseudotumor • Varices, cysts, tumors Page 13 Proptosis in Adults Mar 25, 2013
    14. 14. Inspection – Bilateral • Cranifacial synostosis, osteitis deformans, rickets • TED, Mickulicz’s syndrome • Histiocytosis, Amyloidosis, wegener’s granulomatosis • TumorsPage 14 Proptosis in Adults Mar 25, 2013
    15. 15. Inspection• Direction of displacement – Axial – Non-axial • Lateral • Inferonasal • Superior• Lid signs Page 15 Proptosis in Adults Mar 25, 2013
    16. 16. Palpation• Orbital rims• Regional lymph nodes Page 16 Proptosis in Adults Mar 25, 2013
    17. 17. Auscultation• Globe/temporal region for bruit Page 17 Proptosis in Adults Mar 25, 2013
    18. 18. Other tests• Transillumination• Visual acuity• Pupillary reactions• Ocular motility• Forced duction test• Tonometry• Fundoscopy• Exophthalmometry Page 18 Proptosis in Adults Mar 25, 2013
    19. 19. Systemic examination• GPE – For systemic disease• Thyroid evaluation• Primary neoplasm ??• Otolaryngological examination Page 19 Proptosis in Adults Mar 25, 2013
    20. 20. Investigations LABORATORY INVESTIGATIONS• FBC, TLC, DLC• TFTs• Casoni’s test• Urine analysis Page 20 Proptosis in Adults Mar 25, 2013
    21. 21. …Investigations RADIOLOGY• X-rays• CT• Orbital USG• MRI• Angiography Page 21 Proptosis in Adults Mar 25, 2013
    22. 22. Causes in Adults• Thyroid Exophthalmos• Pseudotumor• Orbital cellulitis• Trauma• Meningioma• Lymphoma• Histiocytoma• Cavernous hemangioma Page 22 Proptosis in Adults Mar 25, 2013
    23. 23. • Osteoma• Varices• Carotid-cavernous fistula• Tumors extending from adjacent areas – Lacrimal gland – Sinuses – lids• Metastasis Page 23 Proptosis in Adults Mar 25, 2013
    24. 24. Page 24 Proptosis in Adults Mar 25, 2013
    25. 25. TED PSEUDOTUMOR LYMPHOMAPathology Hypertrophy of EOM, Hypocellular lymphoid Hypercellular lesion, GAGs accumulation lesion, mature lymphs immature malignant B cellsDemographics 3rd-4th decade, 3rd-6th decade, adults & Old age commonest cause in children adultsAssociated Thyroid disease - lymph nodesPresentation F>M, painful, lid Painful, acute onset, Usually bilateral, retraction, lid lag, axial, axial, unilateral in painless, nonaxial, uni/bilateral, attentive adults, bilateral in child, rubbery palpable gaze, heat intolerance, congestion, mass, adnexal tachycardia, diminshed involvement, reflexesRadiology Fusiform appearance of Ill defined orbital Soft tissue mass, EOM opacification bone erosionTx Steroids, radiotherapy, NSAIDS, steroids, Raiotherapy, decompression radiotherapy, infliximab chemotherapy antimetabolites, Page 25 Proptosis in Adults Mar 25, 2013
    26. 26. CAPILLARY ON SHEATH CCF HEMANGIOMA MENINGIOMAPathology Vascular hemartoma Tubular enlargement of Abnormal ON, origin-meninges, communication btw psammoma bodies carotid artery & cavernous sinusDemographics Infant, commonest benign Late middle aged traumatic…men, orbital tumor in childhood, woman Spontaneous..women, spontaneous involutionAssociated Visceral, nasopharyngeal - HTN, atnerosclerosis, hemangioma, kasabach- trauma, pregnancy, merit syndrome connecive tissue disorderPresentation Nonaxial, +ve Valsalva, Axial, gaze evoked Pulsatile proptosis, superficial/deep amaurosis, EOM whooshing sound, impaired, optociliary ptosis, shunts unilateral/bilateral, chemosis, ant segment ischemiaRadiology Intra/extraconal mass, Tubular enlargment, Ophthslmic veins, poorly defined hyperdense, ON cavernous sinus sheath enhancement enlargementTx Observation, surgery Conservative, surgery Page 26 Proptosis radiotherapy, surgery in Adults Mar 25, 2013
    27. 27. THYROTOXICOSIS• Autoimmune disorder• 3rd – 4th decade, F > M• 25-30% pts present TED – Females 5 times more affected• Inflammation of EOM• Inflammatory cellular infiltration Page 27 Proptosis in Adults Mar 25, 2013
    28. 28. Clinical manifestations• Soft tissue involvement• Lid retraction• Proptosis• Optic neuropathy• Restrictive myopathy Page 28 Proptosis in Adults Mar 25, 2013
    29. 29. Proptosis in TED• Axial• Unilateral/bilateral• Symmetrical/asymmetrical• Complications – Exposure keratopathy – Corneal ulceration – Infection – Compressional optic neuropathy Page 29 Proptosis in Adults Mar 25, 2013
    30. 30. Page 30 Proptosis in Adults Mar 25, 2013
    31. 31. Work-up• Complete Hx – Known thyroid disease – Smoking – Visual changes• Examination• CT orbit• Visual fields / Hess chart• Thyroid function tests Page 31 Proptosis in Adults Mar 25, 2013
    32. 32. Treatment of Proptosis• General – Lubricants – Taping eyelids – Cold compresses Page 32 Proptosis in Adults Mar 25, 2013
    33. 33. Systemic steroids• Oral prednisolone = 60-80mg/day – Tapered over 2-8 weeks• Intravenous methylprednisolone – 0.5g/200ml isotonic saline infusion – 30 min Page 33 Proptosis in Adults Mar 25, 2013
    34. 34. • Radiotherapy – Alone or with steroids• Combined therapy – Radiations + Azathioprine + steroids• Surgical decompression Page 34 Proptosis in Adults Mar 25, 2013
    35. 35. PSEUDOTUMOR• Idiopathic orbital inflammatory disease• Non-infectious, non-Neoplastic• May involve any of soft orbital tissue – Muscles – Lacrimal gland – Tenon capsule – sclera Page 35 Proptosis in Adults Mar 25, 2013
    36. 36. Presentation• Unilateral – adults, may be bilateral – children• 3rd – 6th decade• Acute• Painful• Periorbital swelling• Redness/chemosis Page 36 Proptosis in Adults Mar 25, 2013
    37. 37. • Congestive Proptosis• Ophthalmoplegia• Optic nerve dysfunction• Palpable mass Page 37 Proptosis in Adults Mar 25, 2013
    38. 38. Page 38 Proptosis in Adults Mar 25, 2013
    39. 39. Work-up• Hx• Examination• CT orbit – Ring sign (contrast)• Biopsy – FNAC • In persistent cases Page 39 Proptosis in Adults Mar 25, 2013
    40. 40. Course• Spontaneous remission• Intermittent episodes• Prolonged inflammation – Fibrosis• Frozen orbit – Ophthalmoplegia – Ptosis – Visual impairment Page 40 Proptosis in Adults Mar 25, 2013
    41. 41. Treatment• Observation• Oral NSAIDs• Systemic steroids – Oral prednisolone = 60-80mg/day• Radiotherapy – If no response to steroids Page 41 Proptosis in Adults Mar 25, 2013
    42. 42. • Anti metabolites – If resistant to steroids and radiations • Methotrexate • Mycophenolate mofetil• Systemic infliximab Page 42 Proptosis in Adults Mar 25, 2013
    43. 43. CAVERNOUS HEMANGIOMA• Most common intraorbital tumor of adults• 3rd to 5th decade• Mostly unilateral• Incidence = 4.3% among orbital neoplasms 1• No ethnic/racial predilection• F:M = 7:32 but 8:71 also reported1. Henderson GW. Vascular hamartomas, hyperplasias, and neoplasms. In: Henderson GW, ed.  Orbital Tumors. New York: Raven Press; 1994:94-100.2. Harris GJ, Jakobiec FA. Cavernous hemangioma of the orbit: a clinicopathologic analysis of sixty-six cases. In: Jakobiec, ed. Ocular and Adnexal Tumors. Birmingham, Ala: 1978:741-81. Page 43 Proptosis in Adults Mar 25, 2013
    44. 44. • Pathophysiology – Benign, slowly growing vascular lesions – Increase intraorbital volume to cause proptosis• Morbidity – Compressive optic neuropathy – Extraocular muscle dysfunction – Cosmetic disfigurement – Death from bleeding during surgical removal Page 44 Proptosis in Adults Mar 25, 2013
    45. 45. Presentation• Middle aged• Slowly growing unilateral axial proptosis• Decrease in VA• Diplopia• Rarely gaze evoked amaurosis fugax• May be accelerated by pregnancy Page 45 Proptosis in Adults Mar 25, 2013
    46. 46. Signs• Dilated & tortuous epibulbar vessels• Other defects – Color vision – Visual field – RAPD• Fundus – Optic disc edema & choroidal folds Page 46 Proptosis in Adults Mar 25, 2013
    47. 47. Work-up CT – Well circumscribed, round or oval isointense mass – Usually in lateral part of muscle cone USG – High echogenecity on A-scan...reflect septae within the lesionPage 47 Proptosis in Adults Mar 25, 2013
    48. 48. Page 48 Proptosis in Adults Mar 25, 2013
    49. 49. Treatment Surgical• En-bloc removal• Approach • Lateral orbitotomy…lateral lesions • upper eyelid or a transcaruncular-based medial orbitotomy…medial aspect lesions Page 49 Proptosis in Adults Mar 25, 2013
    50. 50. Page 50 Proptosis in Adults Mar 25, 2013
    51. 51. CAROTID-CAVERNOUS FISTULA• An abnormal communication btw cavernous and external or internal carotid arteries• Classification – Etiology • Traumatic vs. spontaneous – Hemodynamics • High vs. low velocity – Anatomy • Direct vs. indirect (dural) Page 51 Proptosis in Adults Mar 25, 2013
    52. 52. Page 52 Proptosis in Adults Mar 25, 2013
    53. 53. Direct carotid-cavernous fistula• 70-90% of all cases• Communication btw intracavernous part of ICA & cavernous sinus• High arterial blood flow• Causes – Spontaneous…25% • Middle aged woman, atherosclerosis, HTN, pregnancy • Collagen vascular disease, Connective tissue disorders – Trauma (basal or facial skull fracture)…75% – Iatrogenic Page 53 Proptosis in Adults Mar 25, 2013
    54. 54. Indirect carotid-cavernous fistula• Communication btw cavernous sinus & meningeal branches of ICA and/or ECA• Low arterial blood flow• Causes – Spontaneous – Congenital AV-malformations Page 54 Proptosis in Adults Mar 25, 2013
    55. 55. Presentation• Days or weeks after head injury• Hx of surgery or systemic factors – Triad • Pulsatile proptosis • Chemosis • Whooshing noise in head – Decreased vision – Diplopia Page 55 Proptosis in Adults Mar 25, 2013
    56. 56. • Epibulbar injection• Ptosis• Pulsatile proptosis with bruit• Increased IOP• Anterior segment ischemia • Corneal edema • Aqueous flare • Iris atrophy • Rubeosis iridis • Cataract Page 56 Proptosis in Adults Mar 25, 2013
    57. 57. Page 57 Proptosis in Adults Mar 25, 2013
    58. 58. Page 58 Proptosis in Adults Mar 25, 2013
    59. 59. Page 59 Proptosis in Adults Mar 25, 2013
    60. 60. • Exposure keratopathy• Ophthalmoplegia• Fundus changes – Optic disc swelling – Venous dilatation – Intraretinal hemorrhages – CRVO – Ischemic optic neuropathy – NVG Page 60 Proptosis in Adults Mar 25, 2013
    61. 61. Page 61 Proptosis in Adults Mar 25, 2013
    62. 62. Work-up• CT, MRI & Orbital echo – Enlargement of EOM – Dilation of one or both superior ophthalmic veins – Enlargement of the affected cavernous sinus• Arterial Angiography – Definite diagnosis Page 62 Proptosis in Adults Mar 25, 2013
    63. 63. Treatment Medical• Exposure keratopathy• Glaucoma• NVG Page 63 Proptosis in Adults Mar 25, 2013
    64. 64. Surgery• Indication – Post traumatic fistula – Failure to spontaneous closure• Procedures – Surgical repair of the damaged portion of the intracavernous internal carotid artery – Electrothrombosis, Embolization, or Balloon occlusion of the fistula Page 64 Proptosis in Adults Mar 25, 2013
    65. 65. OPTIC NERVE SHEATH MENINGIOMA• Arise from meningiothelial cells of arachnoid villi, hence attached to dura mater• Primary ONSM – Intraorbital or intracanalicular portion or ON – Less common• Secondary ONSM – Extension of intracranial meningioma into orbit – More common Page 65 Proptosis in Adults Mar 25, 2013
    66. 66. Presentation• Age…6th-8th decade• F>M• Chronic, painless, progressive visual impairment• Usually accompanied by proptosis• Mostly unilateral• Headache• Double vision Page 66 Proptosis in Adults Mar 25, 2013
    67. 67. Signs• Classic triad – visual loss – optic atrophy – optociliary shunt vessels (30%)• Restrictive motility defect *• Axial proptosis Sibony PA, Krauss HR, Kennerdell JS, Maroon JC, Slamovits TL. Optic nerve sheath meningiomas. Clinical manifestations. Ophthalmology. Nov 1984;91(11):1313-26 Page 67 Proptosis in Adults Mar 25, 2013
    68. 68. Page 68 Proptosis in Adults Mar 25, 2013
    69. 69. Page 69 Proptosis in Adults Mar 25, 2013
    70. 70. Work-up• CT scan (with contrast) – Fusiform appearance of ON – Mostly at orbital apex – Calcifications usually seen – Bony involvement• MRI – Clearly show small tumors – Intraorbital extension of intracranial meningioma easily detected Page 70 Proptosis in Adults Mar 25, 2013
    71. 71. Page 71 Proptosis in Adults Mar 25, 2013
    72. 72. Treatment• Observation – No intracranial extension and no vision loss Medical• Radiotherapy – Primary radiation – Radiation after surgery Page 72 Proptosis in Adults Mar 25, 2013
    73. 73. Chemotherarpy• Unresectable, recurrent, or previously irradiated• Combinations – 5-fluroouracil, folate, and levamisole – intra-arterial cisplatin with intravenous doxorubicin – Adriamycin and dacarbazine – ifosfamide and mesna Surgery• Surgical excision Page 73 Proptosis in Adults Mar 25, 2013
    74. 74. Page 74 Proptosis in Adults Mar 25, 2013
    75. 75. PROPTOSIS Hx Middle-aged woman Rapid onset Proptosis Unilateral/bilateral Slow growing Motility problems Lid retraction/lag Retropulsion Orbital pain Heat intolerance Axial Proptosis Diplopia Woman…20-40yrs Increased hyperopia Primary tumor Thyroid bruit/enlarged Unilateral (lung, breast) ORBITAL METASTATICTHYROID EYE DISEASE CAVERNOUS HEMANGIOMA TUMOR Page 75 Proptosis in Adults Mar 25, 2013
    76. 76. PROPTOSISOrbital inflammation Hx of traumaSudden onset/chronic Severe conjunctivalAdults/children chemosisProminent red eye Pulsatile ProptosisPain/Diplopia Orbital bruitTrigeminal involvementORBITAL PSEUDOTUMOR AV MALFORMATION Page 76 Proptosis in Adults Mar 25, 2013
    77. 77. TAKE HOME MESSAGE• Proptosis is alarming condition• Localized or systemic cause• Proper approach• Thorough Hx & investigation• Proper management Page 77 Proptosis in Adults Mar 25, 2013
    78. 78. Page 78 Proptosis in Adults Mar 25, 2013
    79. 79. MCQs1. Features of carotid-cavernous fistula include: a. dilated superior ophthalmic vein on CT scan  b. blood in the Schlemmns canal  c. Proptosis of contra lateral eye suggests bilateral carotid- cavernous fistula  d. dural fistula is the commonest type seen following head injury  e. traumatic fistula rarely close spontaneouslya. T    b. T    c. F    d. F    e. T Page 79 Proptosis in Adults Mar 25, 2013
    80. 80. 2. A forty-eight year old woman presents with a several month history of slowly progressive, painless Proptosis and blurred vision in the left eye. She is otherwise healthy. Her examination was notable for choroidal folds OSPage 80 Proptosis in Adults Mar 25, 2013
    81. 81. a. Findings on the scan ?Ans. Well-defined, round, intraconal massb. What is probable Dx of the scan ?Ans. Cavernous hemangioma Page 81 Proptosis in Adults Mar 25, 2013
    82. 82. 3. This is the orbital CT of a man with painless progressive Proptosis OS Page 82 Proptosis in Adults Mar 25, 2013
    83. 83. a. Findings on the scan?Ans. Enlargement of muscles without involvement of the tendinous portionb. What is your diagnosis?Ans. Thyroid ophthalmopathy Page 83 Proptosis in Adults Mar 25, 2013
    84. 84. 4. 54 year old man with 4 days of progressively worsening pain and swelling around the right eye. Page 84 Proptosis in Adults Mar 25, 2013
    85. 85. Q. What is the differential diagnosis?Ans. Preseptal cellulitis orbital cellulitis pseudotumor malignancy trauma Page 85 Proptosis in Adults Mar 25, 2013
    86. 86. 5. A 30 year old woman noticed mild Proptosis which accelerated during her pregnancy. Lesion caused hyperopia & retinal striae. CT showed well defined mass. Most probable Dx is:a. Metastatic breast carcinomab. Cavernous hemangiomac. Thyroid related orbitopathyd. PseudotumorAns. b Page 86 Proptosis in Adults Mar 25, 2013
    87. 87. NEXT Lecture• Dr. Yousaf Jamal – Proptosis in children Journal club• Dr. Naeem KTK Mar 25, 2013

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