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Proptosis
- 1. PROPTOSIS By, Dr. A. Suganya MS Senior Resident Department of Ophthalmology
- 2. DEFINITION • Abnormal forward displacement / protrusion of the eyeball beyond the orbital margin. Proptosis = Exophthalmos General term Thyroid related cause
- 3. CRITERIA • Normal adults – 16 to 21 mm (from lateral orbital rim to the corneal apex) • Proptosis – Protrusion > 22 mm beyond the orbital rim or asymmetry > 2 mm between the eyes
- 4. Classification PROPTOSIS Pseudo Facial asymmetry High myopia, buphthalmos Lid retraction Contralateral enophthalmos True Unilateral Bilateral Acute Intermittent Pulsatile
- 6. ETIOLOGY
- 7. UNILATERAL PROPTOSIS Congenital Dermoid Teratoma Trauma Haemorrhage Foreign body Traumatic aneurysm & emphysema Inflammation Orbital cellulitis Abscess Panophthal mitis Early CST TB, Sarcoidoidis Vascular Varix Aneurysm Cysts Haematic cyst Implantation cyst Parasitic Tumour Primary/ secondary/ metastasis Mucocele of PNS Frontal Ethmoid maxillary
- 8. ORBITAL CELLULITIS RETROBULBAR HAEMORRHAGE CAVERNOUS SINUS ANEURYSM
- 10. BILATERAL PROPTOSIS Developmental anomaly Craniofacial dysostosis Osteopathies Rickets Acromegaly Inflammation Mikulicz’s syndrome Late CSVT Endocrinal Thyroid Tumour Primary – lymphoma/sarcoma Secondary- neuroblastoma, nephroblastoma, Ewings sarcoma, leukaemic infiltrations
- 11. CAVERNOUS VENOUS THROMBOSIS GRAVES OPHTHALMOPATHY CRANIOFACIAL DYSOSTOSIS
- 12. Acute proptosis • Trauma – Orbital emphysema, haemorrhage, fracture of medial orbital wall. • Rupture of ethmoidal mucocele.
- 14. Intermittent proptosis • Orbital varix • Periodic orbital edema • Recurrent orbital hemorrhage • Highly vascular tumours
- 16. Pulsatile proptosis • Carotico cavernous fistula • Saccular aneurysm of ophthalmic artery. • Transmitted cerebral pulsations with deficient orbital roof – Congenital meningocele / meningoencephalocele.
- 17. TYPES OF PROPTOSIS AXIAL NON- AXIAL / ECCENTRIC / ABAXIAL Forward protrusion without displacement Displacement + protrusion Intraconal lesions Extraconal lesions Causes: • Cavernous hemangioma • Optic nerve glioma • Thyroid eye disease • Arteriovenous malformations • Mass lesion within the muscle cone. Causes: 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. • Sinuscarcinomas
- 21. CLINICAL HISTORY CHIEF COMPLAINT: • Protrusion of one or both eyes • Loss of vision – optic nerve compression / exposure keratopathy • Rare – diplopia, ROM, redness/pain/discharge due to exposure keratopathy.
- 22. History of presenting illness: • Age of onset • Nature of onset: sudden / gradual • Progression: slow / rapid • Increase during attacks of URI / valsalva manouvre / postural / crying • H/O of pain • Laterality • H/O of pulsation
- 23. Past history • Thyroid disorder, sarcoidosis • Malignancy- lung, breast, prostate • Trauma • Periocular tumour • Prior periocular surgery
- 24. EXAMINATION GENERAL EXAMINATION: Signs of Graves / sarcoidosis/ malignancy/ infective foci OCULAR EXAMINATION: 1. Visual acuity 2. Eyeball : A. Inspection B. Palpation C. Auscultation D. Transillumination E. Exophthalmometry
- 25. Inspection • Proptosis / pseudoproptosis • Unilateral / bilateral • Direction of protrusion • Ocular motility • Eyelids • Periorbital inflammation • Nose/roof of mouth • Valsalva maneuver • Lagopthalmos,Bell’s phenomenon,exposure keratopathy
- 26. Worm’s eye view Nafziger view
- 27. Palpation • Retropulsion • Orbital thrill/pulsation • Swelling/mass around the eyeball • Regional lymph nodes • Orbital rim/margin • Reducibility of the mass • Infraorbital/supraorbital anesthesia
- 28. Auscultation • To look for bruit • With help of bell of the stethescope • Over eyeball and temporal area • AV Malformation
- 29. Transillumination • Anterior orbital lesions • Using penlight • Interpretation- Bright- Cyst with clear fluid Equal- lipoma Intermediate- dermoid cyst Dark- Lacrimal gland tumour, osteoma
- 30. Exophthalmometry • Hertel’s exophthalmometer • Luedde scale • Naugle exophthalmometer • Gormaz exophthalmometer
- 33. Other ocular examination 3. Conjunctiva 4. Cornea 5. Sclera / Iris 6. Pupil 7. IOP 8. Lens 9. Vitreous 10. Fundus
- 34. LAB INVESTIGATION • Thyroid function test • Complete blood count, peripheral smear, ESR, blood sugar • Stool – for cyst and ova • Urine- bence Jones protein for multiple myeloma
- 35. IMAGING NON-INVASIVE • X-ray: caldwell view, water’s view, lateral view, Rhesis view • Computerised tomography • Ultrasonography • Magnetic resonance tomography INVASIVE • Orbital venography • Carotid angiography
- 36. HPE • Fine needle aspiration biopsy • Incisional biopsy • Excisional biopsy
- 37. Thank you!