3. An abnormal protrusion of one or both eye balls
Anterior displacement of globe by >21mm from lateral orbital
rim
>2mm difference between apex of cornea between two eyes
3
32. Retrodisplacement of globe
Pulsation of globe
Thrill
Palpation of orbital rim
Palpation of anterior orbital mass
Regional lymph nodes
Paranasal sinuses
33
46. Plain X-rays
Enlargement of orbital cavity
Calcification, hyperostosis
Computed tomography
Shape, location, extent and character of lesions in orbit
Measurement of proptosis
49
47. Ultrasonography
Usually differentiate between solid, cystic, infiltrative and spongy
masses
Lesions of posterior orbit cannot be viewed
50
48. Magnetic Resonance Imaging
Provides more soft tissue detail
Better technique for orbitocranial junction or intracranial imaging
51
49. Orbital Venography
Definitive diagnostic study in evaluation of intermittent proptosis
Carotid Angiography
Pulsating proptosis with bruit or thrill
52
Upper limit for Caucasians and Asians is 21mm, African and americans – 24mm
ExophthalmosProptosis due to endocrine cause
Exorbitism:Decrease in volume of orbit causing orbital contents to protrude forwards
Dystopia: Displacement of globe in coronal plane
False impression of proptosis
Shallow orbit seen in craniosynostosis
Acute: several minutes to days :orbital hematoma, ruptured dermoid ,orbital cellulitis ,orbital emphysema
Subacute : period of weeks ;orbital inflammatory disease thyroid orbitopathy
Chronic: more insidious onset over several months :benign tumors
Globe is protruded forward in line of orbital axis ,Axial – globe is pushed forward by mass just behind eyeball ,lesion most likely present in intraconal space
Metastasis involving intraconal space
If globe is pushed downward and inward- lesion is in superotemporal quardrant - lacrimal gland tumor
If globe is pushed downward and outward- lesion is in superonasal quadrand-child-m/c location of rhabdomyosarcoma in adult- mucocele- can be mucocele or frontoethmoidal mucocele
If globe is pushed up and lateral- lesion is in infero medial quardrant- lesion involving lacrimal sac
Congenital-dermoid, teratoma traumatic-orbital hematoma IOFB, inflammaroty-inflammation of orbital tissue, lacrimal gland, whole globe(panophthalmitis) tb Tomors-rhabdomyosarcoma, lymphangioma hemangioma, optic nerve glioma
Congenital lesions like craniosynostotis, cephalocele, microphthalmia with cyst, teratoma
Child born with proptosis- m/c teratoma , cystic eyeball
Metastasis –metastatic neuroblastoma
Tumors extending from adjacent areas-lacrimal gland, sinuses , lids metastasis from breast lung prostate CA
Ocular history medical history family history
Ocular examination- inspection palpation auscultation and measurement of proptosis
Onset- sudden onset or gradual onset
Course whether it is stationary or gradually progressing
Progression it is acute or chronic
Pain either bcoz of infection or inflammation or tumor with perineural invasion esp lacrimal gland tumor , diplopia-either muscle is affected or nerve supplying muscle is affected. Reduction of vision-either lesion is involving optic nerve or compressing optic nerve or lesion itself causing retinal choroidal changes
In general we need to ask about medical history in all case not only in proptosis. In proptosis we specifically ask abt thyroid dzs-thyroid eye disease in hyper is hypo, if old age pt with history of diabetes comes with sudden onset of proptosis- mucoromycosis,TB-it can cause orbital inflammation-m/c tissue involved in TB is lacrimal gland,sarcoidosis-B/l lacrimal gland involvement. Neurofibromatosis if pt is aware- optic nerve glioma, infiltration of orbital tissue by neurofibromatous tissue, systematic cancer- d/t metastasis
If mother has thyroid dzs it can transmit to child, neurofibromatosis
Certain cancer can be hereditary eg breast cancer ovary cancer
Facial asymmetry in cranialdystosia neurofibromatosis
Globe displacement ll give a clue where lesion is arising from
Pulsating proptosis occurs in direct pulsation d/t highly vascular tumor ortransmitted pulsation of csf pulsation in neurofibromatosis absence of greater wing of sphenoid , in trauma
Positional proptosis in Valsalva in orbital varices,pt comes with h/o proptosis apparent while bending forward
Color of lesion if it is visible- hemangioa- red color lymphangioma-blue colour
Surrounding area-red inflamed suggest infectious cause
Ecchymosis- h/o trauma
If no h/o trauma-suspect metastatic neuroblastoma
Localized hyperemia-gives clue where lesion is present
Salmon colored patch-indicative of orbital lymphoma
Cockscrew vessel-caroticocavernous fistula, gives h/o trauma with this vessels
In proptosis they are risk of developing exposure keratitis
Stain-SPK in inferior quardrand
Young pt with PUK with proptosis associated with autoimmune disease-Wegener granulomatosis
Lynch nodules: gives clue for neurofibromatosis
Presence of RAPD with proptosis – either lesion is involving optic nerve or causing compression of optic nerve
Ask pt to close eyes and place a thumb n press on globe and feel if there is resistance or no resistance, resistance-solid mass, no resistance-vascular mass
Pulsation occur in caroticocavernous fistula –thrill can be +, if highly vascular tumor ,palpate orbital rim-if tenderness- infection or inflammation, irregular curvature- malignant lesion, preauricular submandibular cervical nodes
Ausculation is important in caroticocavernous fistula , bell of stethoscope , with bruit- carotid cavernous fistula,orbital AV malformation . Without bruit-neurofibromatosis,meningoencephalocele
Patient is asked to tilt head back and examiner looks up from below
Examiner stands behind the patient, patient head is slightly tilted backward, and examiner sees from back, normally eyes are seen jst at level of orbital rim, if eye protusion is seen proptosis
Ruler is placed in front of the eye and the space between the eye and the ruler is noted
It is transparent plastic ruler which is thicker than normal ruler it is placed on lateral orbital wall and protusiion is measured
It is used to determined the axial position of eyes , placed on lateral orbital rim on each side, pt is asked to dlook at center of examiners forehead
Measure pt left eye with examiners rt eye and vice versa
Find the position fo corneal apex in mm in prism
Uses frontal and maxillary bone as references , useful in fracture patients when lateral canthus has been displaced
Periorbital changes- look for lid changes- s shaped lid-plexiform neurofibroma, eczematous lesion-mycosis fugoids –lid swelling ,conjunctival changes-salmon color mass-orbital lymphoma, crockscrew vessels caroticocavernous fistula
Tonometry-imp in TED,measure IOP in primary gaze and ask pt to look upgaze and again measure IOP and measure the difference in IOP between straight gaze and upgaze if difference is <6mm-non significant- indicates neurological lesion if >6mm of hg- positive seen in TED d/t IR muscle restriction- Braley’s sign
Forced duction test-to determine whether the absence of eye movement is d/t neurological or mechanical cause
Thyroid disease- dry skin ,examine thyoid gland for enlargement
Features of tb-cachexic papable lymph node
Café au lait spots ,
TC DC HB ESR,ANA- autoimmune disease, C-anca- wegenrer granulomatosis, ACE- sarcoidosis
Casonis to r/o hydatid cyst
Stool –cysts/ova
Urine –bence jones protein-MM
Choice of imaging should be based on clinical presentation and the specific pathology being suspected
Plane of scan should be parallel to plane passing thro opticnerve head and lens with eyelids open and pt looking st ahead, interzygomatic line is drawn first,st line connecting ant margin of zygomatic processes. Distance from posterior sclera margin to IZL is measured- 9.9+-1.7mm.
MRI doenst employ isonizing radiation and has no known adverse biological effects
Carotid angiography in aneurysms/ AV malformations
Exact diagnosis of many orbital lesions cannot be made without help of histopathological studies, FNAC-samples are collected using thin hole needles
Incisional biopsy –a piece of tissue is removed from a mass, excisional biopsy –whole lesion or mass is removed