6. Introduction
• Proptosis : forward protrusion of the eyeball.
( passive process) clasically seen in retro-
orbital space occupying lesion.
• Exopthalmos: forward protrusion of eyeball
(active/dynamic process) seen in endocrinological
disorders.
• Pseudoproptosis:this is a clinical appearance of
proptosis where dere is no forward displacement of the
globe.
7. PROPTOMETRY
It is the measurement of the distance between
apex of the cornea and the
bony point usually taken as deepest portion of
the lateral orbital rim with
the eye looking in primary gaze.
9. MEASUREMENT
• ABSOLUTE MEASUREMENT relating the corneal apex
to a bony point on the skull.
• RELATIVE MEASUREMENT comparing the position of
one cornea with the other.
11. AXIAL PROPTOSIS
• Axial proptosis is caused by any space occupying
lesion in the muscle cone or any diffuse orbital
inflammatory or neoplastic lesions.
12. ECCENTRIC PROPTOSIS
• Proptosis caused by any extraconal lesion or
fracture displacement of orbital bones
protruding inwardly.
20. • HISTORY : LEADING QUESTIONS
• ONSET
• DURATION
• PROGRESSION
DETERMINATIION OF LATERALITY
DETERMINATION OF THE PROPTOSIS OR PSEUDO
PROPTOSIS
DIRECTION OF PROPTOSIS
MEASUREMENT OF PROPTOSIS
FACTORS AGGRAGAVATING PROPTOSIS
BRUIT/PULSATIONS ON PROPTOSIS
21. MEASUREMENT OF PROPTOSIS
This instrument consists of a horizontal calibrated bar with movable carriers at each side.
Each carrier consists of mirrors inclined at 45 degrees to reflect both the scale reading and
the apex of the cornea in profile. Notches on the side carriers are placed on the bony
lateral orbital margins of the patient. The patient is then asked to fixated on a point on the
examiner's forehead. The apex of the cornea of each eye is superimposed on the millimeter
scale reading by the inclined mirrors. The measurement of each eye is recorded by the
examiner, alternately viewing with the right and left eye.
22. HILAL & TROCAR METHOD
• A perpendicular from each corneal apex to
this line is dropped, and measured to scale. If
each line is greater than 21 mm, or if there is
an asymmetry of >2 mm between the two, it
indicates abnormality.
25. Investigation in proptosis
Haematological for blood dyscrasia
Otorhinological
(a) Nasopharynx
(b) Examination of paranasal sinuses
Thyroid function tests
X-ray: orbit and skull
Ultrasonography of
Eye ball: axial length and intraocular growth
Soft tissues of orbit: growth, fibrosis and deposit in muscles
CT scan
MRI
Orbital venography
Fine needle biopsy
Excision biopsy
26. • X-RAY:
VIEW STRUCTURES APPRECIATED
Caldwell view: greater and lesser wing of
sphenoid. Superior orbital fissure,
most of the paranasal sinuses
Water’s view: orbital rim, orbital roof and floor
and maxillary sinuses
Lateral view: sphenoid, sphenoid air sinuses,
anterior clinoid and sella turcica
Townne’s view: Infraorbital fissure , Superior
orbital fissure
Axial Basal view
37. CURRENTLY
• V
• I
• S
• A
FEATURES OBJECTIVE SUBJECTIVE
Vision & optic
neuropathy
VA, pupils, optic
nerve evaluation
Vision
Inflammation Congestion
,chemosis,lid
odema
Aching pain
Strabismus Restriction of
ocular movements
Diplopia
Appearnce Proptosis,lid
retraction
Watering,dryness,irr
itation
42. Extraocular muscles
• B/L enlarged: may be asymmetrical
IR----MR
Patient is aware of difficulty reading & diplopia
Restriction of EOM increases the IOP in upgaze >
4mm hg .
Greater myopathy can lead to optic nerve
involvement at the apex===optic neuropathy.
51. Names Signs
Stellwag’s Incomplete & infrequent blinking
mean’s Increase superior scleral show on upgaze
grove Resistance to pulling the retracted upper lid
Boston’s Uneven , jerky movementsof the UL on inf gaze
Gellinek’s Abnormal pigmentation of the UL
Gifford’s Difficulty in everting the upper lid
52. LOWER LID SIGN
Enroth’s sign
• Edema of lower lid
Griffith’s sign
Lower lid lag on
upward gaze
53. Extra ocular movement signs
names signs
moebius Unable to converge eyes
Ballet’s Restriction of one or more EOMS
Jendrassik’s Paralysis of all EOMS
54. Conjunctival & pupillary
Names Signs
Goldzeiher’s Conjunctival injection
Kneis Uneven dilatation in dim light
Cowen’s Jerky contractions of pupil to light
57. STEROIDS: METHYL PRED iv. 1 gm /day/3 days
Intraorbital inj of 40 mg triamcilone
Immunosuppresants: methotrexate {7.5-15mg one day /wk} Azathioprine(1mg/kg/day
Cyclophosphamide(0.1-0.2mg /kg/day)
58. • Mild to moderate: stop smoking
head elevation
lubricating eye drops
• Sight threatening :systemic steroids
induce ptosis with botulinum toxin
orbital radiotherapy & decompression
• Moderate or severe(inactive): orbital decompression
EOM surgery
MANAGEMENT
59. • ACTIVE—medically only in recalcitrant O.N
compression or exposure keratopathy
• INACTIVE– stable case—decompression
performed on proptosed eye to improve
cosmesis.
• Criteria—multiple visits
Decompression