- Proptosis refers to forward displacement of the eyeball beyond the orbital rim, usually due to an increased mass or volume within the orbit. Common causes include tumors, inflammation, trauma, thyroid eye disease, and vascular lesions. - Examination involves measuring exophthalmometry, inspecting for signs of mass effect, pulsation or displacement of the globe, and evaluating for neurologic deficits. Imaging with CT or MRI is important to characterize the lesion causing proptosis.

1. PROPTOSIS

2. PROPTOSIS
• Forward displacement of the eyeball beyond orbital
margins due to a mass/increased orbital contents .
• Proptosis >21 mm or asymmetry of >2 mm
between 2 eyes : abnormal.
• Exophthalmos: specifically describes proptosis
associated with thyroid eye disease (TED).
• Exorbitism: decrease in the volume of orbit
b/l.orbital contents to protrude forwards.
• Pseudoproptosis:apparent protrusion of eyeball
without increase in any orbital contents or mass.
• causes: Buphthalmos High myopia
: C/l ptosis C/l enophthalmos

3. EXOPHTHALMOS PROPTOSIS

4. ANATOMY OF ORBIT
• pear shaped, tapers posteriorly at optic canal.
• Volume of orbit :30 ml.
• 4 walls of 7 bones: ethmoid, frontal, lacrimal,
maxillary,palatine, sphenoid and zygomatic.
• Medial orbital walls are approximately parallel ,
separated by 25 mm.
• Lateral orbital walls angle about 90 degrees from
each other
• The widest dimension :1 cm behind the anterior
orbital rim.
• The thinnest bone is in the medial wall (lamina
papyracea) adjacent to the ethmoid air cells.

5. • Relationship of orbit & PNS :By its location & venous
drainage .
• orbital venous drainage :devoid of valves – two way
communication between orbit and sinuses.
• Roof :anterior cranial fossa & frontal sinus above.
• Medial wall : adjacent nasal cavity, ethmoid &
posterior sphenoid sinus.
• Floor :The maxillary antrum beneath .
• Lateral wall :adjacent to middle cranial ,temporal &
pterygopalatine fossa.
RELATIONS OF ORBITAL WALL

6. CLINICAL ASPECTS
• Ethmoidal sinusitis can breach lamina papyracea &
spread into the orbit.
• The floor is thin medially -> fragmentation in “blow
out” fractures.
• Lacrimal bone at the level of lacrimal fossa is very
thin-> easy penetration during endoscopic DCR. if
maxillary component is predominant ,difficult to
breach the bone in endoscopic DCR.
• Webers suture:Lying anterior to lacrimal fossa has
Infraorbital artery branches pass through it.
Bleeding during lacrimal sac sx.
• Traumatic Optic Neuropathy :indirect injury to optic
canal & direct injury by bony fragments in canal.

7. CLASSIFICATION OF PROPTOSIS
1. Unilateral proptosis
2. Bilateral proptosis
3. Acute proptosis
4. Intermittent proptosis
5. Pulsating proptosis
6. Axial proptosis
7. Non-axial proptosis.

8. U/L PROPTOSIS
1)congenital - dermoid
teratoma
2)Traumatic - orbital hemorrhage
emphysema
IOFB
3)inflammation - orbital cellulitis/abscess
cavernous sinus thrombosis
pseudotumor
tuberculosis/gumma
sarcoidosis
4) vascular - orbital varix
5) Cysts - parasitic
6)Tumor - primary or secondary
7)mucocoele of paranasal sinuses

9. BILATERAL PROPTOSIS
1) Developmental abn/l - Oxycephaly
2)osteopathies - Rickets / Acromegaly
3)Tumors - Lymphoma / Leukemia
Ewings sarcoma
Neuroblastoma
4)Endocrinal - Thyroid eye disease
5)Inflammatory - Fungal granuloma
Mikulickz syndrome
6)Systemic - Histiocytosis
systemic amyloidosis

10. Lymphoma-> b/l proptosis

11. craniosynostosis

12. A/C PROPTOSIS
• orbital emphysema
• fracture of the medial orbital wall
• orbital haemorrhage
• rupture of ethmoidal mucocele.

13. INTERMITTENT PROPTOSIS
• orbital varix
• periodic orbital oedema
• recurrent orbital haemorrhage
• highly vascular tumours.

14. PULSATING PROPTOSIS
• Carotico cavernous fistula
• saccular aneurysm of ophthalmic artery.
• transmitted cerebral pulsations with deficient
orbital roof.
Congenital meningocele
Meningoencephalocele
Neurofibromatosis
Traumatic or operative hiatus.

15. AXIAL PROPTOSIS
• Cavernous hemangioma
• Optic nerve glioma
• Thyroid eye disease
• Arteriovenous malformations, and
• Mass lesion within the muscle cone.

17. NON -AXIAL PROPTOSIS
• Lesions with prominent component outside muscle
cone .
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.
• Sinus carcinomas

18. METASTASIS => PROPTOSIS

19. LACRIMAL GLAND
MUCOCELE TUMOUR
FRONTAL SINUS

21. HISTORY
• Age of Onset , duration , progression
• Constant or intermittent
• Variation with posture
• Decreased vision – b4/after
• Stationary/progressive
• Associated field defects
• Pain
• Double vision
• Periorbital neurosensory loss
• bruits
• symptoms aggravated by crying,coughing,straining,
nose blowing?
• Past h/o : Trauma,fever, chills ,cancer, thyroid d/s ,
TB , DM ,HTN ,HIV , Syphilis, Old photographs

22. HEMORRHAGE INTO A LYMPHANGIOMA
• A sudden dramatic proptosis with conjunctival prolapse in a child with recent
URTI
GAZE-EVOKED AMAUROSIS
• may be associated with an orbital apex tumor.
MALIGNANT LESION (adenoid cystic carcinoma)
• Pain associated with a short history of a mass in the region of lacrimal gland.
• Periorbital neurosensory loss in the absence of trauma
BENIGN LESION (pleomorphic adenoma)
• a gradually progressive painless mass in the region of the lacrimal gland.
ARTERIOVENOUS SHUNT
• history of “tinnitus”
ORBITAL VARICES
• Proptosis provoked by straining may suggest.
AMYLOIDOSIS
• spontaneous unilateral periorbital bruising in an adult may suggest.
NEUROBLASTOMA
• bilateral bruising in a child
SCIRRHOUS ORBITAL METASTASIS.
• Acquired exophthalmos in a female patient with a past history of breast
carcinoma

23. GENERAL PHYSICAL EXAMINATION
• Skin and oropharynx
cutaneous /intraoral vascular lesions: lymphangioma
café au lait spots :neurofibromatosis.
• Cranial Nerve Examination:
periorbital and corneal sensation.
• Examination of Chest and Abdomen:
systemic malignancy: undiagnosed ca breast
• The regional/ distant/ generalized lymphadenopathy
lymphoproliferative disorder.

24. OCULAR EXAMINATION
• Visual acuity, Refraction, visual fields, colour vision.
• Facial asymmetry,Head posture,Lid retraction/ptosis
• ocular alignment,Extraocular movements
• Examination of the anterior segment including pupil.
• INSPECTION:
• examiner looks from above standing behind patient/looks
up from below with the patient’s head tilted back
1]Type of proptosis (axial / non-axial),location of mass,
visible pulsation, skin changes.
2] Lagophthalmos,conjunctival congestion/discolouration.
3] Corneal exposure, change in size with valsalva.
4] examination of the globe and ocular adnexa
* Dilated episcleral vessels: arteriovenous shunt.

25. *A “salmon patch” lesion beneath the upper eyelid:
orbital lymphoma, amyloidosis, sarcoidosis, leukemia,
lymphoid hyperplasia, rhabdomyosarcoma.
*Eversion of the upper eyelid ->waxy yellow
infiltrate with tortuous vessels : amyloid lesion.
*S-shaped deformity of upper eyelid : plexiform NF.
PALPATION :
1] Size, shape, surface, margins,consistency.
2] Signs of inflammation, tenderness, reducibility,motility.
3] Variation with valsalva, resistance to retropulsion,Thrill.
4] Corneal sensation, infraorbital / supraorbital anesthesia
5] Any swelling around the eyeball, regional lymph nodes
& orbital rim.
AUSCULTATION
abnormal vascular communications -> bruit
caroticocavernous fistula.

28. • Fundus examination : signs of venous engorgement
haemorrhage
papilloedema
optic atrophy
choroidal folds
• Intraocular pressure

29. EXOPHTHALMOMETRY
• Measurement is done from the lateral orbital rim to the anterior
corneal surface.
• A difference >2 mm between eyes ->proptosis.
• Exophthalmometers
Hertel’s exophthalmometer
Luedde scale
Gormaz exophthalmometer.
• Three types
Absolute exophthalmometry - compared with n/l reading (>21mm)
Relative exophthalmometry - relative distance of the 2 corneas from
lateral orbital rim.
Comparative exophthalmometry -exophthalmos of at different times.

30. procedure
1) With closed eyes, locate the orbital notch on the
temporal side of the orbital rim near lateral canthus.
2) grooves placed in the orbital notch. The separation of
exophthalmometer noted
3)The patient told to open their eyes and look straight ahead.
4)Red lines should overlap to avoid the parallax.
5)corneal apex position on the scale noted.
6)From mirrors located at each end findings are recorded in mm.
Limitations
• Poor fixation, depressed /fractured lateral orbital
rim,convergence, parallax errors, head movements affect the
readings.
• separation of the grooved arcs is narrow, readings falsly low.
• separation of grooved arcs too wide :readings falsly high

32. • Ludde’s Exophthalmometer
• Transparent plastic mm ruler which is thicker than
normal ruler.
• Notch conforms to angle of lateral orbital rim.
• Scale readings: 0mm (end of notch) to 40mm.
• Parallax is minimized by using scale on both sides of
the rod.

33. LABORATORY INVESTIGATIONS
• CXR :sarcoidosis
ca bronchus
Wegener’s granulomatosis
• TFT/thyroid ab :Graves’disease
• Angiotensin-converting enzyme:sarcoidosis
• c-ANCA & RFT :Wegener’s granulomatosis
• Immunology screen : SLE

34. ORBITAL IMAGING
• CECT - initial choice of investigation .
• MRI - orbital apex,CNS involvement,soft tissue
infiltration and RB.
• USG – 2 assess internal reflectivity of lesion &
calcification in RB.
• CT/MRI angiography for vascular lesions.

35. CT : DERMOID CYST

36. CT OF AXIAL PROPTOSIS

38. dermoid cyst orbital cellulitis

40. RHABDOMYOSARCOMA
ORBITAL LYMPHANGIOMA

42. TED
HEMANGIOMA
METASTATIC CA

45. THANQ