Causes of proptosis

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