1. Proptosis is the abnormal forward displacement of the eyeball. It can be evaluated based on the 6 Ps: pain, progression, proptosis, pulsation, palpation, and periorbital changes. 2. Clinical evaluation involves measuring the degree of proptosis using methods like Hertel's exophthalmometer. Imaging studies like CT and MRI help determine the cause and extent of proptosis. 3. Common causes of proptosis include thyroid eye disease, orbital tumors, infections, vascular lesions, and trauma. The document discusses the clinical anatomy of the orbit and approaches to classify and investigate proptosis.

1. EVALUATION OF
PROPTOSIS
DR. RAKSHYA BASNET
1ST YEAR RESIDENT
NAMS,LEI

2. LAYOUT
• Introduction
• Clinical anatomy of orbit
• Classification of proptosis
• Evaluation of proptosis on basis of THE 6 P’S
• Investigation

3. • anterior displacement of globe by >20 mm from lateral orbital rim
• >2mm difference between apex of cornea of two eyes

4. OTHER TERMS
1.Exophthalmos is a term reserved for proptosis due to endocrine
cause, but it is used interchangeably
2.Exorbitism decrease in volume of orbit : orbital contents to
protrudeforwards

5. 3.Pseudoproptosis
1. Enlarged globe
2. Asymmetric orbital size
3. Asymmetric palpebral fissure
4. Contralateral enophthalmos

6. CLINICAL ANATOMY

7. ORBITALWALLRELATIONS
Roof :anterior cranial fossa& frontal sinus above
Medial wall : adjacent nasal cavity, ethmoid&posterior sphenoid sinus
Lateral wall :adjacent to middle cranial ,temporal&pterygopalatine fossa

8. ORBIT
Below- maxillary sinus
• Relationship of orbit & PNS :By its location &
venous drainage
• orbital venous drainage :devoid of valves –
two way communication between orbit and
sinuses

9. SPACES IN RELATION TO ORBIT
1. subperiosteal
2. Peripheral/extraconal
3. Central/intraconal
4. Sub tenon’s
5. subarachnoid

10. 1.SUBPERIOSTEAL SPACE
 Common tumors in this space are
Dermoid cyst, epidermoid cyst,mucocele,
subperiosteal abscess, myeloma, osteomatous
tumour, haematoma and fibrous dysplasia
 plain x-rays most useful in this space

11. • Common tumors in this space:
malignant lymphoma, capillary hemangioma,
intrinsic neoplasm of lacrimal gland,
pseudotumors
• Produces non-axial proptosis
• Tumors in this space are explored by
anterior orbitotomy
2.Peripheral space

12. • Common tumors include
Cavernous hemangioma of adults,
solitary neurofibroma,
neurilemmomas, nodular orbital
meningiomas, optic nerve gliomas
• Produces axial proptosis
• Tumors in this space explored by
lateral orbitotomy
3.Central space

13. PATHOPHYSIOLOGY
Increase in volume within fixed bony
orbital
contents of the orbit are displaced
anteriorly
(widest area of orbit)
globular protusion of eye ball
Proptosis and Exophthalmos

14. patterns of orbital involvement
1. INFLAMMATORY EFFECT: redness, swelling, pain,
heat, and loss of function
2. MASS EFFECT: Displacement with or without signs
of involvement of sensory or neuromuscular sign

15. 3. VASCULAR CHANGE: venous dilation, pulsation,
expansion with straining (Valsalva) and haemorrhage
4. INFILTRATIVE CHANGE: evidence of destruction,
entrapment, or both

16. CLASSIFICATION
1) Etiological
2) Onset
3) Direction
4) Axiality
5) Laterality
6) Age of onset

17. CLASSIFICATION
1.Etiology
• Inflammatory
• Infectious
• Vascular
• Neoplastic
• Idiopathic

18. 2.Onset
• Acute-several minutes, several hours, or 1 to 2 days
• Subacute-period of weeks
• Chronic-more insidious onset over several months

19. 3.DIRECTION
• POSITIVE-if the lesion occupies space
and pushes orbital structures away
eg-intraconal schwannoma
• NEGATIVE -if it draws structures toward
eg.orbital metastasis of sclerosing carcinoma

20. 4.AXIALITY
--AXIAL
Thyroid eye diseaseOptic nerve glioma
metastasis

21. SUPERIOR
1.Maxillary sinus tumours
Inferiomedial
2.Dermoid cyst
3.Lacrimal gland tumour
Non-axial

22. INFEROLATERAL
•Fronto-ethmoidal mucocele
•abscess
•Sinus carcinomas
•osteomas

23. 5.LATERALITY
• Unilateral Proptosis
1.Congenital
2.Traumatic
3.Inflammatory Lesions
4.Circulatory Disturbances & Vascular Lesions
5.Cysts of orbit:
6.Tumors:
7.Mucocele of PNS:

24. 1. Developmental Anomalies of Skull
2. Osteopathies
3. Inflammatory Conditions
4. Endocrinal Exophthalmos
5. Tumors
6. Systemic Disease
Bilateral proptosis

25. IN CHILDREN
• Unilateral (most common): orbital cellulites
• Bilateral (most common):leukemia, metastatic
neuroblastoma

26. 6.PROPTOSIS : ACCORDING TO AGE
CAUSES IN INFANT
 congenital lesions like craniosynostosis, cephalocele, micropthalmia
with cyst, teratoma,
 retinoblastoma
 capillary hemangioma
 juvenile xantho granuloma
 metastatic neuroblastoma

27. CAUSES IN CHILDREN
• Orbital cellulitis
• Dermoid cyst
• Capillary hemangioma
• Optic nerve glioma
• Rhabdomyosarcoma
• Retinoblastoma
• Leukemia
• Lymphangioma
• Metastasis
– Metastatic
neuroblastoma
– Ewing's sarcoma

28. CAUSES IN ADULTS
• Thyroid Exophthalmos
• Pseudotumor
• Orbital cellulitis
• Trauma
• Meningioma
• Lymphoma
• Histiocytoma
• Cavernous hemangioma
• Osteoma
• Varices
• Carotid-cavernous fistula
• Tumors extending from adjacent areas
– Lacrimal gland
– Sinuses
– lids
• Metastasis

29. 6 P’S
1. Pain
2. Progression
3. Proptosis
4. Pulsation
5. Palpation
6. Periorbital changes

30. 1.PAIN
– Inflammatory disease
– Infectious disease
– Orbital hemorrhage
– Malignant Carcinoma (nasopharyngeal or lacrimal gland)
– Metastatic lesions
The 6 P’s

31. 2.PROGRESSION
THE SIX P’s (Cont. )

32. THE SIX P’S (CONT. )2. PROGRESSION
Abrupt within hours
1. Bleeding in lymphangioma
2. Orbital emphysema
3. Fracture of medial orbital wall
4. Retrobulbar Haemorrhage
5. Traumatic haematoma
6. Ruptured dermoid
7. Rupture of ethmoidal mucocele
1. Orbital emphysema

33. Onset occurring over days to
weeks
• Idiopathic orbital inflammatory disease
• Orbital cellulitis
• Thrombophlebitis
• Rhabdomyosarcoma
• Thyroid ophthalmopathy
• Neuroblastoma
• Metastatic tumour

34. THE SIX P’S (CONT. )
Onset occurring over months to years
• Dermoids
• Benignmixed tumours
• Neurogenic tumours
• Cavernous hemangioma
• Lymphoma
• Fibrous histiocytoma
• Osteoma

35. Intermittent proptosis
• Orbital varices
• Haemangioma
• Carotid Cavernous fistula

36. 3.PROPTOSIS
i.True or pseudoproptosis
ii.Laterality
– Unilateral/bilateral
iii.Direction of displacement
– Axial
– Non-axial
 Lateral
 Inferonasal
 Superior
The 6 P’s

37. PROPTOSIS
Clinically best appreciated by
worm’s eye view
-examiner looks up from below with
patient’s head tilted back
The 6 P’s

38. Nafziger’s Method

39. • patient sits in front of examiner, head slightly drawn
back & looks downwards
• examiner stands behind patient, looks over
patient’s forehead by bending over patient’s head
• examiner raises patient’s upper lids with his index
fingers from sides
• examiner compares position of apex of cornea on
each side
• patient bends his head forward and cornea should disappear
at same time.

40. CLINICAL METHODS FOR MEASUREMENT OF PROPTOSIS:
A) PLASTIC RULER:
can measure
proptosis from the
lateral orbital rim to
corneal apex,holding
ruler parallel to ground

41. B)LUEDDE’S EXOPHTHALMOMETER:
-Transparent plastic mm ruler which is thicker than
normal ruler
- is better than hertel’s if there is facial
asymmetry

42. C)HERTEL’S Exophthalmometry
• Most commonly used
• Three types
Absolute exophthalmometry - compared with n/lreading (>21mm)
Relative exophthalmometry - relative distance of the2 corneas from lateral orbitalrim.
Comparative exophthalmometry -exophthalmos of at different times.

43. Steps of hertel’s exophthalmometry

44. Stepsof Hertel’s exopthalmometer
1. make sure instrument is ready
2. explain patient
3. ask patient to sit in erect position
4. take a seat one arm away from patient and make sure your eyes and
patient’s eyes are at same level
5. ask patient to look at the centre of your forehead
6. place Hertel against lateral walls of patient
7. Measure patient’s left eye with examiner’s right eye
8. move our view so that 2 red lines on prism are are in overlapping
position
9. find the position of corneal apex in millimeter scale in prism
10.record proptosis with base reading

45. Grading:
• Mild : 21 – 23 mm
• Moderate: 24 – 27 mm
• Severe: 28 mm or more

46. D)Naugle’s exophthalmometer:
-Useful in fracture patients when lateral canthus has
been displaced
-uses frontal and maxillary bone as references

47. 4.Pulsation
Causes:
 Pulsating vascular lesions (caroticocavernous fistula)
 saccular aneurysm of ophthalmic artery
 deficient orbital roof (congenital meningocele or meningoencephalocele,
neurofibromatosis, traumatic or operative hiatus)
The 6 P’s contd..

48. Auscultation
• Globe/temporal region for bruit

49. PULSATION
Without bruit
• Neurofibromatosis
• Meningoencephaloceles
• Encephaloceles
• Result of surgical removal of the orbital roof
With bruit
• Carotid cavernous fistula
• Dural arteriovenous fistula
• Orbital arteriovenous fistula

50. 1. Local Temperature
2. Tenderness
3. orbital margins
4. Retropulsion of globe
5. Regional lymph node
6. If mass palpable note
 Position
 Size,surface, attachnents
 Consistency(hard , rubbery, spongy or soft)
 Compressibility/ Reducibility
5.PALPATION
The 6 P’s contd..

51. ORBITAL RIM
• Palpation of orbital rim done to note any changes in
contour or dehiscence of orbital wall....

52. RETROPULSION
• should be estimated by applying equal digital pressure over two eyes,
simultaneously
• best done with examiner’s thumb over closed lids-retroocular
resistance encountered in presence of solid tumors

53. LYMPH NODES
• regional lymph node preauricular lymph node and
metastatic dz. supraclavicular, and cervical nodes.

54. THE SIX P’S (CONT.)
6. PERIORBITAL CHANGES
• S shaped eyelid (plexiform neurofibroma)
• Salmon colored mass in cul-de-sac-lymphoma
• Eyelid retraction and lid lag-TED

55. Ecchymosis of eyelid skin-metastatic neuroblastoma,leukemia,amyloidosis
Eczematous lesions of eyelid-mycosis fungoides
Edematous swelling of lowerlid (meningioma)

56. -Prominent temple –sphenoid wing
meningioma
-corkscrew conjunctival vessels –arteriovenous
fistula

57. D. Other tests
1. Transillumination
2. Visual acuity
3. Pupillary reaction
4. Ocular motility
5. Forced duction test
6. Tonometry

58. 1.TRANSILLUMINATION
(fluid / air filled)

59. 2.Visual acuity:
 Loss of vision preceding exophthalmos suggests tumor of optic nerve like glioma in children
 Orbital tumors decrease central acuity by
--pressing on back of eyeball producing changes in refraction or sallman’s macular folds or
optic atropy in late stages

60. VISION LOSS
• Due to involvement of optic nerve by compression, infiltration, vascular
compromise, inflammation
• Marked proptosis with no visual loss—cavernous hemangioma &
neurilemmoma
• Marked visual loss with mild to moderate proptosis—optic nerve glioma and
optic nerve sheath meningioma

61. 3.FUNDUS
i. Optic disc changes :
- Optic disc oedema
- Optic atrophy
- Optociliary shunt vessels
(optic nerve sheath meningioma,
cavernous haemangioma)

62. ….
ii. Choroidal folds :
- Tumor
- Dysthyroid ophthalmopathy
- inflammatory lesions
iii. Retinal vascular changes
- Venous dilatation & tortuosity
(arteriovenous communication)
- Venous dilatation & disc swelling
(orbital mass)
- Vascular occlusion (optic nerve tumor)

63. 4.PUPILLARY REACTIONS
-Look carefully for RAPD suggestive of optic nerve damage
-Is an indication for plotting visual fields in both eyes

64. 5.OCULAR MOVEMENTS
Limitation of ocular motility due to
 Restrictive myopathy (thyroid opthalmopathy)
 Splinting of optic nerve(optic nerve sheath meningioma)
 Neurological deficit from orbital apex lesions

65. Differentiation of restrictive from neurological motility defect
6.Forced duction test:
Positive result: difficulty or inability to move globe indicates restrictive problem
Negative result: no resistance will be encountered indicates neurologic problem

66. 7.TONOMETRY
Raised IOP in TED in upward gaze i.e. positional IOP changes
Braley’s sign
Positive result: increase of 6mmHg or more indicates due to muscle restriction
Negative result: < 6mmHg IOP indicates neurological lesion

67. • Systemic examination
• Café au lait spots
• Skin pigmentation
• Features of hyperthyroidism
• Cutaneous hemangioma elsewhere
• Scalp bony lesions
• Organomegaly or lumps in abdomen
• Otorhinolaryngological examination: paranasal sinus or nasopharyngeal mass
• NERVES; Ocular movements (III, IV, VI),Ptosis (III),Lagophthalmos (VII)

68. Investigations

69. LAB.. • Haematological studies (TLC, DLC, ESR, VDRL test)
• Thyroid function test
• Casoni’s test (to rule out hydatid cyst)
• Stool examination: cysts, ova
• Urine: Bence Jones proteins for multiple myeloma
• Serum ACE
• Lysozyme
• Antineutrophil cytoplasmic antibody

70. RADIOLOGY
1. X-rays
2. Orbital USG
3. CT scan
4. MRI
5. Angiography
Non-invasive
invasive
1. Orbital venography
2. Carotid angiography

71. IMAGING TECHNIQUE:
(A)Non-invasive techniques:
1.Plain X-rays: Caldwell view, Water’s view, lateral view & Rhese view (for optic foramina).
• Enlargement of orbital cavity & optic foramina, calcification, hyperostosis.

72. 2. Ultrasonography:
• Valuable initial scanning procedure for orbital lesions
• Can usually differentiate between solid, cystic, infiltrative & spongy masses
• Lesions of posterior orbit can’t be viewed

73. 3. Computed Tomography:
- Most valuable for delineating the shape, location , extent and
character of lesions in orbit esp.orbital trauma,bony tumors
- Not only bones but foreign body and soft tissues also
- Contrast for vascularized tumor,orbital abscess

74. MEASUREMENT OF PROPTOSIS
• By measuring distance from anterior corneal
surface to interzygomatic line
• Distance from the posterior scleral margin to
interzygomatic line.
76

75. 4. Magnetic resonance imaging (MRI):
• Sensitive for detecting differences between normal
& abnormal tissues.
• Better technique for orbitocranial junction or
intracranial,intracanalicular optic nerve

76. 5. CT and MR angiography:
- Arteriovenous malformation
- Aneurysms
- Arteriovenous fistulas

77. INVASIVE PROCEDURES
Orbital venography: orbital varix suspected
Carotid angiography: pulsating exophthalmos & with bruit or thrill

78. PATHOLOGY
The diagnosis of an orbital lesion usually requires analysis of
tissue obtained through an orbitotomy.
• FNAC
• incisional biopsy
• Excisional biopsy
• Core biopsy

79. MANAGEMENT
Medical Surgical
Radiotherapy
Chemotherapy
Palliative Surgery
Depending upon
the types of lesions

80. OPTHALMOLOGIST OTOLARYNGOLOGIST
RADIOLOGIST
PATHOLOGIST NEUROSURGEON
CLINICIANproptosis
ONCOLOGIST

81. BIBLIOGRAPHY
• Wolff’s Anatomy of the eye and orbit 7th Edition
• AAO
• BCSC: Orbit Eyelids and Lacrimal System
• Parsons’ Diseases of the eye 22nd edition
• Disease of orbit, jack rootman,2nd edition

82. •Thank you