presentation on proptosis

1. PROPTOSIS
By,
Dr. A. Suganya MS
Senior Resident
Department of Ophthalmology

2. DEFINITION
• Abnormal forward displacement / protrusion of
the eyeball beyond the orbital margin.
Proptosis = Exophthalmos
General term Thyroid related cause

3. CRITERIA
• Normal adults – 16 to
21 mm (from lateral
orbital rim to the
corneal apex)
• Proptosis – Protrusion
> 22 mm beyond the
orbital rim or
asymmetry > 2 mm
between the eyes

4. Classification
PROPTOSIS
Pseudo
Facial
asymmetry
High myopia,
buphthalmos
Lid retraction
Contralateral
enophthalmos
True
Unilateral Bilateral Acute Intermittent Pulsatile

5. Pseudoproptosis

6. ETIOLOGY

7. UNILATERAL PROPTOSIS
Congenital
Dermoid
Teratoma
Trauma
Haemorrhage
Foreign body
Traumatic
aneurysm &
emphysema
Inflammation
Orbital
cellulitis
Abscess
Panophthal
mitis
Early CST
TB,
Sarcoidoidis
Vascular
Varix
Aneurysm
Cysts
Haematic
cyst
Implantation
cyst
Parasitic
Tumour
Primary/
secondary/
metastasis
Mucocele
of
PNS
Frontal
Ethmoid
maxillary

8. ORBITAL CELLULITIS RETROBULBAR HAEMORRHAGE
CAVERNOUS SINUS ANEURYSM

9. ORBITAL TUMOUR
ORBITAL DERMOID

10. BILATERAL PROPTOSIS
Developmental
anomaly
Craniofacial
dysostosis
Osteopathies
Rickets
Acromegaly
Inflammation
Mikulicz’s
syndrome
Late CSVT
Endocrinal
Thyroid
Tumour
Primary –
lymphoma/sarcoma
Secondary-
neuroblastoma,
nephroblastoma,
Ewings sarcoma,
leukaemic
infiltrations

11. CAVERNOUS VENOUS THROMBOSIS
GRAVES OPHTHALMOPATHY
CRANIOFACIAL DYSOSTOSIS

12. Acute proptosis
• Trauma – Orbital emphysema, haemorrhage,
fracture of medial orbital wall.
• Rupture of ethmoidal mucocele.

13. ORBITAL EMPHYSEMA
ETHMOIDAL MUCOCELE

14. Intermittent proptosis
• Orbital varix
• Periodic orbital edema
• Recurrent orbital hemorrhage
• Highly vascular tumours

15. ORBITAL VARIX
ORBITAL EDEMA

16. Pulsatile proptosis
• Carotico cavernous fistula
• Saccular aneurysm of ophthalmic artery.
• Transmitted cerebral pulsations with deficient orbital
roof – Congenital meningocele / meningoencephalocele.

17. TYPES OF PROPTOSIS
AXIAL NON- AXIAL / ECCENTRIC / ABAXIAL
Forward protrusion without displacement Displacement + protrusion
Intraconal lesions Extraconal lesions
Causes:
• Cavernous hemangioma
• Optic nerve glioma
• Thyroid eye disease
• Arteriovenous malformations
• Mass lesion within the muscle cone.
Causes:
Superior globe displacement:
• Neural/mesenchymal /vascular tumors
in inferior orbit.
• Maxillary sinus tumors invading the
orbital floor.
Inferomedial globe displacement
• Dermoid cysts in superolateral orbit.
• Lacrimal gland tumors.
Inferolateral globe displacement
• Frontoethmoidal mucoceles.
• Abscesses.
• Osteomas.
• Sinuscarcinomas

20. CLINICAL EVALUATION

21. CLINICAL HISTORY
CHIEF COMPLAINT:
• Protrusion of one or both eyes
• Loss of vision – optic nerve compression /
exposure keratopathy
• Rare – diplopia, ROM, redness/pain/discharge
due to exposure keratopathy.

22. History of presenting illness:
• Age of onset
• Nature of onset: sudden / gradual
• Progression: slow / rapid
• Increase during attacks of URI / valsalva
manouvre / postural / crying
• H/O of pain
• Laterality
• H/O of pulsation

23. Past history
• Thyroid disorder, sarcoidosis
• Malignancy- lung, breast, prostate
• Trauma
• Periocular tumour
• Prior periocular surgery

24. EXAMINATION
GENERAL EXAMINATION:
Signs of Graves / sarcoidosis/ malignancy/ infective foci
OCULAR EXAMINATION:
1. Visual acuity
2. Eyeball :
A. Inspection
B. Palpation
C. Auscultation
D. Transillumination
E. Exophthalmometry

25. Inspection
• Proptosis / pseudoproptosis
• Unilateral / bilateral
• Direction of protrusion
• Ocular motility
• Eyelids
• Periorbital inflammation
• Nose/roof of mouth
• Valsalva maneuver
• Lagopthalmos,Bell’s phenomenon,exposure
keratopathy

26. Worm’s eye view
Nafziger view

27. Palpation
• Retropulsion
• Orbital thrill/pulsation
• Swelling/mass around the eyeball
• Regional lymph nodes
• Orbital rim/margin
• Reducibility of the mass
• Infraorbital/supraorbital anesthesia

28. Auscultation
• To look for bruit
• With help of bell of the stethescope
• Over eyeball and temporal area
• AV Malformation

29. Transillumination
• Anterior orbital lesions
• Using penlight
• Interpretation-
Bright- Cyst with clear fluid
Equal- lipoma
Intermediate- dermoid cyst
Dark- Lacrimal gland tumour, osteoma

30. Exophthalmometry
• Hertel’s exophthalmometer
• Luedde scale
• Naugle exophthalmometer
• Gormaz exophthalmometer

31. Luedde exophthalmometer
Naugle exophthalmometer

32. Hertel exophthalmometer
Gormaz exophthalmometer

33. Other ocular examination
3. Conjunctiva
4. Cornea
5. Sclera / Iris
6. Pupil
7. IOP
8. Lens
9. Vitreous
10. Fundus

34. LAB INVESTIGATION
• Thyroid function test
• Complete blood count, peripheral smear, ESR,
blood sugar
• Stool – for cyst and ova
• Urine- bence Jones protein for multiple
myeloma

35. IMAGING
NON-INVASIVE
• X-ray: caldwell view, water’s view, lateral view,
Rhesis view
• Computerised tomography
• Ultrasonography
• Magnetic resonance tomography
INVASIVE
• Orbital venography
• Carotid angiography

36. HPE
• Fine needle aspiration biopsy
• Incisional biopsy
• Excisional biopsy

37. Thank you!