The document discusses various causes and clinical approaches to evaluating proptosis in adults. Common causes in adults include thyroid eye disease, pseudotumor, orbital cellulitis, trauma, meningioma, lymphoma, and cavernous hemangioma. A thorough history, examination, and imaging studies are needed to differentiate between causes and guide treatment.
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Lymphoid tumors, cavernous hemangiomas, and meningiomas are the most common orbital tumours in adults.
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Proptosis in adults
1. PROPTOSIS
Adults
Dr. Yousaf Jamal
FCPS Resident
Ophthalmology Unit
Hayatabad Medical Complex
20-02-2010
Mar 25, 2013
2. CONTENTS
• Introduction
• General Causes
• Clinical approach + Differentiating features
• Causes in Adults
• Common causes discussion
• Summary
• Take home message
• MCQs
Page 2 Proptosis in Adults Mar 25, 2013
3. Introduction
• Proptosis *
– Forward displacement or bulging, especially
eyeball
• Exophthalmos
– Abnormal protrusion of eyeball *
– Proptosis secondary to endocrinological
dysfunction **
* Dorland’s medical dictionary 26th edition
** Henderson JW. Orbital Tumors. 3rd ed. New York: Raven Press; 1994.
Page 3 Proptosis in Adults Mar 25, 2013
4. General Causes
• Congenital • Acquired
– Dermoid cyst – Inflammatory
– Orbital teratoma – Infectious
– Congenital cystic – Trauma
eyeball – Vascular
– Cysts
– Neoplastic
Page 4 Proptosis in Adults Mar 25, 2013
41. Treatment
• Observation
• Oral NSAIDs
• Systemic steroids
– Oral prednisolone = 60-80mg/day
• Radiotherapy
– If no response to steroids
Page 41 Proptosis in Adults Mar 25, 2013
42. • Anti metabolites
– If resistant to steroids and radiations
• Methotrexate
• Mycophenolate mofetil
• Systemic infliximab
Page 42 Proptosis in Adults Mar 25, 2013
43. CAVERNOUS HEMANGIOMA
• Most common intraorbital tumor of adults
• 3rd to 5th decade
• Mostly unilateral
• Incidence = 4.3% among orbital neoplasms 1
• No ethnic/racial predilection
• F:M = 7:32 but 8:71 also reported
1. Henderson GW. Vascular hamartomas, hyperplasias, and neoplasms. In: Henderson GW, ed. Orbital Tumors. New
York: Raven Press; 1994:94-100.
2. Harris GJ, Jakobiec FA. Cavernous hemangioma of the orbit: a clinicopathologic analysis of sixty-six cases. In: Jakobiec,
ed. Ocular and Adnexal Tumors. Birmingham, Ala: 1978:741-81.
Page 43 Proptosis in Adults Mar 25, 2013
44. • Pathophysiology
– Benign, slowly growing vascular lesions
– Increase intraorbital volume to cause proptosis
• Morbidity
– Compressive optic neuropathy
– Extraocular muscle dysfunction
– Cosmetic disfigurement
– Death from bleeding during surgical removal
Page 44 Proptosis in Adults Mar 25, 2013
45. Presentation
• Middle aged
• Slowly growing unilateral axial proptosis
• Decrease in VA
• Diplopia
• Rarely gaze evoked amaurosis fugax
• May be accelerated by pregnancy
Page 45 Proptosis in Adults Mar 25, 2013
46. Signs
• Dilated & tortuous epibulbar vessels
• Other defects
– Color vision
– Visual field
– RAPD
• Fundus
– Optic disc edema & choroidal folds
Page 46 Proptosis in Adults Mar 25, 2013
47. Work-up
CT
– Well circumscribed, round or oval isointense mass
– Usually in lateral part of muscle cone
USG
– High echogenecity on A-scan...reflect septae
within the lesion
Page 47 Proptosis in Adults Mar 25, 2013
51. CAROTID-CAVERNOUS FISTULA
• An abnormal communication btw cavernous
and external or internal carotid arteries
• Classification
– Etiology
• Traumatic vs. spontaneous
– Hemodynamics
• High vs. low velocity
– Anatomy
• Direct vs. indirect (dural)
Page 51 Proptosis in Adults Mar 25, 2013
53. Direct carotid-cavernous fistula
• 70-90% of all cases
• Communication btw intracavernous part of
ICA & cavernous sinus
• High arterial blood flow
• Causes
– Spontaneous…25%
• Middle aged woman, atherosclerosis, HTN, pregnancy
• Collagen vascular disease, Connective tissue disorders
– Trauma (basal or facial skull fracture)…75%
– Iatrogenic
Page 53 Proptosis in Adults Mar 25, 2013
54. Indirect carotid-cavernous fistula
• Communication btw cavernous sinus &
meningeal branches of ICA and/or ECA
• Low arterial blood flow
• Causes
– Spontaneous
– Congenital AV-malformations
Page 54 Proptosis in Adults Mar 25, 2013
55. Presentation
• Days or weeks after head injury
• Hx of surgery or systemic factors
– Triad
• Pulsatile proptosis
• Chemosis
• Whooshing noise in head
– Decreased vision
– Diplopia
Page 55 Proptosis in Adults Mar 25, 2013
62. Work-up
• CT, MRI & Orbital echo
– Enlargement of EOM
– Dilation of one or both superior ophthalmic veins
– Enlargement of the affected cavernous sinus
• Arterial Angiography
– Definite diagnosis
Page 62 Proptosis in Adults Mar 25, 2013
63. Treatment
Medical
• Exposure keratopathy
• Glaucoma
• NVG
Page 63 Proptosis in Adults Mar 25, 2013
64. Surgery
• Indication
– Post traumatic fistula
– Failure to spontaneous closure
• Procedures
– Surgical repair of the damaged portion of the
intracavernous internal carotid artery
– Electrothrombosis, Embolization, or Balloon
occlusion of the fistula
Page 64 Proptosis in Adults Mar 25, 2013
65. OPTIC NERVE SHEATH
MENINGIOMA
• Arise from meningiothelial cells of arachnoid
villi, hence attached to dura mater
• Primary ONSM
– Intraorbital or intracanalicular portion or ON
– Less common
• Secondary ONSM
– Extension of intracranial meningioma into orbit
– More common
Page 65 Proptosis in Adults Mar 25, 2013
66. Presentation
• Age…6th-8th decade
• F>M
• Chronic, painless, progressive visual
impairment
• Usually accompanied by proptosis
• Mostly unilateral
• Headache
• Double vision
Page 66 Proptosis in Adults Mar 25, 2013
70. Work-up
• CT scan (with contrast)
– Fusiform appearance of ON
– Mostly at orbital apex
– Calcifications usually seen
– Bony involvement
• MRI
– Clearly show small tumors
– Intraorbital extension of intracranial meningioma
easily detected
Page 70 Proptosis in Adults Mar 25, 2013
72. Treatment
• Observation
– No intracranial extension and no vision loss
Medical
• Radiotherapy
– Primary radiation
– Radiation after surgery
Page 72 Proptosis in Adults Mar 25, 2013
73. Chemotherarpy
• Unresectable, recurrent, or previously
irradiated
• Combinations
– 5-fluroouracil, folate, and levamisole
– intra-arterial cisplatin with intravenous doxorubicin
– Adriamycin and dacarbazine
– ifosfamide and mesna
Surgery
• Surgical excision
Page 73 Proptosis in Adults Mar 25, 2013
75. PROPTOSIS
Hx
Middle-aged woman Rapid onset Proptosis
Unilateral/bilateral Slow growing Motility problems
Lid retraction/lag Retropulsion Orbital pain
Heat intolerance Axial Proptosis Diplopia
Woman…20-40yrs Increased hyperopia Primary tumor
Thyroid bruit/enlarged Unilateral (lung, breast)
ORBITAL METASTATIC
THYROID EYE DISEASE CAVERNOUS HEMANGIOMA
TUMOR
Page 75 Proptosis in Adults Mar 25, 2013
76. PROPTOSIS
Orbital inflammation Hx of trauma
Sudden onset/chronic Severe conjunctival
Adults/children chemosis
Prominent red eye Pulsatile Proptosis
Pain/Diplopia Orbital bruit
Trigeminal involvement
ORBITAL PSEUDOTUMOR AV MALFORMATION
Page 76 Proptosis in Adults Mar 25, 2013
77. TAKE HOME MESSAGE
• Proptosis is alarming condition
• Localized or systemic cause
• Proper approach
• Thorough Hx & investigation
• Proper management
Page 77 Proptosis in Adults Mar 25, 2013
79. MCQs
1. Features of carotid-cavernous fistula include:
a. dilated superior ophthalmic vein on CT scan
b. blood in the Schlemmn's canal
c. Proptosis of contra lateral eye suggests bilateral carotid-
cavernous fistula
d. dural fistula is the commonest type seen following head
injury
e. traumatic fistula rarely close spontaneously
a. T b. T c. F d. F e. T
Page 79 Proptosis in Adults Mar 25, 2013
80. 2. A forty-eight year old woman presents with a
several month history of slowly progressive,
painless Proptosis and blurred vision in the
left eye. She is otherwise healthy. Her
examination was notable for choroidal folds
OS
Page 80 Proptosis in Adults Mar 25, 2013
81. a. Findings on the scan ?
Ans. Well-defined, round, intraconal mass
b. What is probable Dx of the scan ?
Ans. Cavernous hemangioma
Page 81 Proptosis in Adults Mar 25, 2013
82. 3. This is the orbital CT of a man with painless
progressive Proptosis OS
Page 82 Proptosis in Adults Mar 25, 2013
83. a. Findings on the scan?
Ans. Enlargement of muscles without involvement of the tendinous
portion
b. What is your diagnosis?
Ans. Thyroid ophthalmopathy
Page 83 Proptosis in Adults Mar 25, 2013
84. 4. 54 year old man with 4 days of progressively
worsening pain and swelling around the right
eye.
Page 84 Proptosis in Adults Mar 25, 2013
85. Q. What is the differential diagnosis?
Ans. Preseptal cellulitis
orbital cellulitis
pseudotumor
malignancy
trauma
Page 85 Proptosis in Adults Mar 25, 2013
86. 5. A 30 year old woman noticed mild Proptosis
which accelerated during her pregnancy.
Lesion caused hyperopia & retinal striae.
CT showed well defined mass. Most
probable Dx is:
a. Metastatic breast carcinoma
b. Cavernous hemangioma
c. Thyroid related orbitopathy
d. Pseudotumor
Ans. b
Page 86 Proptosis in Adults Mar 25, 2013
87. NEXT
Lecture
• Dr. Yousaf Jamal
– Proptosis in children
Journal club
• Dr. Naeem KTK
Mar 25, 2013
Editor's Notes
Lid swelling , ecchymosis n chemois suggest cellulitis, lid lag n staring suggst TED.
Retropulson also for pulsations..Lymphatic supply of retina??