The document discusses proptosis, defined as abnormal protrusion of the eyeball, and its differential diagnosis including pseudoproptosis caused by conditions such as myopia and trauma. It outlines examination techniques, history gathering, imaging modalities, and various causes of proptosis, distinguished between axial and non-axial proptosis. Important diagnostic tests and criteria for assessing proptosis are also highlighted, along with their clinical significance.

1. WORK-UP OF
PROPTOSIS
MODERATOR : DR. VINNATI KANGALE MAAM
PRESENTED BY: DR SONALI SAHU

2. DEFINITIONS:
EXOPHTHALMOS: protrusion of globe secondary to thyroid eye disease
DYSTOPIA: Dystopia implies displacement of the globe in the coronal plane,
usually due to an extraconal orbital mass such as a lacrimal gland tumour.
Proptosis describes an abnormal protrusion of the globe with respect orbit, which
may be caused by retrobulbar lesions or, less frequently, a shallow orbit.
CRITERIA FOR PROPTOSIS:
1) Proptosis more than 22mm beyond the orbital rim.
2) An asymmetry of more than 2mm between the eyes.

4. PSEUDOPROPTOSIS
Pseudoproptosis is either the stimulation of an abnormal prominence of
the eye or a true asymmetry that is not caused by a mass, a vascular
abnormality, or an inflammatory process.
Causes of pseudoproptosis:
• Myopia
• Glaucoma
• Trauma
• Contralateral ptosis
• Lid retraction
• Facial nerve paralysis
• Contralateral small globe
• Congential asymmetrical orbital size.

7. HISTORY
• Age of onset & nature – sudden/gradual
• Course & duration of proptosis
• associated symptoms:
loss of vision – gradual or sudden
Defective color vision
scotoma
Pain
diplopia
• Any association with cough or straining
• Any associated known systemic disease
Thyroid disease
Malignancy (lung, breast, prostate)
• Any history of trauma
• Any positive family history
• Any change in direction or protrusion

8. GENERAL EXAMINATION
• Age, built, weight
• Vitals
• pallor, icterus, clubbing or cyanosis
• Respiratory, cvs & cns general examination
• Facial asymmetry, scars , deformities
• Swelling in thyroid region
• Signs of trauma
• Signs of any cranial nerve palsies
• Any deformity of skull , teeth & bones

9. OCULAR EXAMINATION
• Visual acuity &BCVA
• Color vision testing
• Visual fields
• measurement of palpebral width (there should be no scleral show)
• Anterior chamber examination
• Pupillary reaction
• Slit lamp biomicroscopy
• Orbital margins
• Ocular movements
• Look for any mechanical ptosis
• Fullness of eyelids (enoth sign)
• Measurements for IPD
• Diplopia work up

10. INSPECTION
• Age
• Any skeletal deformity of skull
• Asymmetry of face
• General appearance for any staring looks
• Proptosis is unilateral or bilateral
• Any associated squint
• Versions and ductions in all gazes
• Direction of displacement of globe
• Any swelling , chemosis, congestion, lid retraction,
lagophthalmos
• Signs of trauma

11. The following questions should be answered
before examination for proptosis :
1) Is the eyeball in normal position ?
2) If so, is the contralateral eyeball sunken
(enophthalmic) ?
3) Is the eyeball proptosed ?

12. SIGNS OF NORMAL POSITION OF THE GOLBE:
1) upper lids should cover one fifth of upper part of
normal cornea or 2mm from upper limbus.
2) lower lids should just touch cornea at lower limbus.
3) no strip of sclera should be visible either above or
below the cornea.

13. 4) if a straight measuring scale is put in front of eyeball in such
a position that upper part rests over mid point of eyebrow and
lower part rests on maxilla, then outer margin of upper lid
should just touch inner edge of scale. if it pushes scale away,
the eyeballs pushed forward. if there is gap between inner edge
of scale and lid eyeball is pulled in.

14. EXAMINATION OF A SUSPECTED CASE OF
PROPTOSIS
• Patient is made to sit comfortable and examiner stands behind
the patient.
• The patient’s head is tilted back slightly
• Look at the most prominent part of the upper lid
• Normally the center of upper lid should be just visible at the level
of upper rim of orbit
• If it protrudes beyond that, the eyeball is proptosed

15. NAFFZIGER’S METHOD: relative protrusion can be
obsereved by simple standing behind a seated patient and
gazing downward (tangentially) toward chin from forehead to
assess protusion of eye beyond orbital rim.

16. WORM’S EYE VIEW: it is
similar to Naffziger’s method
but the difference is that
exminer examines up from
below wit the paitent’s head-
titled back.

17. OCULAR MOVEMENTS
If the ocular movements are
restricted:
 FORCED DUCTION TEST
 DIFFERNTIAL IOP
 SACCADIC EYE MOVEMENTS
 ELECTROMYOGRAPHY

18. FORCED DUCTION TEST
• How to perform?
A. Topical anaesthetic drops are instilled.
B. A cotton soaked in anaesthetic solution is inserted into both eyes over the
muscles to be tested and left for about 5 minutes.
C. The insertion of the muscle in the involved eye is grasped with forceps and
the globe is rotated in the direction of limited mobility.
D. The test is repeated in the unaffected eye.
E. The test is said to be positive when it is difficult to move the eye well in the field
of action. This happens in entrapment of muscle, in fracture of orbit or in thyroid
myopathy, excessive scarring of conjunctiva.
F. The test is said to be negative in neurological paralysis where the globe can be
moved with ease.

21. DIFFERENTIAL IOP TEST
• Intraocular pressure is measured in the primary position of gaze and then
with the patient attempting to look into the direction of limited mobility.
• POSITIVE RESULT: An increase of 6 mmhg or more denotes resistance
transmitted to the globe by muscle restriction (BRALEY SIGN).
• NEGATIVE RESULT: An increase of <6 mmhg suggests a neurological
lesion.
• The advantages of this test over forced duction is a lesser degree of
discomfort and an end-point that is objective rather than subjective.

22. SACCADIC EYE MOVEMENTS
In neurological lesions are reduced in velocity, while restrictive defects
manifest normal saccadic velocity with sudden halting of ocular
movement.
EMG is normal to elevated in cases of restrictive lesions
Decreased in cases of paralytic lesions
EMG ( ELECTROMYOGRAPHY)

23. FINGER INSERTION TEST
• Insert the little finger between orbital margin and eyeball
• Feel for any mass and its consistency
• Vascular tumors are soft in consistency other are firm to hard

24. RETROPULSIO
N:
• Paitent is asked to close the lids
• Apply light pressure on closed lids
with palms.
• Feel the reducibility of globe.

25. BENDING FROWARD AND COUGHING
• Ask the pt to bend forward and also to cough so as to
produce strain
• Proptosis can be induced in orbital varix after a latent
period of 5 seconds
• Proptosis due to orbital varix is always unilateral and
usually left sided due to narrower jugular foramen on the
left.

26. VALSALVA MANEUVER
 Ask the pt to bend forward and also to
cough so as to produce strain
 Proptosis can be induced in orbital varix
after a latent period of 5 seconds
 Proptosis due to orbital varix is always
unilateral and usually left sided due to
narrower jugular foramen on the left

27. PULSATION AND BRUIT
Pulsation is caused either by an arteriovenous
communication or a defect in the orbital roof.
• In the former, pulsation may be associated with a bruit
depending on the size of the communication.
• In the latter the pulsation is transmitted from the brain by
the cerebrospinal fluid and there is no associated bruit.
• Mild pulsation is best detected on the slit-lamp,
particularly during applanation tonometry.
A bruit is a sign of carotid-cavernous fistula. It is best heard
with the bell of the stethoscope and is lessened or
abolished by gently compressing the ipsilateral carotid
artery in the neck.

28. EXOPHTHALMOMETRY
Exophthalmometers measure the
distance between apex of cornea
and the lateral rim of orbit i.e the
severity of proptosis

29. • The scale is caliberated in mm, 0 to30
• No anesthesia required
• Pt is asked to sit or lie down and fix his
gaze to a distant object
• The scale is put at right angle to the
lateral wall of orbit
• The apex of cornea is viewed through the
transparent scale and reading is taken in
mm
• Normal 15 to 20 mm
LUEDDE’S TRANSPARENT
SCALE

30. HERTEL EXOPHTALMOMETER

33. GORMAZ EXOPHTHALMOMETER

34. NAUGLE’S EXOPHTALMOMETER
• In case of acquired or congential
asymmetry of the lateral orbital rims a
Hertel exophthalmometer is misleading.
• In these cases, A NAUGLE
EXOPHTHALMOMETER is preferred
since the referring structure is not the
lateral orbital rim but the frontal and
infraorbital structures.

35. FUNDUS EXAMINATION

36. LAB INVESTIGATIONS:
CBC & ESR
FBS PPBS
URINE: routine & microscopy, culture &
sensitivity
STOOL: cyst & ova
Lipid renal & liver profile
Thyroid profile
Casoni’s test for hyadatid cyst
ACE enzyme for sarcoidosis
ANCA antibody for wegener’s
Immunology screening for lupus

37. IMAGING IN PROPTOSIS:
Following imaging modalities can be used:
1) X ray
2) USG
3) CT SCAN
4) MRI

38. X RAY ORBIT
Helps in localizing orbital pathology:
1. Caldwell view: This shows greater and lesser wing of
sphenoid. Superior orbital fissure, most of the paranasal
sinuses.
2. Waters' view: This gives details of orbital rim, orbital
roof and floor and maxillary sinuses.
3. Lateral view: This shows sphenoid, sphenoid air
sinuses, anterior clinoid and sella turcica.
4. Axial (basal view).
5. Optic foramen view: X-ray of both the foramen should
be taken for comparison especially in optic nerve glioma.

39. WHAT TO LOOK FOR IN X-RAY ORBIT
1. Size of orbit
2. Symmetry of orbit
3. Bone changes
4. Intraorbital calcification
5. Changes in paranasal sinuses
6. Retained intraorbital foreign body
7. Changes in optic foramen and optic
canal
8. Superior orbital fissure width
9. Fracture in the orbital rim
10. Fracture in orbital walls
Enlarged Optic Foramen In
NF-1

40. USG: Helpful in thyroid
Ophthalmopathy where
it
Demonstrate extra large
Lateral and medial recti
MRI: non invasive procedure
Soft tissue details are better appreciated

41. Computerized Tomography of Orbit Following
types of tomography are done in orbital
diseases:
1. Axial tomography: This is the most commonly
used mode to locate intraorbital/ retroorbital
lesions.
2. Coronal tomography demonstrates bone
erosion in malignant tumours, mostly of lacrimal
gland.
3. Lateral tomography is used to see blow out
fracture of orbit.

42. MEASUREMENT OF PROPTOSIS
• The technique for assessment of proptosis using mid-axial orbital
CT scan was first described by Hilal and Trokel in 1977.
• A straight line is drawn between the anterior margins of zygomatic
processes, using the mid-axial orbital scan. The distance between
the anterior aspect of cornea and the inter-zygomatic line is then
measured.
• Values > 21 mm or an asymmetry greater than 2 mm between the
globes, is highly suggestive of proptosis.
• Another technique of assessing proptosis is by measuring the
distance between the inter-zygomatic line and posterior sclera.
Less than 1/3rd globe lying behind the inter-zygomatic line is
strongly indicative of proptosis. (Figure 2).
• It is worth noting that the above two methods can be applied to
both CT as well as MRI scan.

43. DIFFERENT CAUSES OF PROPTOSIS

47. CAUSES OF AXIAL PROPTOSIS:
• Graves disease
• Optic nerve glioma and meningioma
• Hemangioma

48. CAUSES OF NONAXIAL PROPTOSIS:
• Dermoid
• Dermolipoma
• Carcinoma of ethmoid
• Carcinoma of frontal sinus
• Carcinoma of maxillary antrum
• Nasopharyngeal tumor
• Carcinoma of maxillary antrum
• Nasopharyngeal tumor