2. PROPTOSIS
• Forward displacement of the eyeball beyond orbital
margins due to a mass/increased orbital contents .
• Proptosis >21 mm or asymmetry of >2 mm
between 2 eyes : abnormal.
• Exophthalmos: specifically describes proptosis
associated with thyroid eye disease (TED).
• Exorbitism: decrease in the volume of orbit
b/l.orbital contents to protrude forwards.
• Pseudoproptosis:apparent protrusion of eyeball
without increase in any orbital contents or mass.
• causes: Buphthalmos High myopia
: C/l ptosis C/l enophthalmos
4. ANATOMY OF ORBIT
• pear shaped, tapers posteriorly at optic canal.
• Volume of orbit :30 ml.
• 4 walls of 7 bones: ethmoid, frontal, lacrimal,
maxillary,palatine, sphenoid and zygomatic.
• Medial orbital walls are approximately parallel ,
separated by 25 mm.
• Lateral orbital walls angle about 90 degrees from
each other
• The widest dimension :1 cm behind the anterior
orbital rim.
• The thinnest bone is in the medial wall (lamina
papyracea) adjacent to the ethmoid air cells.
5. • Relationship of orbit & PNS :By its location & venous
drainage .
• orbital venous drainage :devoid of valves – two way
communication between orbit and sinuses.
• Roof :anterior cranial fossa & frontal sinus above.
• Medial wall : adjacent nasal cavity, ethmoid &
posterior sphenoid sinus.
• Floor :The maxillary antrum beneath .
• Lateral wall :adjacent to middle cranial ,temporal &
pterygopalatine fossa.
RELATIONS OF ORBITAL WALL
6. CLINICAL ASPECTS
• Ethmoidal sinusitis can breach lamina papyracea &
spread into the orbit.
• The floor is thin medially -> fragmentation in “blow
out” fractures.
• Lacrimal bone at the level of lacrimal fossa is very
thin-> easy penetration during endoscopic DCR. if
maxillary component is predominant ,difficult to
breach the bone in endoscopic DCR.
• Webers suture:Lying anterior to lacrimal fossa has
Infraorbital artery branches pass through it.
Bleeding during lacrimal sac sx.
• Traumatic Optic Neuropathy :indirect injury to optic
canal & direct injury by bony fragments in canal.
21. HISTORY
• Age of Onset , duration , progression
• Constant or intermittent
• Variation with posture
• Decreased vision – b4/after
• Stationary/progressive
• Associated field defects
• Pain
• Double vision
• Periorbital neurosensory loss
• bruits
• symptoms aggravated by crying,coughing,straining,
nose blowing?
• Past h/o : Trauma,fever, chills ,cancer, thyroid d/s ,
TB , DM ,HTN ,HIV , Syphilis, Old photographs
22. HEMORRHAGE INTO A LYMPHANGIOMA
• A sudden dramatic proptosis with conjunctival prolapse in a child with recent
URTI
GAZE-EVOKED AMAUROSIS
• may be associated with an orbital apex tumor.
MALIGNANT LESION (adenoid cystic carcinoma)
• Pain associated with a short history of a mass in the region of lacrimal gland.
• Periorbital neurosensory loss in the absence of trauma
BENIGN LESION (pleomorphic adenoma)
• a gradually progressive painless mass in the region of the lacrimal gland.
ARTERIOVENOUS SHUNT
• history of “tinnitus”
ORBITAL VARICES
• Proptosis provoked by straining may suggest.
AMYLOIDOSIS
• spontaneous unilateral periorbital bruising in an adult may suggest.
NEUROBLASTOMA
• bilateral bruising in a child
SCIRRHOUS ORBITAL METASTASIS.
• Acquired exophthalmos in a female patient with a past history of breast
carcinoma
23. GENERAL PHYSICAL EXAMINATION
• Skin and oropharynx
cutaneous /intraoral vascular lesions: lymphangioma
café au lait spots :neurofibromatosis.
• Cranial Nerve Examination:
periorbital and corneal sensation.
• Examination of Chest and Abdomen:
systemic malignancy: undiagnosed ca breast
• The regional/ distant/ generalized lymphadenopathy
lymphoproliferative disorder.
24. OCULAR EXAMINATION
• Visual acuity, Refraction, visual fields, colour vision.
• Facial asymmetry,Head posture,Lid retraction/ptosis
• ocular alignment,Extraocular movements
• Examination of the anterior segment including pupil.
• INSPECTION:
• examiner looks from above standing behind patient/looks
up from below with the patient’s head tilted back
1]Type of proptosis (axial / non-axial),location of mass,
visible pulsation, skin changes.
2] Lagophthalmos,conjunctival congestion/discolouration.
3] Corneal exposure, change in size with valsalva.
4] examination of the globe and ocular adnexa
* Dilated episcleral vessels: arteriovenous shunt.
25. *A “salmon patch” lesion beneath the upper eyelid:
orbital lymphoma, amyloidosis, sarcoidosis, leukemia,
lymphoid hyperplasia, rhabdomyosarcoma.
*Eversion of the upper eyelid ->waxy yellow
infiltrate with tortuous vessels : amyloid lesion.
*S-shaped deformity of upper eyelid : plexiform NF.
PALPATION :
1] Size, shape, surface, margins,consistency.
2] Signs of inflammation, tenderness, reducibility,motility.
3] Variation with valsalva, resistance to retropulsion,Thrill.
4] Corneal sensation, infraorbital / supraorbital anesthesia
5] Any swelling around the eyeball, regional lymph nodes
& orbital rim.
AUSCULTATION
abnormal vascular communications -> bruit
caroticocavernous fistula.
29. EXOPHTHALMOMETRY
• Measurement is done from the lateral orbital rim to the anterior
corneal surface.
• A difference >2 mm between eyes ->proptosis.
• Exophthalmometers
Hertel’s exophthalmometer
Luedde scale
Gormaz exophthalmometer.
• Three types
Absolute exophthalmometry - compared with n/l reading (>21mm)
Relative exophthalmometry - relative distance of the 2 corneas from
lateral orbital rim.
Comparative exophthalmometry -exophthalmos of at different times.
30. procedure
1) With closed eyes, locate the orbital notch on the
temporal side of the orbital rim near lateral canthus.
2) grooves placed in the orbital notch. The separation of
exophthalmometer noted
3)The patient told to open their eyes and look straight ahead.
4)Red lines should overlap to avoid the parallax.
5)corneal apex position on the scale noted.
6)From mirrors located at each end findings are recorded in mm.
Limitations
• Poor fixation, depressed /fractured lateral orbital
rim,convergence, parallax errors, head movements affect the
readings.
• separation of the grooved arcs is narrow, readings falsly low.
• separation of grooved arcs too wide :readings falsly high
31.
32. • Ludde’s Exophthalmometer
• Transparent plastic mm ruler which is thicker than
normal ruler.
• Notch conforms to angle of lateral orbital rim.
• Scale readings: 0mm (end of notch) to 40mm.
• Parallax is minimized by using scale on both sides of
the rod.
