Proptosis, or the abnormal protrusion of the eye, can be caused by a variety of conditions. A thorough diagnostic workup includes a medical history, physical exam, and imaging tests like CT or MRI to determine the cause. Common etiologies include thyroid eye disease, optic nerve tumors, and intraconal masses. Treatment depends on the underlying condition but may involve medications, surgery such as orbital decompression, or radiation therapy. Accurately diagnosing the cause of proptosis through diagnostic testing is essential for guiding effective management of the condition.

1. PROPTOSIS :
INVESTIGATION & MANAGEMENT
Dr Ramchandra D Hendge

2. Proptosis
 Definition :
 Abnormal protrusion of globe
 Displacement of globe relative to orbital rims
 Exophthalmos : abnormal protrusion of eye balls in
endocrine disorders specially in thyroid dysfunction

3. Classification
 1) Based on direction
 2) Based on severity
 3) Based on presentation
 4) Based on etiology
 5) Based on movement

4. Etiology
Axial Proptosis- Eccentric/Abaxial Proptosis
Optic nerve tumours Thyroid orbitopathy
Intra conal haemangioma Dermoid cyst
Infections & Inflammations
Neurofibroma
Lacrimal gland tumour

5. Approach to diagnosis
History Clinical exam Investigations
Inspection Blood Ix
Palpation Imaging
Percussion X-ray
Auscultation USG
Tests CT
MRI
Angiography
Histopathology
FNAC
Biopsy

6. History
 Onset , duration, progress
 DOV, colour vision defect
 Diplopia
 Discoloration of lids
 Association with straining
 Postural variation
 Oral hygiene

7. Clinical Examination
 Inspection
 Palpation
 Percussion
 Auscultation
 Clinical Tests

8. Auscultation
 Globe/temporal region for bruit

9. Differential Tonometry
 Useful in fibrosis of muscles & lesions compressing globe
 Rise in IOP >6mmHg suggestive of pathology
 Rise in IOP due to mechanical compression of globe
 Gaze- Upward for muscles & in direction of mass in
space occupying lesions

10. Ruler Test

11. Exophthalmometry/ Proptometry
1) Clinical
2) Stereo Photographic
3) Radiographic
 Clinical Exophthalmometry
1. Hertel
2. Luedde
3. Naugle
4. Gormaz

12. Hertel Exophthalmometer
 Measures distance of corneal apex from lateral orbital rim
 Lateral orbital rim serves as reference point
 Difficult to use in lateral wall fracture or surgery

14. Leudde Exophthalmometer
 Light weight, cheaper, easier
 allows accurate measurement of proptosis by viewing at right
angle

15. Naugle Exophthalmometer
 Uses fixation points slightly above and below superior &
inferior orbital rims
 Measures difference in proptosis of two eyes rather than
absolute proptosis
 Useful in lateral
orbital wall fracture
or surgery

17. Gormaz Exophthalmometer
 Measure distance between two lateral orbital
margins
 Require topical anaesthesia

18. Blood Investigations
 Complete haemogram
 ESR
 FBS/PPBS
 Thyroid function tests
 Serum c-ANCA levels
 Serum ANA levels

19. Other Investigations
 Sputum for AFB
 Montoux test

20. X -ray
 Should be the first screening imaging investigation
 Useful specially for bony pathology
 Useful in detecting :
Benign tumours
Calcification( Meningioma, retinoblastoma,
lacrimal gland carcinoma)
Hyperostosis( Meningioma, fibrous dysplasia,
osteoblastic secondaries)

21. Caldwell view/General view
Structures seen-
Medial wall ,
orbital rim

22. Water’s view/Orbital view
Structures
seen-
anterior
2/3rd of
orbital
floor

23. Lateral
Structures
seen-
Orbital
roof

25. Ultra sonography
 Rapid, non invasive , simple, no radiations
 Compact & Portable
 Can be done in OPD & before surgery by ophthalmologist
 No need to depend upon radiologists
 Gives information about characteristics of lesions
 Size of lesion can be measured

26.  Principle- Piezo electric effect
 Probes- Sound waves-6-20 MHz
 Lower frequencies-> lower resolution->better penetration
 Higher frequencies-> higher resolution->lesser penetration
 Gives echogenicity based on reflectivity of structure

27. TYPES
 A scan/Amplitude scan
 B scan/ Brightness scan Trans ocular
 C scan/ Coronal scan Para ocular
 D scan / 3D scan

28. Hydatid cyst
• Double wall sign
• Un-echoic space

29. Vascular tumor
• Well
demarcated, intra-
conal lesion with
high internal
reflectivity

30. Orbital Cellulitis
Well defined ,
encapsulated
lesion

31. CT Scan
 Is superior to X ray & USG
 Gives shape , size , location & nature of lesion
 Resolution ~0.5 mm
 8 slices required to scan orbit
 Causes radiation exposure but its comparable with orbital X
ray
 HRCT with 1mm sections gives information about optic nerve
tumours

32. Sections
 Axial section-
shows both globes,
horizontal recti ,
optic nerves, orbital
soft tissue & bony
structures

33.  Coronal section-
 Anterior- Globe with
recti muscles
 Posterior – all recti
muscles, oblique
muscles, optic nerve &
soft tissue of orbit

34. Thyroid orbitopathy
Fusiform
dilatation of belly
of recti muscles

35. Hematoma

36. Meningioma
 Iso-dense with
optic nerve
 Takes contrast
 Tram track sign
on axial CT
 Non enhancing
dot sign on coronal
CT

37. Pseudotumour of orbit
 Generalised
enlargement of
muscles

38. MRI
 Most sensitive modality for soft tissue lesions
 No radiation exposure
 Specially useful in optic nerve lesions, pseudo tumour, orbital
metastasis & tumours having intra cranial expansion
 Metallic implants/ metallic foreign bodies are the only
absolute contraindications

39.  T1/T2 weighting- refers to methods of measuring the
relaxation times of excited protons after magnetic field is
switch off.
 T1- Fat-Bright
Vitreous- Dark
 T2- Fat-Dark
Vitreous- Bright

40. Cavernous Hemangioma
 T1- Iso-intese
with muscle, if
thrombosis-hyper
intense
 T2- Hyper intense
with muscle
 Contrast-
Irregular
enhancement with
delayed wash out

41. Lacrimal gland tumor
Pleo-morphic adenoma-
 T1,T2- Intermediate
intensity
 Contrast- bright
enhancement

42. Pseudotumor
 T1,T2- Hypo
intense
 Contrast-
Diffuse
enhancement

43. Angiography
Orbital Venography :
 Useful in diagnosis of orbital varix, cavernous sinus
thrombosis & obstruction of ophthalmic vein by external mass
 Dye is injected in frontal or angular veins & sequential X
rays are taken in AP view.
 not used now a days

45. Orbital Arteriography :
 Useful in diagnosis of A-V malformations , carotid-cavernous
fistula , aneurysms etc
 Contrast dye is injected in ipsi-lateral common or internal
carotid artery and sequential X rays are taken.
 Contrast medium may cause allergic reactions
 Not used now a days due to CT,MRI & MR Angiography.

46. Ophthalmic artery Anurysm
Hyper lucent
mass in orbit

47. Histopathology
 Definitive diagnosis is by histopathology
Biopsy Techniques :
 FNAC
 Core biopsy
 Incisional biopsy
 Excisional biopsy

48. FNAC
 Minimal invasive
 Rapid diagnosis
 USG/CT guided FNAC
 Accuracy >80%
 Indications :
Lymphoma,melanoma,meningioma
 Scanty material, difficult to evaluate
 Risk of globe perforation,h’age

49.  Core biopsy –better than FNAC
 Inscisional biopsy- sample obtained under direct visualisation
 Excisional biopsy- Best method for tissue sampling
Both diagnostic &therapeutic

50. Pathology Techniques
1. Cytology
2. Gross examination
3. Routine histopathology
4. Histochemistry-Sudan black(Fat)
5. Immuno-histochemistry –HMB45 for melanomas, S100 for
schwannomas & neurofibromas
6. Electron microscopy

51. Management of proptosis
 Local measures
 Medical therapy
 Radiation
 Surgical options

52. Local measures
 Sun glasses
 Sleep in supine position with head elevated
 Taping of lids at night
 Prisms in diplopia

53. Medical therapy
 Topical tear substitutes
 Systemic diuretics - minimal role
 Parenteral antibiotics
 Pain killers
 Corticosteroids

54. Corticosteroids
Indications
 Compressive optic neuropathy
 Prior to orbital decompression
 Pseudo tumor
 Traumatic optic neuropathy
 Hydatid cyst

55. Corticosteroids - regimen
 60-100mg(1mg/kg) orally prednisolone in divided
doses
 Pulse intravenous therapy of methyl prednisolone
1gm on alternate days for 3-5days
 Local steroid injections have no role

56. Complications
 Weight gain
 Gastrointestinal irritation
 Reactivation infections (tuberculosis)
 Cataract
 Glaucoma
 Osteoporosis
 Adrenal gland suppression

57. Immunosuppressive
Indications-
 Refractory cases of thyroid orbitopathy, pseudotumour,
sarcoidosis , hematological malignancies etc
 Commonly used drugs- Cyclosporin, methotrexate,
azathioprine, cyclophosphamide etc
 Anti tumor necrosis factor drugs – infiximab

58. Radiation Therapy
Indications-
 Pseudotumour
 Lymphoma
 Rhabdomyosarcoma
 Meningioma
 Thyroid orbitopathy

59. Surgical management
 Orbital decompression
 Strabismus surgery
 Eye lid surgery

60. Orbital decompression
 Done in stable cases
 Severe exophthalmos
 Exposure keratopathy
 Optic nerve compression
 Cosmetic purpose

61. Surgical approaches to orbit
(1) Lateral orbitotomy (Krönlein procedure)
(2) Superior decompression via craniotomy(Naffziger procedure)
(3) Medial wall removal and ethmoidectomy
(4) Orbit floor removal
(5) Combined ethmoidectomy
and medial orbit floor

62. Complications: Orbital Decompression
 Diplopia
 Hyper aesthesia in distribution of infra orbital nerve
 Nasolacrimal duct obstruction
 Cerebrospinal fluid leak
 Frontal lobe hematoma

63. Strabismus surgery
Indications :
 Done in stable inactive thyroid orbitopathy
 Angle of deviation stable for at least 6–12 months
Goal :
 To minimize diplopia in primary position

64. Eye lid surgeries
 Mild eyelid retraction- no surgeries
 Main indication is exposure keratopathy

65. Conclusion
 Proptosis is an important manifestation of a large number of
orbital diseases. Thorough clinical examination coupled with
appropriate investigations clinches the diagnosis and helps in
management.

66. THANK YOU