1. A 38-year-old man presented with unilateral right eye proptosis and downward displacement following frontal sinus surgery. He was diagnosed with invasive aspergillosis secondary to the surgery. 2. Clinical evaluation of proptosis involves assessing signs like lid swelling, ptosis, eye movement limitations, visual acuity changes, and optic nerve involvement through tests like visual field and fundoscopy. Imaging with CT or MRI is useful to identify the cause. 3. Common causes of proptosis include thyroid eye disease, orbital tumors, trauma like blowout fractures, and infectious etiologies like orbital cellulitis secondary to sinusitis. Evaluation and diagnosis involves a thorough history, exam and appropriate imaging.

1. Proptosis
Ahmed Osama Hashem MD,FRCS
Consultant &Lecturer Ophthalmology

2. Basic anatomy

3. Skull

4. Orbit

5. Orbit anatomy
• Resemble a pear whose stalk is the optic canal,,,,

6. Pear shaped ,,,,,,,,,, stalk optic canal ,,
(widest aperture anterior and narrowing
posteriorly)

7. 4 walls ---- 7 bones

8. Superior orbital wall,,,Roof
Roof:
1-Lesser wing of sphenoid ,
2-frontal
Defect
Pulsatile proptosis
Lacrimal gland fossa
laterally
Trochlea medially

9. Lateral orbital wall,,
Lateral wall 2 bones
1-greater wing of sphenoid
2-zygomatic
Only orbital wall not
related to paranasal
sinus
Anterior globe vulnerable
to lateral trauma because
the wall only protect the
posterior

10. Medial orbital wall,,
4 bones:
1-maxillary
2-lacrimal
3-ethmoid
4-sphenoid
Related to sphenoid
and ethmoid sinus
Lamina papyracea ,covers
the medial wall,very thin
For this reason: commonest
cause for orbital cellulitis is
ethmoidal sinusitis,,

11. Inferior orbital wall,,,Floor
3 bones
1-zygoma
2-maxillary
3-palatine
Posteromedial portion is
relatively weak
= blow out fracture
floor=roof of maxillary sinus
Maxillary carcinoma invading
Orbit may displace the globe
upwards,,,,

12. Definition
• Abnormal protrusion of the eye ball

13. Causes
• De novo mass
• Increase bulk of some intraorbital content i.e EOM or orbital fat

14. N.B
• Anterior orbital lesions result in displacement of globe without
proptosis…

15. Clinically
• Direction
-Axial
-Non axial
• According to site,,,
Unilateral proptosis(Thyroid,dermoid cyst,Trauama,inflammation,tumour,vascular lesion)
,bilateral(Thyroid,systemic disease,skull disorder)
-Acute proptosis(blow out frature with orbital emphysema)
Intermittent proptosis(orbital varix)
-Pulsating proptosis

16. Clinical evaluation

17. history
• Age(4th-5th decade thyroid ,,, ,Onset,duration,progression,chronological sign and symptoms (most tumors gradual except Rhabdomyosarcoma in
children (Acute) DD infection
• Sex (Thyroid ophthalmopathy Female : male 8:1) metastasis Breast ,,, Prostate
• Diplopia, Diminution of vision
• Discomfort ,,watering pain
• Difficulty during closing the eye while sleep
• Pulsatile ,, intermittent ?
• Medical history (i.e DM Diabetic Ketoacidosis Mucormycosis) ,,,in contrary to ,Aspergillus occur in healthy individual ..
Previous surgery (Sinus surgery)
Smoking (Lung cancer commonest 1ry causing metastasis)

18. Mucormycosis
Fungal infection

20. A 38-year-old man following frontal sinus surgery with proptosis
and downward displacement in the right eye secondary to
invasive aspergillosis.

21. Aspergillus

22. Cavernous hemangioma vs capillary
(Age)Commenest benign MCQ..

24. Orbital Rhabdomyosarcoma (Commonest
child orbital malignancy)

25. Commonest Adult tumor ,,(Orbital lymphoma,, ,,
Salmon patch---Lscrimal gland) Malignant

26. Neuroblastoma (NB)
• is a type of cancer that forms in certain types of nerve tissue. It most
frequently starts from one of the adrenal glands, but can also develop
in the neck, chest, abdomen, or spine. Symptoms may include bone
pain, a lump in the abdomen, neck, or chest, or a painless bluish lump
under the skin.

27. Neuroblastoma Commonest Child Orbital
metastasis

28. Most common metastatic tumor
in children Neuroblastoma

29. Local examination
• Inspection:
• Differentiate proptosis from pseudoproptosis

30. Surface Anatomy
• Superior Palpebral sulcus
• Lateral canthus
• Medial canthus
• Palpebral fissure (space between lid margins)
• Upper lid cover 1/6 ….
• Lower lid .. At level of ..

31. • Both the upper and lower eyelids meet at medial and lateral canthi
with the opening the papebral fissure between them.

35. Pseudoproptosis DD of proptosis
• Facial asymmetry
• A very large ipsilateral globe as in very high myopia or buphthalmos.
• Contralateral enophthalmos
• Ipsilaterl Lid retraction
• Contralateral ptosis

36. Enophthalmos
• Definition: recession of the globe in the orbit
• Causes:
1-small globe(micro,nanophthalmos,phthisis bulbi)
2-blow-out fracture,,,fracture floor)
3-atrophy of the orbital content (irradiation of the orbit for malignant
tumour)
4-cicatrizing orbital lesions:metastatic schirrous carcinoma

37. Blow out fracture

38. Cause
• Blow-out fractures of the orbit result from blunt trauma by blunt
objects of small diameter, such as a fist, tennis ball, or baseball.

39. What is the diagnosis?
Mention 3 clinical signs for this diagnosis?

40. What is the diagnosis?
Mention 2 useful investigations?

41. Inv.
• CT studies

42. What is the diagnosis?
The most common cause is ………

43. This CT scan shows fracture of the orbital floor and
opacification of the maxillary sinus.
Such a patient usually complain of …………

44. Is it unilateral or bilateral?

47. Axial or Non-axial

51. Non axial proptosis

52. Non-axial proptosis

53. Unilateral axial proptosis

54. Soft tissue involvement
• Lid edema ? I.e preseptal cellulitis ,orbital cellulitis ..
• Ptosis ?
• Chemosis and conjunctival injection?

55. Preseptal cellulitis

56. Orbital cellulitis

57. Palpation
• Thrill
• Retrodisplacment (to know compressibility of the tumour)
• Swelling around the eyeball
• Regional lymph nodes
• Orbital rim

58. Auscultation
• Search abnormal vascular communication that generate a bruit
• (caroticocavernousfistula)

59. Transillumination

60. Cystic lesions
• Dermoid cyst
• Encephalocele
• Dacryops
• Mucocele of paranasal sinus

62. Encephalocele

63. Encephalocele

64. Fronto ethomidal mucocele

65. Visual acuity
How does it affect visual acuity?
1-ON compression
2-Refractive change due to pressure on the back of the eye,,,
hypermetropia!
3-Exposure keratopathy

67. Pupil
• Marcus Gunn pupil(optic nerve compression)

68. Ocular motility
• Ophthalmoplegia
1-ocular mass interfere with motility.
2-Underaction of inflamed muscle
3-ocular motor nerve lesion
4-Tethering (blow out fracture)
5-Splinting of optic nerve by (meningioma)
6-Restrictive myopathy in thyroid eye disease

69. Ocular motility testing

71. How to differentiate neurological from
restrictive?
1-Forced duction test.
2-Differential intraocular pressure test.

74. Fundoscopy
• Venous engorgement
(Dilatation and tortuosity)
Occlusion. I,e orbital cellulitis )
• Hemorrhage
• Papilledema
• Optic atrophy (Compressive optic neuropathy)

75. Venous dilatation and tortuosity

76. Opticociliary shunt

77. Exophthalmometry(Hertel)

80. Severity
• With a plastic ruler resting on bone at the lateral canthus,,,
• Or exophthalmometer:corneal apieces are viewed in the mirrors and
amount of protrosion of the globe is read from a scale
• Normal reading is 12-18 mm
• Reading greater than 20 mm indicative of proptosis ,,,,
• Difference of 2mm between the 2 eyes is suspecious,,,,

81. Displacment,,,
• Extent of vertical or horizontal displacment is measured by ruler over
the bridge of the nose.

82. Invest.
• Labs (white blood cells increase in infection)
• CT MRI US
• Biopsy
• Lumbar puncture CSF fluid analysis ( if meningeal or cerebral signs
develop)

83. Preseptal vs Orbital cellulitis CT

84. CT vs MRI

88. Thank you