- The document discusses the evaluation of proptosis, which is the abnormal forward protrusion of the eyeball. It defines different types of orbital abnormalities and provides the approach to examining a patient with proptosis, including taking a thorough history, performing a local and systemic examination, ordering appropriate imaging and lab tests, and considering histopathological studies if needed. The causes of proptosis can be divided into categories such as inflammatory, mass effect, vascular changes, and infiltrative processes. Key aspects of the evaluation are to determine if the proptosis is unilateral or bilateral and whether there are associated signs and symptoms to suggest an underlying cause.

1. EVALUATION OF A
CASE OF
PROPTOSIS
DR ARPITA

2. • PROPTOSIS is defined as forward
protrusion of the eyeball
• Proptosis of more than 21mm or more
than 2mm asymmetry between the two
eyes is abnormal
• EXOPHTHALMOS is specifically used to
describe the proptosis of eyes a/w Thyroid
eye disease
• ENOPHTHALMOS is defined as
retrodisplacement of eye into orbit

3. PSEUDOPROPTOSIS
• It is the false impression of proptosis
• Seen in conditions like
1. Buphthalmos
2. High myopia
3. Contralateral ptosis
4. Contralateral enophthalmos

4. CAUSES OF PROPTOSIS
UNILATERAL BILATERAL
1) CONGENITAL - DERMOID/TERATOMA DEVELOPMENTAL ANOMALIES - OXYCEPHALY
2)TRAUMATIC- ORBITAL HRAGE/EMPHYSEMA
/IOFB
OSTEOPATHIES- RICKETS / ACROMEGALY
3)INFLAMMATION – ORBITAL
CELLULITIS/ABSCESS/CAVERNOUS SINUS
THROMBOSIS/PSEUDOTUMOR/TUBERCULOSI
S/GUMMA/SARCOIDOSIS
TUMORS-LYMPHOMA / LEUKEMIA / EWINGS
SARCOMA / NEUROBLASTOMA
4)VASCULAR-ORBITAL VARIX ENDOCRINAL - THYROID EYE DISEASE
5)CYSTS-PARASITIC INFLAMMATORY -
WEGENERS/HISTIOCYTOSIS/SJOGRENS/
FUNGAL GRANULOMA
6)TUMOR- PRIMARY OR SECONDARY
7)MUCOCOELE OF PARANASAL SINUSES

5. • Acute proptosis - Orbital emphysema /
orbital hemorrhage
• Intermittent proptosis – Orbital varix ,
periodic orbital edema , recurrent orbital
hemorrhage
• Pulsating proptosis – caroticocavernous
fistula , saccular aneurysm of ophthalmic
artery , congenital meningocoele ,
meningoencephalocoele , traumatic or
operative hiatus in orbital roof

7. APPROACH
HISTORY
LOCAL
EXAMN
SYSTEM
EXAMN
INVESTIG
ATIONS
IMAGING

8. HISTORY TAKING
• Protrusion of eyeball - Age of Onset ,
duration , progression
• Constant or intermittent
• Variation with posture / strain
• Decreased vision – preceded/followed
• Stationary/progressive
• Associated field defects

9. • h/o Pain
• h/o Double vision
• h/o Trauma
• h/o fever , chills ,systemic symptoms
• h/o cancer
• h/s/o thyroid disease ,TB , DM ,HTN ,HIV ,
Syphilis

12. • The patterns of orbital involvement can be divided into four
basic categories.
• INFLAMMATORY EFFECT: inflammation may be either
infectious or noninfectious in nature and is associated with
signs and symptoms of redness, swelling, pain, heat, and
loss of function. There is often a mass effect present.
MASS EFFECT: displacement with or without signs of
involvement of sensory or neuromuscular structure.
Displacement points to the location of the diseases and may
help to characterize its nature.
VASCULAR CHANGE: features suggesting vascular disease
include venous dilation, pulsation, expansion with straining
(Valsalva), and hemorrhage.
INFILTRATIVE CHANGE: infiltrative diseases are usually
associated with evidence of destruction, entrapment, or
both. These include effects on ocular movement or
neurosensory function (e.g., optic neuropathy, pain, or
paresthesia).

13. • Sudden dramatic proptosis in a child with recent
upper resp tract infetion – hemorrhage into a
lymphangioma
• Gaze evoked amaurosis – orbital apex tumor
• Pain a/w short h/o mass in region of lacrimal
gland – adenoid cystic Ca
• Long h/o painless mass – pleomorphic adenoma
• h/o tinnitus – AV shunt
• Proptosis increasing on straining – orbital varix
• Spontaneous unilateral periorbital bruising –
amyloidosis
• Spontaneous B/L bruising - neuroblastoma

14. LOCAL EXAMINATION
• 1) INSPECTION –
• Proptosis or pseudoproptosis
• Unilateral or bilateral
• Axial or eccentric
• 2) PALPATION – size ,shape,surface,margins
consistency , tenderness , compressibility
Thrill /increase with valsalva/ orbital rims /
regional lymph nodes
• 3)AUSCULTATION - bruit

17. • 7) ADNEXA –
• Dilated episcleral vessels – AV shunt
• Optociliary shunt vessels- optic nerve sheath
meningioma
• Salmon patch beneath upper eyelid – orbital
lymphoma
• Eversion of upper lid – waxy yellow infiltrate
with tortuous vessels- amyloid
• S shaped deformity of upper lid – plexiform
neurofibroma
• Lid retraction or lidlag - thyroid ophthalmopathy

19. 4) EOM MOTILITY – decreased in thyroid
orbitopathy,extensive tumor growths and
neurological deficit
5) VISUAL ACUITY – maybe decreased due to
Refractive changes due to pressure on
eyeball
Optic nerve compresssion
Exposure keratopathy
6) PUPIL REACTION – RAPD suggests optic
nerve compression

20. 7) COLOR VISION , VISUAL FIELDS
8)FUNDOSCOPY – may reveal hemorrhages ,
papilloedema , optic atrophy , choroidal folds

21. MEASUREMENT OF PROPTOSIS
• Measured by a group of instruments called
exophthalmometer or proptometer
• All instruments are meant to measure the
distance b/w thw apex of cornea and lateral
wall of orbit
• OPTICAL- Lueddes scale and Hertels
exophthalmometer
• MECHANICAL – Gormaz exophthalmometer

28. SYSTEMIC EXAMINATION
• Thyroid examination
• Primary tumors elsewhere in the body –
CVS/RS/Abdomen/PV/Rectal
• ENT examination

29. LAB INVESTIGATIONS
• Hematological - CBC , ESR, VDRL
• Thyroid function tests
• Serum ANA , c- ANCA , ACE
• BUN , Creatinine
• C-XRAY , Mantoux test
• Casonis test – r/o hydatid cyst
• Stool examination – cysts /ova
• Urine analysis – bence jones proteins - MM

30. IMAGING
• XRAY –
• Calcification/hyperostosis – Meningiomas
• Waters view – blow out fractures
• Rhese view – optic foramen and SOF
• CT- SCAN Size , position and shape of
• USG lesion
• MRI

31. • ORBITAL VENOGRAPHY – Orbital varix
• CAROTID ANGIOGRAPHY – Aneurysms /AV
communications

32. HISTOPATHOLOGICAL STUDIES
• FNAB
• Incisional biopsy
• Excisional biopsy

39. • Proptosis with white reflex – retinoblastoma
• U/L fast progressing proptosis , fever , toxic
child , pain – orbital cellulitis
• U/L axial proptosis with early vision loss –
optic nerve glioma
• B/L proptosis , fever and toxemia – cavernous
sinus thrombosis
• Pale child , bleeding from gums , U/L or B/L
proptosis – leukemia
• U/L proptosis ,pain ,fever,hazy cornea and
loss of vision - panophthalmitis