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Proptosis

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Proptosis

  1. 1. EVALUATION OF A CASE OF PROPTOSIS DR ARPITA
  2. 2. • PROPTOSIS is defined as forward protrusion of the eyeball • Proptosis of more than 21mm or more than 2mm asymmetry between the two eyes is abnormal • EXOPHTHALMOS is specifically used to describe the proptosis of eyes a/w Thyroid eye disease • ENOPHTHALMOS is defined as retrodisplacement of eye into orbit
  3. 3. PSEUDOPROPTOSIS • It is the false impression of proptosis • Seen in conditions like 1. Buphthalmos 2. High myopia 3. Contralateral ptosis 4. Contralateral enophthalmos
  4. 4. CAUSES OF PROPTOSIS UNILATERAL BILATERAL 1) CONGENITAL - DERMOID/TERATOMA DEVELOPMENTAL ANOMALIES - OXYCEPHALY 2)TRAUMATIC- ORBITAL HRAGE/EMPHYSEMA /IOFB OSTEOPATHIES- RICKETS / ACROMEGALY 3)INFLAMMATION – ORBITAL CELLULITIS/ABSCESS/CAVERNOUS SINUS THROMBOSIS/PSEUDOTUMOR/TUBERCULOSI S/GUMMA/SARCOIDOSIS TUMORS-LYMPHOMA / LEUKEMIA / EWINGS SARCOMA / NEUROBLASTOMA 4)VASCULAR-ORBITAL VARIX ENDOCRINAL - THYROID EYE DISEASE 5)CYSTS-PARASITIC INFLAMMATORY - WEGENERS/HISTIOCYTOSIS/SJOGRENS/ FUNGAL GRANULOMA 6)TUMOR- PRIMARY OR SECONDARY 7)MUCOCOELE OF PARANASAL SINUSES
  5. 5. • Acute proptosis - Orbital emphysema / orbital hemorrhage • Intermittent proptosis – Orbital varix , periodic orbital edema , recurrent orbital hemorrhage • Pulsating proptosis – caroticocavernous fistula , saccular aneurysm of ophthalmic artery , congenital meningocoele , meningoencephalocoele , traumatic or operative hiatus in orbital roof
  6. 6. APPROACH HISTORY LOCAL EXAMN SYSTEM EXAMN INVESTIG ATIONS IMAGING
  7. 7. HISTORY TAKING • Protrusion of eyeball - Age of Onset , duration , progression • Constant or intermittent • Variation with posture / strain • Decreased vision – preceded/followed • Stationary/progressive • Associated field defects
  8. 8. • h/o Pain • h/o Double vision • h/o Trauma • h/o fever , chills ,systemic symptoms • h/o cancer • h/s/o thyroid disease ,TB , DM ,HTN ,HIV , Syphilis
  9. 9. • The patterns of orbital involvement can be divided into four basic categories. • INFLAMMATORY EFFECT: inflammation may be either infectious or noninfectious in nature and is associated with signs and symptoms of redness, swelling, pain, heat, and loss of function. There is often a mass effect present. MASS EFFECT: displacement with or without signs of involvement of sensory or neuromuscular structure. Displacement points to the location of the diseases and may help to characterize its nature. VASCULAR CHANGE: features suggesting vascular disease include venous dilation, pulsation, expansion with straining (Valsalva), and hemorrhage. INFILTRATIVE CHANGE: infiltrative diseases are usually associated with evidence of destruction, entrapment, or both. These include effects on ocular movement or neurosensory function (e.g., optic neuropathy, pain, or paresthesia).
  10. 10. • Sudden dramatic proptosis in a child with recent upper resp tract infetion – hemorrhage into a lymphangioma • Gaze evoked amaurosis – orbital apex tumor • Pain a/w short h/o mass in region of lacrimal gland – adenoid cystic Ca • Long h/o painless mass – pleomorphic adenoma • h/o tinnitus – AV shunt • Proptosis increasing on straining – orbital varix • Spontaneous unilateral periorbital bruising – amyloidosis • Spontaneous B/L bruising - neuroblastoma
  11. 11. LOCAL EXAMINATION • 1) INSPECTION – • Proptosis or pseudoproptosis • Unilateral or bilateral • Axial or eccentric • 2) PALPATION – size ,shape,surface,margins consistency , tenderness , compressibility Thrill /increase with valsalva/ orbital rims / regional lymph nodes • 3)AUSCULTATION - bruit
  12. 12. • 7) ADNEXA – • Dilated episcleral vessels – AV shunt • Optociliary shunt vessels- optic nerve sheath meningioma • Salmon patch beneath upper eyelid – orbital lymphoma • Eversion of upper lid – waxy yellow infiltrate with tortuous vessels- amyloid • S shaped deformity of upper lid – plexiform neurofibroma • Lid retraction or lidlag - thyroid ophthalmopathy
  13. 13. 4) EOM MOTILITY – decreased in thyroid orbitopathy,extensive tumor growths and neurological deficit 5) VISUAL ACUITY – maybe decreased due to Refractive changes due to pressure on eyeball Optic nerve compresssion Exposure keratopathy 6) PUPIL REACTION – RAPD suggests optic nerve compression
  14. 14. 7) COLOR VISION , VISUAL FIELDS 8)FUNDOSCOPY – may reveal hemorrhages , papilloedema , optic atrophy , choroidal folds
  15. 15. MEASUREMENT OF PROPTOSIS • Measured by a group of instruments called exophthalmometer or proptometer • All instruments are meant to measure the distance b/w thw apex of cornea and lateral wall of orbit • OPTICAL- Lueddes scale and Hertels exophthalmometer • MECHANICAL – Gormaz exophthalmometer
  16. 16. SYSTEMIC EXAMINATION • Thyroid examination • Primary tumors elsewhere in the body – CVS/RS/Abdomen/PV/Rectal • ENT examination
  17. 17. LAB INVESTIGATIONS • Hematological - CBC , ESR, VDRL • Thyroid function tests • Serum ANA , c- ANCA , ACE • BUN , Creatinine • C-XRAY , Mantoux test • Casonis test – r/o hydatid cyst • Stool examination – cysts /ova • Urine analysis – bence jones proteins - MM
  18. 18. IMAGING • XRAY – • Calcification/hyperostosis – Meningiomas • Waters view – blow out fractures • Rhese view – optic foramen and SOF • CT- SCAN Size , position and shape of • USG lesion • MRI
  19. 19. • ORBITAL VENOGRAPHY – Orbital varix • CAROTID ANGIOGRAPHY – Aneurysms /AV communications
  20. 20. HISTOPATHOLOGICAL STUDIES • FNAB • Incisional biopsy • Excisional biopsy
  21. 21. • Proptosis with white reflex – retinoblastoma • U/L fast progressing proptosis , fever , toxic child , pain – orbital cellulitis • U/L axial proptosis with early vision loss – optic nerve glioma • B/L proptosis , fever and toxemia – cavernous sinus thrombosis • Pale child , bleeding from gums , U/L or B/L proptosis – leukemia • U/L proptosis ,pain ,fever,hazy cornea and loss of vision - panophthalmitis

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