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1. Dr. Ashma Shrestha
1st Year Resident
LEIRC, NAMS
29th September 2021
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2.  Introduction
 Pathophysiology
 Classification
 Evaluation
 History
 Examination
 Investigation
 Imaging
2

3.  An abnormal protrusion of one or both eye balls
 Anterior displacement of globe by >21mm from lateral orbital
rim
 >2mm difference between apex of cornea between two eyes
3

4.  Exophthalmos
 Exorbitism
4

5.  Ipsilateral eyelid retraction
 Macrophthalmos
 Contralateral ptosis
 Contralateral enophthalmos
 Contralateral micropththalmos
 Shallow orbit
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6. Increase in volume within
fixed bony orbit
Contents of orbit are
displaced anteriorly
Globular protrusion of eyeball
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7.  Etiology
 Duration
 Direction of globe displacement
 Laterality
 Age of onset
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8.  Infectious
 Inflammatory
 Vascular
 Neoplastic
 Idiopathic
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9.  Acute
 Subacute
 Chronic
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10. Axial
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Optic nerve glioma
Metastasis
Thyroid eye disease

11. Non-axial
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Superior
Maxillary sinus tumors
Inferomedial
Dermoid cyst Lacrimal gland tumor

12. Inferolateral
 Fronto-ethmoidal mucocele
 Abscess
 Sinus carcinomas
 Osteomas
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13. Unilateral Proptosis
 Congenital
 Traumatic
 Inflammatory
 Vascular
 Thyroid eye disease
 Cysts of orbit
 Tumors
 Mucocele of PNS
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14. Bilateral Proptosis
 Thyroid eye disease
 Developmental anomalies of skull
 Inflammatory
 Tumors
 Osteopathies
 Systemic disease
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15. Infants
 Congenital lesions
 Retinoblastoma
 Capillary hemangioma
 Juvenile xanthogranuloma
 Metastatic neuroblastoma
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16. Children
 Orbital cellulitis
 Dermoid cyst
 Capillary hemangioma
 Optic nerve glioma
 Rhabdomyosarcoma
 Retinoblastoma
 Leukemia
 Lymphangioma
 Metastasis
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17. Adults
 Thyroid exophthalmos
 Orbital cellulitis
 Trauma
 Meningioma
 Lymphoma
 Histiocytoma
 Cavernous hemangioma
 Varices
 Carotid-cavernous fistula
 Tumors extending from
adjacent areas
 Metastasis
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18. History Local
Examination
Systemic
Examination Investigations Imaging
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19.  Onset of proptosis
 Course and progression of proptosis
 History of trauma
 Associated symptoms of pain, diplopia, reduction of vision
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20.  Thyroid disease
 Diabetes
 Tuberculosis
 Sarcoidosis
 Neurofibromatosis
 Systemic cancer
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21.  Ocular disease
 Cancer
 Systemic familial disease
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22.  Inspection
 Palpation
 Auscultation
 Measurement of proptosis
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23.  General ocular appearance
 Eyelid
 Lacrimal drainage system
 Conjunctiva
 Cornea
 Iris
 Pupil
 Ocular motility
 Fundus
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24. General Ocular Appearance
 Facial asymmetry
 Globe displacement
 Pulsating proptosis
 Positional proptosis
 Color
 Surrounding area
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25. Eyelid
 Lid retraction
 Lid lag
 Ptosis
 Ecchymosis
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26. Eyelid
 S-Shaped eye lid
 Eczematous lesion of eyelid
 Edematous swelling of lower eyelid
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27. Conjunctiva
 Localized hyperemia
 Salmon colored patch
 Dilated episcleral vessels
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28. Cornea
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29. Iris Pupil
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30. Ocular motility
 Restrictive myopathy
 Optic nerve sheath meningioma
 Neurological deficit from orbital
apex lesions
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31. 32
Fundus
 Optic disc edema
 Optic atrophy
 Choroidal folds
 Retinal vascular changes
Disc edema
Choroidal folds

32.  Retrodisplacement of globe
 Pulsation of globe
 Thrill
 Palpation of orbital rim
 Palpation of anterior orbital mass
 Regional lymph nodes
 Paranasal sinuses
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33. 34

34. Worms eye view
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35. Naffziger’s Method
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36. Plastic ruler test
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37. Luedde’s Exophthalmometer
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38. Hertel’s Exophthalmometer
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39.  Mild- 21-23mm
 Moderate- 24-27mm
 Severe- 28mm or more
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40. Naugle’s Exophthalmometer
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41. 42
6P’s
Pain
Progression
Proptosis
Pulsation
Palpation
Periorbital Changes

42.  Transillumination
 Visual acuity and refraction
 Tonometry
 Forced duction test
 Diplopia charting
 Color vision
 Visual field evaluation
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43.  Skin pigmentation
 Café au lait spots
 Features of thyroid disease
 Organomegaly or lumps in abdomen
 Nasopharyngeal mass
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44.  Hematological
 Thyroid function tests
 Serum ANA, C-ANCA, ACE
 Chest Xray
 Mantoux test
 Casoni’s test
 Stool examination
 Urine analysis
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45.  Noninvasive
 Plain X-ray
 Orbital USG
 CT Scan
 MRI
 Invasive
 Orbital venography
 Carotid angiography
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46.  Plain X-rays
 Enlargement of orbital cavity
 Calcification, hyperostosis
 Computed tomography
 Shape, location, extent and character of lesions in orbit
 Measurement of proptosis
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47.  Ultrasonography
 Usually differentiate between solid, cystic, infiltrative and spongy
masses
 Lesions of posterior orbit cannot be viewed
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48.  Magnetic Resonance Imaging
 Provides more soft tissue detail
 Better technique for orbitocranial junction or intracranial imaging
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49.  Orbital Venography
 Definitive diagnostic study in evaluation of intermittent proptosis
 Carotid Angiography
 Pulsating proptosis with bruit or thrill
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50.  Fine Needle Aspiration Cytology
 Incisional biopsy
 Excisional biopsy
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51.  Basic and Clinical Science Course; Orbit, Eyelids and Lacrimal
System, AAO 2019-2020
 Disease Of Orbit, Jack Rootman, 2nd Edition
 Kanski’s Clinical Ophthalmology,9th Edition
 Disease Of Eye, Parson, 22nd Edition
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