This document discusses proptosis (forward displacement of the eyeball), its causes, signs, symptoms, and evaluation. Proptosis can be unilateral or bilateral, acute or intermittent. It may be caused by congenital defects, trauma, infections, vascular lesions, cysts, tumors, or endocrine disorders like Graves' disease. Evaluation involves inspection, palpation, tests of eye movement and vision, exophthalmometry to measure protrusion, and diagnostic imaging or biopsy when indicated based on suspected etiology.

1. By Peter C Roy
2009 batch

2. Forward displacement of eyeball beyond
the orbital margins.
Exophthalmos is synonymous, but is
usually used for the displacement
associated with thyroid disease.

3. Unilateral Proptosis
Bilateral Proptosis
Acute Proptosis
Intermittebt Proptosis
Pulsation Proptosis

4.  Congenital:
• Dermoid cyst
• Congenital cystic eyeball
• Orbital teratoma
 Traumatic:
• Orbital haemorrhage
• Retained intraorbital Foreign Body
• Traumatic aneurysm
• Emphysema of orbit

5.  Inflammatory Lesions
• Acute:
 Orbital cellulitis
 Abscess
 Panophthalmitis
 Thrombophlebitis
 Cavernous sinus thrombosis
• Chronic:
 Pseudotumours
 Tuberculoma
 Gumma
 Sarcoidosis

6.  Circulatory disturbances and vascular
lesions:
• Angioneurotic edema
• Orbital varix
• Aneurysms
 Cysts of orbit
• Hematic cyst
• Implantation cyst
• Parasitic cyst
 Tumors: primary, secondary, metastatic
 Mucoceles of frontal, ethmoidal, maxillary
sinuses

7. Orbitopalpebral cyst
Preseptal cellulitis
Pseudotumours of right orbit

8.  Developmental anomalies of skull
• Craniofacial dysostosis
eg. Oxycephaly (tower skull)
 Osteopathies
• Osteitis deformans
• Rickets
• Acromegaly.
 Inflammatory condition
• Mikulicz’s syndrome (enlarged lacrimal and parotid
glands caused by infiltration with lymphocytes)
• Late stage of cavernous sinus thrombosis.

9.  Endocrinal exophthalmos
• Thyrotoxic or thyrotropic.
 Tumours
• Symmetrical lymphoma or
• Lymphosarcoma
• Secondaries from Neuroblastoma
• Ewing’s sarcoma
• Leukemic infiltration.
 Systemic diseases
• Histiocytosis
• Systemic Amyloidosis
• Wegener’s Granulomatosis

10. Graves ophthalmopathy with
bilateral exophthalmos and lid
retraction
Oxycephaly

11. Develops with extremely sudden onset
Common causes are
• Orbital emphysema
• Fracture of medial orbital wall
• Orbital hemorrhage
• Rupture of ethmoidal mucocele

12.  Appears and disappears on its own.
 Common causes are
• Periodic orbital oedema
• Orbital varix
• Reccurent orbital haemorrhage
• Highly vascular tumours

13.  Causes:
• Pulsating vascular lesions like Caroticocavernous
fistula and saccular aneurysms of ophthalmic
artery.
• Also by transmitted cerebral pulsations
associated with deficiency of orbital roof. These
include congenital meningocele or
meningoencephalocele, neurofibromatosis,
traumatic or operative hiatus

14. One eye may look to be larger than the
other eye
Causes
• Unilateral high axial myopia
• Unilateral buphthalmos
• Pseudocornea or anterior staphyloma
• Retraction of eyelid of one eye
• Enophthalmos of opposite eye

15. Pseudocornea RE
Myopia RE
Buphthalmos LE

16. Local Examination
Inspection - to diff proptosis and
pseudoproptosis, if proptosis is unilateral or
bilateral, to note the shape of the skull
Palpation – swellings, regional lymph nodes,
orbital rim
 Auscultation – to know abnormal vascular
communications like caroticocavernous fistula
 Transillumination
 Visual acuity – may decrease due to pressure
in the back of the eyeball, optic nerve
compression, exposure keratopathy

17. Pupil reactions
Fundoscopy – venous engorgement,
hemorrage, disc edema
Occular motility – decreased in thyroid
ophthalmopathy
Exophthalmometry –
• Measures the protrusion of the apex of the cornea
from the from outer orbital margin
• Normal – 10 to 21 mm, symmetrical in both eyes
• Difference of more than 2 mm is significant

18. Luedde’s Exophthalmometer
Hertel’s Exophthalmometer
(can measure both eyes
simultaneously)

19. Systemic Examination
Laboratory investigations
• thyroid function test
• haematological studies
• Casoni’s test
• Stool examination for ova and cysts
• Urine analysis for bence jones proteins
Imaging techniques
• Non-invasive – Plain X rays, Compted
tomography scanning, Ultrasonography, MRI
• Invasive – Not done

20. Histopathological studies
• Fine needle aspiration biopsy
• Incisional biopsy
• Excitional biopsy