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proptosis.pptx
- 1. ORBIT
- 2. • Quadrangular pyramids situated between the anterior cranial fossa and the maxillary sinuses below. • 40 mm in height, width and depth • Formed by 7 seven bones: Frontal, Maxilla, Zygomatic, Sphenoid, Palatine, Ethmoid and Lacrimal. • Has 4 walls - medial, lateral, superior and inferior.
- 3. WALLS OF ORBIT • Medial - 2 orbits are parallel, common for #. • Inferior - (floor) triangular, commonly involved in blow--out #. • Lateral - triangular, covers posterior half. • Roof - formed by orbital plate of frontal bone. • Apex - posterior end where 4 walls converge, 2 orifices, the optic canal which transmits optic nerve and ophthalmic artery and Superior orbital fissure which transmits arteries, veins and nerves.
- 5. CONTENTS OF ORBIT • Volume: 30 cc. • 1/5th is occupied by eyeball. • Part of optic nerve, Extraocular muscles, lacrimal gland, lacrimal sac, ophthalmic artery and its branches, 3rd, 4th and 6th cranial nerves and ophthalmic & maxillary divisions of cranial nerves, sympathetic nerve and fascia.
- 7. Definition • Forward movement of globe in relation to skull. • It is measured by protrusion of apex of cornea from outer orbital rim.
- 8. Clinical Evalution History • Onset (acute, gradual) • Duration(days, years or since childhood) • Progression Rapid (infection/inflammation/hemorrhage/malignant transformation) Intermediate(Periodic orbital edema, recurrent orbital hemorrhage/chocolate cyst and highly vascular tumor, orbital varices, capillary hemangiomas) Slow( tumor) • Associated ( decreased in vision, pain, redness, diplopia or squint and limitation of eyeball) • Variable ( increasing or decreasing with Valsalva maneuverer)
- 9. Causes of decreased vision astigmatism, exposure keratopathy, optic nerve compression, murcormycosis can cause CRVO. Causes of pain infection, inflammation, neoplasia when bone and nerve is involved and acute pressure change (orbital haemorrhage). Causes of redness infection, inflammation Causes of diplopia restriction of muscles 1. Orbital mass 2. Myositis 3. Thyroid eye disease 4. Tethering (# of floor of orbit) 5. Direct nerve involvement( SOF/CSS)
- 10. CAUSES OF PROPTOSIS BASED ON THE AGE OF ONSET Newborn Children Young adults Middle age Senile • Orbital cellulits • Orbital neoplasm • Rhabdomyosarc oma • Hemangioma • Dermoid cyst • Orbital cellulitis • Optic nerve glioma • Carniosynostosis lymphomas • Thyroid ophthalmopathy • Pseudotumor • Orbital cellulits • Osteomas • Infiltrative tumors • Pseudotumor • Endocrine • Malignant lymphomas/leuk emias • Optic nerve sheath meningiomas • mucocele • Malignant and metastatic tumor of orbit • Pseudotumor • Leukemia • Lymphomas • Sarcomas
- 11. CAUSES OF UNILATERAL PROPTOSIS Pathology Eitiologies Congential Dermoid Teratoma Traumatic Orbital hemorrhage Emphysema Inflammation Orbital cellulitis/ abscess Cavernous sinus thrombosis Pseudotumor Tuberculosis Sarcoidosis Vascular Orbital varix cysts parasitic Tumor Primary or secondary
- 12. COMMON CAUSES OF BILATERAL PROPTOSIS Pathology Etiologies Inflammations • Thyroid orbitopathy • Wegener’s granulomatosis • Idiopathic inflammatory pseudotumor • Myositis • Sarcoidosis • Sjogren’s syndrome Neoplasia • Lymphoma • Leukemia • Metastatic carcinoma • Optic nerve glioma Vascular lesions • Arteriovenous shunts varix
- 13. PAST HISTORY 1. Drugs 2. Chemotherapy 3. Radiotherapy 4. Smoking 5. Trauma 6. Surgery
- 14. Family history Neurofibromatosis Familial idiopathic proptosis
- 16. INSPECTION FACIAL ASYMMETRY ex Meningioma, Neurofibromatosis HIRSHBERG TEST to look for dystopia
- 17. AXIAL • Axial both eyeballs are coming out in centre • Common causes • Thyroid eye disease • Optic nerve tumour • Cavernous haemangioma
- 18. • NON-AXIAL • Non axial it can come out in any direction. • Down and out: dermoid, frontal and ethmoidal glands • Down and in: lacrimal gland tumor • Upwards : maxillary sinus tumor • Outwards: lesion of anterior ethmoidal sinus, nasopharngeal tumor.
- 19. 1. Periorbital margin • Fullness • Ecchymosis • Scars 2. Eyelid shape like S shape seen in neurofibromatosis and dacryoadenitis. retraction of lid – thyroid eye disease Eyelid changes (mass) lesion surface Prominent vessels nodules ulceration Pulsation Pulsatile proptosis ( cortico- cavernous fistula)
- 20. Fracture of roof of orbit Sphenoid dysplasia Meningocele Pulsation increasing with Valsalva mauver ( orbital varix) it causes intermittent proptosis Transmitted pulsations
- 21. Conjunctiva • Congestion (infection or inflammation) • Chemosis • Arterialization of vessels ( increase episcleral venous pressure) seen in thyroid eye disease, Sturge weber syndrome, cartico cavernous fistula. • Previous photograph ( orbital varix)
- 23. Relative >2mm Absolute >21 mm Asian- 18 mm Caucasians- 20mm Black- 22 mm
- 24. Non axial proptosis • 2 ruler method • Naugle exophthalmometer • Mc-coy facial tri-square
- 25. PALPATION • Orbital margin temperature, tenderness • Mass size, shape, surface localised/diffuse, mobile, fixed to bone, consistency and reducibility. • Retropulsion test (retrobulbar tumours) • Mild pulsations slit lamp examination ( applanation tonometer)
- 26. • Thyroid eye disease lid lag sign convergence (decreased) jaw fore sign( forehead wrinkles lost)
- 27. Auscultation Bruit (bell part of stethoscope) – present in carito cavernous fistula Negative varices will have negative burit In thyroid patients Lymph nodes Neck swelling + - do palpation and ask to drink water
- 28. Ocular examination 1. Vision 2. Extra ocular muscle 3. Pupil examination – RAPD 4. Cornea – exposure keratopathy, corneal sensations 5. Sclera- inflammation/ any nodule 6. Iris- lish nodules(neurofibromatosis) 7. Lens- post subscapular cataract( NF-2) 8. Fundus-swelling (retrobulbar tumour ), optic atrophy, optocillary shunts ( CRVO, MENINGOMA, GLUCOMA, IDOPATHIC INTRACRANIAL HYPERTENSION)
- 29. 8. IOP – differential IOP Difference of >6mmHg (barely sign)
- 30. Systemic Examination • Pulse • Temperature • Tremors (Fine) • Skin changes(Café-au-lait spots) seen in NF or any inflammatory condition like sarcoidosis or Tuberculosis.
- 31. IMAGING • CECT – Bones/ Mass • MRI- soft tissue, involving the orbital apex , inflammatory disease , intracranial extension and vascular • USG – Vascular tumours and cyst • Invasive procedures • Orbital venography: orbital varix • Carotid angiography: pulsatile proptosis • Biopsy • FNAC • Systemic test peripheral smear
- 32. Prominent Eyeball Rule out pseudo-proptosis True proptosis CT/MRI Mass + Neoplasia Vascular Neural Bony Lacrimal gland Fibrous/ mesenchymal metastasis Infective Orbital cellulitis Abscess Cystic Dermoid cyst etc Vascular CC fistula No inflammation Trauma/structural Fracture, craniosynostosis Vasculitis Wegner's Churg- Strauss Inflammation Inflammatory disorder TED IgG4 related Infections Orbital cellulitis- preseptal
- 33. THANK-YOU
Editor's Notes
- 1st we will take history and sart with onset, it can be acute or gradua lprogress rapid means hours to days, intermediate weeks to months slow from months to years now ask whether this proptosis is associated with other things or not like
- Usually pain rule out neoplasia or it can be some bone involvement or nerve involvement Rescrition of muscle because of orbital mass because it is so big it is restricting the muscle, muscle involvement like in myositis ththering like fracture of floor of orbit like muscle is stuck than eyeball is not able to move bcoz of direct injury to nerve , nerve can be involved like for example the sof/css and this can be ruled out by forced duction test which will be negeative in paralytic squint and + in restriction
- In drugs ask for thyroid drugs,
- Before inspection we need to rule out pseudoproptosis see this patient looks like left eye has proptosis but it is not it is looking proptosis because there is scleral show below and what is happening actually this is right eye ball this is left eyeball left is bigger there is difference in size of eyeball refractive error can be more in the left enisometric can be there left eyeball is high myopic or eyelid retraction which also looks like proptosis other can be contralateral ptosis in this other eye looks like slightly proptotic or if there is shallow orbit
- 1st we have to know the asymmetry of the patient facial asymmetry can be seen LIKE IN TEMPORAL FOSSA FULLNESS Now take out troch and do Hirshberg test to see the prominence of the eyeball and than u look the eyeball is in which direction known as dystropia it can be done by nafgigger view in which u stand behind the patient and see which eyeball we see 1st or which is more prominent and if we see from front than it is worms view
- Direction of dystropia can be axial or non axial optic nerve tumor like glioma, mengioma and retrobulbar tumor like cavernous hemangioma
- In lacrimal gland tumors eyeball will go down and out will cause inferior dystropias
- Periorbital changes Or any eyelid changes Any Scar from the perivous surgery If there is any mass on eyelid than u have to see surface Carotico cavernous fistula is when there is fistula b/w the cavernous sinus and ICA the blood will go into the cavernous sinus and there will be pulsation bcoz the blood is in ICA is impulses.
- Other causes of pulsatile proptosis are the eyeball protected from this brain and brain has pulsations but the eyeball is protected from brain by orbit but if there is herniation of the brain the brain can herniate and press onto the eyeball that be seen in the During the inspection we will see whether it is increasing with valsva manuver which is there in orbital varix it causes intermittent proptosis if it is increasing it suggests the communication of the extra vessels with the normal circulation that happens in orbital varix
- In conjunctiva we see if there is any congestion that suggest any infection or inflammation whether there is chemosis again suggests any infection and inflammation going on or whether there is Arterilization of the vessels now this suggests there is increased episceral venous pressure for ex it can be seen in thyroid eye disease sws ccf these are some example where cox crew vessels of conjunctiva is there Ask patient for previous photographs For ex pt is having orbital varix than u see in childhood lesion was there and how it is growing with years.
- Exopthalmometer is a measurement of proptosis and the most common instrument is hurtles exophthalmometer BUT THERE ARE SOME DISADVANTAGES it is done in axial proptosis only some other are Naugle which is preferred in presence of an orbital fracture or after lateral orbitotomy and in children there is luedd this is just a ruler which u put it on lateral orbital margin and u see where the eyeball is having proptosis so hertel is most common
- U hv to keep the edge at the lateral orbital margin what is proptosis from the lateral orbital margin u see how much is the corneal apex of the cornea that is telling about the proptosis value it comes out to be value like this 20, 30 in hertels exophalmometr we keep the to 2 end at lateral orbital margin it is an 1 eye at a time see there are markings over here so when the 2 lateral orbital margins there will be a reading on the scale note down that reading it is very imp because in future u r seeing a progression of proptosis this has to be constent otherwise we are not doing the proptosis correctly so base setting should be noted down that should be constent in future examination above here there is a scale and there is marking there are 2 red lines u can see. To measure if u r testing left eye u have to see by ur right eye u close ur left eye and u see from ur right eye u are the same level as patient and u have remove the parallax u hv to eliminate parallax by these 2 red lines should coinside and the apex it at which level of marking what will give u correct measurement of proptosis. U have to do this for the other eye as well if it is more than 2 mm that is a relative measurement relative means as compared to the other eye means more than 2 mm proptosis difference that is significant but there is absolute value also coming that is more than 21 mm that is taken as significant but ofcourse it depends on the race like in Asian normal is 18 mm in causacians 20mm and blacks they have shallow orbits 22 mm
- In this we have to see whether as compared to other eyeball ur eyeball is how much inferior, lateral, superior and medially and ofcourse how much it is proptosed.
- To start the palpation ask the patient to close his eyes and look down take ur little finger and gentaly insuniate to check for resistance we feel the orbital margins whether there is any bony defect or whether we can incuniate our finger if there is any mass in b/w mass and the bone that is incuniation u can check temperature ,tenderness and look for resistance to retropulsation resistance to retropulsation is down like this use five fingers bring the fingers close together and gently retropulse if there is any resistance felt than it is seen in retrobulbar tumors and if there is any mass + we have to note down the size, shape, temperature, tenderness we have to see whether the mass is localized or diffuse is it mobile or is it fixed to the bone or not the consistency reducibility.
- lid is not going down because whenever we look down the lps muscle relax and eyelid follows the globe but in thyroid there is lid retraction. So eyeball goes down but the eyelid will not follow the globe eyelid remains behind this is called as lid lag sign. Wrinkling we ask the patient to see in superior gaze now see the wrnikles of the forehead if there is loss of wrnikles that suggests jawfore sign in thyroid eye disease.
- U have to check bruit whenever there is arterilor communication u will hear the bruit check it with the bell part of stethoscope u make the patien close the eye and u hear the burit in thyroid patients check neck as well and the lymphnodes check peri auricular, submental lymph nodes , submandibular lymph nodes and u check the neck as well if there is a swelling in the neck as well that also as to be mentioned if neck swelling present than palpation has be done also ask the pt to drink water and see wheather swelling is moving or not with drnking water
- Fundus there Can be swelling of the optic nerve seen in retrobulbar tumor later which can lead to optic atrophy, optocillary shunts these are enlarged pre-existing capillaries usually they are seen in the temporal part of the disc and they are tortueus vessels there is a mass there is a obstruction to the normal drainage there is a communication b/w the central retinal vein and the choroidal circulation
- Should be seen in thyroid or a proptosis case differitial iop is that the difference b/w the baseline iop vs the iop in a direction in which there is a limited movability of the eyeball so iop measurement at baseline when the patient is looking straight for example in thyroid eye disease there is a inferior rectus contraction and pt has difficulity to look up now ask the pt to look up and than u measure the iop.when there is a resistance to the eyeball movement the resistance is transmitted to the eyeball and than it can cause increase intraocular pressure
- Ct scan is good for bones, trauma fractures, foregin bodies , emphyemas And for any mass we have to localise there the mass is like intraconal, extraconal exact location of mass in relation to the other structures of the orbit this will help us to plan the surgery and also in there is contrast enhacement it will tell us vascularized tumor or not We do mri when we suspect the proptosis is due to soft tissue FNAC IS avoided in dermoid tumors, hydaited cyst plomorphic adenoma orbital varix it confirms the diagnosis and also outlines the size and extent of the lesion that helps in proper surgical planning…. Carotid angiography it helps to identify the location and extend of ophthalimic artery aneurysms, av malformations.
- DIFFRENTIALS OF PROPTOSIS Vascular tumors like orbital varix , neural tomors like schonomas neurolomas, meningoma, glioma or optic nerve tumors