EVALUATION OF PROPTOSIS

Presented by DR.Tasmia Ibrahim

DR. MD. Dedarul HassanDO student(LEI&H)

PROPTOSIS

Is defined as abnormal protrusion of the eyeball along

with lids & orbital contents.

CLASSIFICATION

Proptosis can be divided into following clinicalgroups:

• 1. Unilateral /Bilateral proptosis• 2.Axial / Eccentric proptosis• 3. Acute /Intermittent proptosis• 4. Pulsatile/Non-pulsatile proptosis

Causes of Proptosis• UNILATERAL (Axial) Thyroid associated orbitopathy Optic nerve glioma Lymphoma Lymphangioma Orbital cellulitis Retinoblastoma Idiopathic orbital inflammatory disease Optic nerve sheath meningioma Cavernous haemangioma Deep dermoid

Cont….

• UNILATERAL (Non axial )

Lacrimal gland tumour Deep dermoid Neurofibroma Ethmoidal mucocele

Cont….Bilateral Thyroid associated orbitopathy Lymphoma Secondary metastasis

Congenital Dermoid Teratoma Congenital cystic eyeball

Cont…

Painful proptosis Pseudotumour Tolosa-Hunt syndrome Orbital cellulities Acute dacryoadenitis

Pulsating proptosis Meningocele Meningoencephalocele

Pseudoproptosis

It is a false impression of proptosis.

Causes : High myopia Buphthalmos Ipsilateral lid retraction Contralateral enophthalmos Facial asymmetry

Severity of Proptosis

Can be measured with a plastic rule resting on the lateral orbital margin or by an exophthalmometer. Reading greater than 20 mm indicates proptosis and a difference of atleast 2 mm between the two eyes is suspicious regardless of the absolute value.

Mild proptosis : 21-23 mm Moderate proptosis : 24-27 mm Severe proptosis : 28 mm or more

Why vision detoriates in proptosis

Optic nerve compression Exposure keratopathy Astigmatism Choroidal fold

APPROACH

HISTORYLOCAL

EXAMNSYSTEM.EXAMN

INVESTIGATION

SIMAGIN

G

History

• Age of onset , duration , progression• Constant or intermittent• Variation with posture / strain• Decreased vision • Associated field defects• Pain • Double vision • Trauma• Fever , chills ,systemic symptoms• H/O thyroid disease ,TB , DM ,HTN ,HIV , Syphilis

Examination

Examinations : General Systemic Complete ocular examination Local examinations

Inspection:Facial asymmetryBulging of eye Orbital rim Palpebral fissure is widen or not Oral and nasal orifice Thyroid moves with deglutition or not Any skull deformity Fine tremor in fingers Hircshberg reflex

Cont…. Three Measurements :I. Anterior-posterior measurementII. Horizontal measurementIII. Vertical measurement

Primary position Ant-posterior measurement

Horizontal measurement Vertical measurement

Palpation: Palpation of orbital rim Reducibility(in vascular lesions) Compressibility(in capillary haemangioma) Temperature Tenderness Any thrill present or absent

Cont… Others Naffziger’s sign Ocular motility- decreased in thyroid

orbitopathy,extensive tumor growths and neurological deficit

Pupillary reaction-RAPD suggests optic nerve compression

Pretibial myxoedema-Thyroid eye disease Valsalva manauver Fundus examination- reveal hemorrhages ,

papilloedema , optic atrophy , choroidal folds, optico-ciliary shunt

Routine & Systemic Investigations CBC PBF Thyroid function test : T3,T4,TSH USG of thyroid Thyroid scanning FNAC X-ray soft tissue neck Incisional biopsy

Investigations : Cont…..

Imaging

CT scan of brain and orbit MRI of brain and orbit MRA and MRV

InterpretationsCT scan findings in different orbital lesions:

TAO : Enlargement of muscle belly with well defined margin.

IOID : Ill defined orbital opacification with loss of definite contents.

Carotid cavernous fistula : Enlargement of extra ocular muscle and superior ophthalmic vein.

Cont….

Lacrimal gland carcinoma : Globular lesions with irregular serrated edges, bony erosion and calcification present.

Dermoid : Well-circumscribed cystic lesions.

Lymphoma : Diffuse enlargement of peri orbital tissue, can follow the curvature of eyeball.

General management of proptosis Intensive medical therapy : Systemic steroid Radiotherapy Combined : Radiotherapy,chemotherapy,Steroid Surgical decompression Orbital surgery Follow up

Take home message

o Proptosis is an alarming conditiono Localized or systemic causes are presento Proper approach should be takeno Thorough examination & investigation is musto Proper management results good prognosis

References

Clinical Ophthalmology-A systematic approach By Jack J Kanski & Bowling

American academy of ophthalmology

Clinical examination of Ophthalmic cases By ML Agarwal & Sanjeev Agarwal

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

• 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