Child proptosis

1. APPROACH
TO
A CASE OF
CHILD PROPTOSIS

2. APPROACH
TO
A CASE OF
CHILD PROPTOSIS
Presented by-
Dr. Kawshik Nag Dr. Sabiha Siraj Mohua
MS Resident (Ophthalmology) Phase A
Chattogram Medical College
Placement: Dept. of Paediatric Haemato-oncology

3. PROPTOSIS

4. Proptosis
• Forward protrusion of the eyeball beyond the orbital margin is
called proptosis.
• Readings greater than 20 mm are indicative of proptosis and a
difference of 2–3 mm or more between the two eyes is suspicious
regardless of the absolute values.

5. Proptosis or Exophthalmos?
• Exophthalmos means
– an active or dynamic protrusion of the eyeball (usually bilateral).
– Classically seen in thyroid ophthalmopathy.
• Proptosis means
– a passive protrusion of the eyeball,
– classically seen in space occupying lesion in the orbit (usually unilateral).

6. Why optic nerve is not tear off?
• The intraorbital portion of the optic
nerve is longer (25 mm) than the
distance between the back of the globe
and the optic canal (18 mm).
• This allows for significant forward
displacement of the globe (proptosis)
without excessive stretching of the
nerve.

7. Pseudoproptosis
The false impression of proptosis may be due to -
– facial asymmetry,
– enlargement of the globe (e.g. high myopia or buphthalmos),
– lid retraction or
– contralateral enophthalmos.

8. Left proptosis visualized from above

9. Causes of Proptosis
Inflammatory Orbital Cellulitis
Neoplastic Lymphoma, Rhabdomyosarcoma,
Retinoblastoma
Metastatic Acute Meloid Leukaemia, Neuroblastoma

10. Approach
History Ocular
examination
Systemic
examination
Investigations Treatment

11. History
• Protrusion of eyeball -
– Age of Onset ,
– duration , progression (Acute – hours to days, Chronic – months to
years)
– Pain,
• Decreased vision – preceded/followed
• Associated field defects

12. History
• 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.

13. Ocular examination
• Visual acuity,
• Refraction,
• IOP,
• Eyelids,
• Conjunctiva,
• Cornea,
• Iris,
• Fundus,
• Pupil,
• Ocular motility.

14. Ocular examination
• Local examination of mass:
– Inspection:
• Proptosis or
pseudoproptosis
• Unilateral or Bilateral
– Palpation:
• Size,
• Shape,
• Surface,
• Margin,
• Consistency,
• Tenderness,
• Compressibility,
• Skin over the lesion.
• Insiunated between mass
and orbital rim.

15. Measurments of proptosis
– Asymmetry > 2mm or more between the eyes. (Asymmetrical
proptosis)
– Or, Readings greater than 20 mm are indicative of proptosis.
 Clinical methods for measurement:
– Plastic ruler,
– Luedde’s exophthalmometer,
– Hertel’s exophthalmometer,
– Naugle’s exophthalmomter.

16. Plastic ruler
• can measure proptosis from the lateral orbital rim to the corneal apex
holding the ruler parallel to ground.

17. Luedde’s exophthalmometer
Advantages:
- Notch confirms to lateral orbital
rim.
- The scale starts from tip of
instrument,where the notch
meets the
lateral orbital rim.

18. Hertel’s exophthalmometer
• It may use prisms or mirrors set at 45 degree angles.
• It is best for serial follow up of patients.

19. Naugle’s exophthalmomter
• In case of acquired or congential asymmetry of the lateral orbital rims a
Hertel exophthalmometer is misleading.

20. Quick clinical assessment
Worm’s eye view Bird's eye view (Naffziger’s sign)

21. Systemic examination
• Primary tumors elsewhere in the body – CVS / RS / Abdomen / PV / Rectal
• ENT examination

22. Investigations

23. A. Laboratory investigations:
• Hematological - CBC , ESR, VDRL
• Thyroid function tests
• Serum ANA , c- ANCA , ACE
• BUN , Creatinine
• Casonis test – r/o hydatid cyst
• Stool examination – cysts /ova
• Urine analysis – bence jones proteins - MM

24. B. Imaging Technique
Non-invasive techniques:
1. Plain X-rays.
2. Computed tomography scanning
3. Ultrasonography
4. Magnetic resonance imaging (MRI).
Invasive procedures:
1. Orbital venography
2. Carotid angiography.
3. Radioisotope studies.

25. C. Histopathological studies
1. Fine-needle aspiration biopsy (FNAB).
2. Incisional biopsy.
3. Excisional biopsy.

26. Differentiating Ocular Features

27. ORBITAL CELLULITIS RHABDOMYOSARCOMA LYMPHOMA
 H/O lid trauma, sinus
diseases,
 Pain,
 Unilateral,
 Lid edema with reddish
color,
 Fast progressing proptosis,
 Fever,
 VA impaired,
 Ophthalmoplegia/restricted
motility.
 H/O nose bleeds,
 Pain,
 Unilateral,
 Rapid onset,
 Swollen bluish lids,
 Ptosis,
 Chemosis,
 Cervical lymph node
involvement.
 Painless,
 Bilateral proptosis,
 Rubbury palpable
mass,
 Adnexal
involvement.

28. NEUROBLASTOMA RETINOBLASTOMA LEUKAEMIA
 Orbital metastesis with
periorbital ecchymosis (Racoon
eyes),
 Proptosis,
 Palpable supraorbital masses,
 Lid edema,
 Ptosis,
 Opsoclonus (dancing eye
syndrome),
 Anisocoria,
 Heterochromia iridis.
 Leukocoria (white
puipillary reflex),
 Strabismus,
 Decrease VA,
 Inflammatory changes,
 Hyphema,
 VH resulting black
pupil.
 Proptosis,
 Lid swelling,
 Ecchymosis,
 If optic nerve
involves -
Papilloedema, Loss
of vision

29. Racoon eyes leukocoria
Conjunctival Chemosis

30. Optic disc edema Optic disc pallor