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Differential Diagnosis of ProptosisAbdullatiff Sami Al-RashedMovement Block 4.4 (Opthalmology Week)212516770College of Medicine, King Faisal University Al-Ahsa, Saudi Arabia
Introduction• Proptosis, or exophthalmos, is a protrusion of the eye
caused by a space occupying lesion.
• Can be either bilateral or unilateral.
• Measurement of the degree of exophthalmos is performed using an exophthalmometer.
Exophthalmometer
A difference of prominence of more than 2 mm between the two eyes is
significant.
Graves disease
Introduction
• Autoimmune disorder with orbital involvement and associated with thyroid dysfunction.
• Women are affected more than men.
• Proptosis could be unilateral or bilateral
Symptoms
Eyelid Signs in Graves Disease
Dalrymple sign:
Upper eyelid is retracted with visible sclera
superior to the limbus and widened palpebral
fissure with developing exposure keratitis
(overactive muscle of Müller)
Eyelid Signs in Graves Disease
Gifford sign:
Upper eyelid is difficult to evert (due to eyelid
edema)
Eyelid Signs in Graves Disease
Von Graefe sign:
Upper eyelid retracts when the eye
depresses (overactive muscle of Müller)
Eyelid Signs in Graves Disease
Stellwag Sign (Rare blinking)
Eyelid Signs in Graves Disease
Kocher sign ( Fixed Gaze )
Diagnosis
Treatment• Methylcellulose or hypromellose eyedrops:
– To aid lubrication and improve comfort.
• Systemic steroids (prednisolone 30–120 mg daily):– usually reduce inflammation if more severe symptoms are
present.
• Surgical decompression of the orbit:– Particularly if pressure of orbital contents on the optic nerve
threatens vision.
• Lid surgery:– Protect the cornea if lids cannot be closed.
Orbital cellulitis
Introduction
• Acute inflammation of the contents of the orbital cavity with the cardianl symptoms of limited motility and general malaise.
• Orbital cellulitis is the most frequent cause of exophthalmos in children.
Symptoms
Symptoms
InvestigationsTest Results
CBC Leukocytosis
ESR Increased
Blood culture To detect specific organisms
Nasal swap For gram stain
CT scan orbit
MRI For orbital abscess and evaluating for cavernous sinus disease
Complications
Optic neuritis Cavernous sinus thrombosis
Treatment
• High-dose intravenous antibiotic therapy:– Infants are treated with ceftriaxone and school-age
children with oxacillin combined with cefuroxime in the appropriate doses.
• Treatment of underlying sinusitis– Indicated in applicable cases.
Orbital Hemingioma
Hemangioma • Hemangiomas are the most common benign orbital
tumors in both children and adults.
• They usually occur in a nasal superior location.
• Capillary hemangiomas are more common in children (they swell when the child screams)
• Cavernous hemangiomas are more common in adults.
Hemangioma
• Treatment is only indicated where the tumor threatens to occlude the visual axis with resulting amblyopia or where there is a risk of compressive optic neuropathy.
• Capillary hemangiomas in children can be treated with cortisone or low-dose radiation therapy.
Other causes of proptosis
References
