Proptosis in ophthalmology

PROPTOSIS

PROPTOSIS• Forward displacement of the eyeball beyond orbital

margins due to a mass/increased orbital contents .

• Proptosis >21 mm or asymmetry of >2 mm between 2 eyes : abnormal.

• Exophthalmos: specifically describes proptosisassociated with thyroid eye disease (TED).

• Exorbitism: decrease in the volume of orbit b/l.orbital contents to protrude forwards.

• Pseudoproptosis:apparent protrusion of eyeball without increase in any orbital contents or mass.

• causes: Buphthalmos High myopia

: C/l ptosis C/l enophthalmos

EXOPHTHALMOS PROPTOSIS

ANATOMY OF ORBIT• pear shaped, tapers posteriorly at optic canal.

• Volume of orbit :30 ml.

• 4 walls of 7 bones: ethmoid, frontal, lacrimal, maxillary,palatine, sphenoid and zygomatic.

• Medial orbital walls are approximately parallel , separated by 25 mm.

• Lateral orbital walls angle about 90 degrees from each other

• The widest dimension :1 cm behind the anterior orbital rim.

• The thinnest bone is in the medial wall (lamina papyracea) adjacent to the ethmoid air cells.

• Relationship of orbit & PNS :By its location & venous drainage .

• orbital venous drainage :devoid of valves – two way communication between orbit and sinuses.

• Roof :anterior cranial fossa & frontal sinus above.• Medial wall : adjacent nasal cavity, ethmoid &

posterior sphenoid sinus.• Floor :The maxillary antrum beneath .• Lateral wall :adjacent to middle cranial ,temporal &

pterygopalatine fossa.

RELATIONS OF ORBITAL WALL

CLINICAL ASPECTS• Ethmoidal sinusitis can breach lamina papyracea &

spread into the orbit.

• The floor is thin medially -> fragmentation in “blow out” fractures.

• Lacrimal bone at the level of lacrimal fossa is very thin-> easy penetration during endoscopic DCR. if maxillary component is predominant ,difficult to breach the bone in endoscopic DCR.

• Webers suture:Lying anterior to lacrimal fossa has Infraorbital artery branches pass through it. Bleeding during lacrimal sac sx.

• Traumatic Optic Neuropathy :indirect injury to optic canal & direct injury by bony fragments in canal.

CLASSIFICATION OF PROPTOSIS1. Unilateral proptosis

2. Bilateral proptosis

3. Acute proptosis

4. Intermittent proptosis

5. Pulsating proptosis

6. Axial proptosis

7. Non-axial proptosis.

U/L PROPTOSIS1)congenital - dermoid

teratoma

2)Traumatic - orbital hemorrhage

emphysema

IOFB

3)inflammation - orbital cellulitis/abscess

cavernous sinus thrombosis

pseudotumor

tuberculosis/gumma

sarcoidosis

4) vascular - orbital varix

5) Cysts - parasitic

6)Tumor - primary or secondary

7)mucocoele of paranasal sinuses

BILATERAL PROPTOSIS1) Developmental abn/l - Oxycephaly

2)osteopathies - Rickets / Acromegaly

3)Tumors - Lymphoma / Leukemia

Ewings sarcoma

Neuroblastoma

4)Endocrinal - Thyroid eye disease

5)Inflammatory - Fungal granuloma

Mikulickz syndrome

6)Systemic - Histiocytosis

systemic amyloidosis

Lymphoma-> b/l proptosis

craniosynostosis

A/C PROPTOSIS• orbital emphysema

• fracture of the medial orbital wall

• orbital haemorrhage

• rupture of ethmoidal mucocele.

INTERMITTENT PROPTOSIS• orbital varix

• periodic orbital oedema

• recurrent orbital haemorrhage

• highly vascular tumours.

PULSATING PROPTOSIS• Carotico cavernous fistula

• saccular aneurysm of ophthalmic artery.

• transmitted cerebral pulsations with deficient orbital roof.

Congenital meningocele

Meningoencephalocele

Neurofibromatosis

Traumatic or operative hiatus.

AXIAL PROPTOSIS

• Cavernous hemangioma

• Optic nerve glioma

• Thyroid eye disease

• Arteriovenous malformations, and

• Mass lesion within the muscle cone.

NON -AXIAL PROPTOSIS• Lesions with prominent component outside muscle

cone .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.• Sinus carcinomas

METASTASIS => PROPTOSIS

LACRIMAL GLAND MUCOCELE TUMOURFRONTAL SINUS

HISTORY• Age of Onset , duration , progression • Constant or intermittent • Variation with posture • Decreased vision – b4/after• Stationary/progressive• Associated field defects• Pain• Double vision • Periorbital neurosensory loss• bruits • symptoms aggravated by crying,coughing,straining,

nose blowing?• Past h/o : Trauma,fever, chills ,cancer, thyroid d/s ,

TB , DM ,HTN ,HIV , Syphilis, Old photographs

HEMORRHAGE INTO A LYMPHANGIOMA• A sudden dramatic proptosis with conjunctival prolapse in a child with recent

URTI GAZE-EVOKED AMAUROSIS

• may be associated with an orbital apex tumor.

MALIGNANT LESION (adenoid cystic carcinoma)• Pain associated with a short history of a mass in the region of lacrimal gland.• Periorbital neurosensory loss in the absence of trauma

BENIGN LESION (pleomorphic adenoma)• a gradually progressive painless mass in the region of the lacrimal gland.

ARTERIOVENOUS SHUNT• history of “tinnitus”

ORBITAL VARICES• Proptosis provoked by straining may suggest.

AMYLOIDOSIS• spontaneous unilateral periorbital bruising in an adult may suggest.

NEUROBLASTOMA• bilateral bruising in a child

SCIRRHOUS ORBITAL METASTASIS.• Acquired exophthalmos in a female patient with a past history of breast

carcinoma

GENERAL PHYSICAL EXAMINATION

• Skin and oropharynx

cutaneous /intraoral vascular lesions: lymphangioma

café au lait spots :neurofibromatosis.

• Cranial Nerve Examination:

periorbital and corneal sensation.

• Examination of Chest and Abdomen:

systemic malignancy: undiagnosed ca breast

• The regional/ distant/ generalized lymphadenopathy

lymphoproliferative disorder.

OCULAR EXAMINATION

• Visual acuity, Refraction, visual fields, colour vision.

• Facial asymmetry,Head posture,Lid retraction/ptosis

• ocular alignment,Extraocular movements

• Examination of the anterior segment including pupil.

• INSPECTION:

• examiner looks from above standing behind patient/looks up from below with the patient’s head tilted back

1]Type of proptosis (axial / non-axial),location of mass,visible pulsation, skin changes.

2] Lagophthalmos,conjunctival congestion/discolouration.3] Corneal exposure, change in size with valsalva.4] examination of the globe and ocular adnexa

* Dilated episcleral vessels: arteriovenous shunt.* Opticociliary shunt vessels optic nerve meningioma.

*A “salmon patch” lesion beneath the upper eyelid: orbital lymphoma, amyloidosis, sarcoidosis, leukemia, lymphoid hyperplasia, rhabdomyosarcoma.

*Eversion of the upper eyelid ->waxy yellow infiltrate with tortuous vessels : amyloid lesion.

*S-shaped deformity of upper eyelid : plexiform NF.

PALPATION :1] Size, shape, surface, margins,consistency.2] Signs of inflammation, tenderness, reducibility,motility.3] Variation with valsalva, resistance to retropulsion,Thrill.4] Corneal sensation, infraorbital / supraorbital anesthesia5] Any swelling around the eyeball, regional lymph nodes

& orbital rim.AUSCULTATION

abnormal vascular communications -> bruit caroticocavernous fistula.

• Fundus examination : signs of venous engorgement

haemorrhage

papilloedema

optic atrophy

choroidal folds

• Intraocular pressure

EXOPHTHALMOMETRY• Measurement is done from the lateral orbital rim to the anterior

corneal surface.

• A difference >2 mm between eyes ->proptosis.

• Exophthalmometers

Hertel’s exophthalmometer

Luedde scale

Gormaz exophthalmometer.

• Three types

Absolute exophthalmometry - compared with n/l reading (>21mm)

Relative exophthalmometry - relative distance of the 2 corneas from lateral orbital rim.

Comparative exophthalmometry -exophthalmos of at different times.

procedure1) With closed eyes, locate the orbital notch on thetemporal side of the orbital rim near lateral canthus.2) grooves placed in the orbital notch. The separation of

exophthalmometer noted3)The patient told to open their eyes and look straight ahead.4)Red lines should overlap to avoid the parallax. 5)corneal apex position on the scale noted. 6)From mirrors located at each end findings are recorded in mm.Limitations• Poor fixation, depressed /fractured lateral orbital

rim,convergence, parallax errors, head movements affect the readings.

• separation of the grooved arcs is narrow, readings falsly low. • separation of grooved arcs too wide :readings falsly high

• Ludde’s Exophthalmometer

• Transparent plastic mm ruler which is thicker than normal ruler.

• Notch conforms to angle of lateral orbital rim.

• Scale readings: 0mm (end of notch) to 40mm.

• Parallax is minimized by using scale on both sides of the rod.

LABORATORY INVESTIGATIONS• CXR :sarcoidosis

ca bronchusWegener’s granulomatosis

• TFT/thyroid ab :Graves’disease

• Angiotensin-converting enzyme:sarcoidosis

• c-ANCA & RFT :Wegener’s granulomatosis

• Immunology screen : SLE

ORBITAL IMAGING• CECT - initial choice of investigation .

• MRI - orbital apex,CNS involvement,soft tissue infiltration and RB.

• USG – 2 assess internal reflectivity of lesion & calcification in RB.

• CT/MRI angiography for vascular lesions.

CT : DERMOID CYST

CT OF AXIAL PROPTOSIS

dermoid cyst orbital cellulitis

RHABDOMYOSARCOMAORBITAL LYMPHANGIOMA

TED

HEMANGIOMA

METASTATIC CA

THANQ