step wise approach to case of proptosis

1. Aarti Kerketta

2. PROPTOSIS
Forward displacement of the eye
(H.I.E Saunders.Dorland’s Medical Dictionary 26th Ed. Harcourt International Edition (2001)
EXOPHTHALMOS
Proptosis secondary to endocrinological dysfunction
(Henderson JW. Orbital Tumors 3rd ed. New York: Raven press;1994 )

3. By Hertel’s
Exophthalmometer
Distance between lateral
orbital margin and corneal
apex greater than:
•13 to 15mm in Asians¹
•21 mm adult Caucasians²
•23 mm adult African-
American²
On CT scans³
•Globe protrusion > 21
mm anterior to the inter-
zygomatic line on mid
axial scans at the level of
the lens.
•Asymmetry between the
two sides >2mm
¹Sarinnapakoran V et al,Proptosis in normal Thai samples and thyroid patients.J Med Ass Thai 2007;90(4):679-83
²BeugerDG et al,Proptosis In: Ophthalmic secrets.Vander JF, GualtJA, Philadelpia,Pennsylvania,2002Chapter 36,p269
³Naik MN et al, Interpretation of computed tomography imaging of eye and orbit.A systemic approach.Indian J
Ophthalmology 2002;50(4):339-53

4.  Orbit is pyramidal shaped cavity
bounded by four
OPEN anteriorly
 Contents-
 Surrounded by
 Volume of orbit - 30 cc
PATHOPHYSIOLOGY
SINUSE
S
GLOBE,MUSCLES
FASCIA,VESSELS,
NERVES,FAT,
LACRIMAL GLAND,
LACRIMAL SAC
CRANIUM
BONY WALLS

5. EFFECT OF PROPTOSIS
COSMETIC
FUNCTIONAL
DISABILITY

6. SYMPTOMS
 Forward protrusion or displacement of eye
 Visual disturbances- diminution of vision, diplopia
 Discomfort- grittiness, watering, pain
 Difficulty in closing eyes fully while sleeping or blinking
 Increase in visible white part of eye

7. PROMINENT
APPEARING GLOBE
PSEUDOPROPTOSIS
ENLARGED
GLOBE
EXTRAOCULAR
MUSCLE
WEAKNESS
CONTRALATERAL
ENOPHTHALMOS
ASYMMETRIC
PALPEBRAL
FISSURES
•HIGH AXIAL
MYOPIA
•BUPHTHALMOS •IPSILATERAL
EYELID
RETRACTION
•CONTRALATERAL
PTOSIS
TRUE PROPTOSIS
History and physical examination
SHALLOW ORBIT NORMAL ORBIT
•CRANIOFACIAL
DYSOSTOSIS
•TRAUMA ENDOCRINAL
DISEASE
VASCULAR
MALFORMATION
INFLAMMATORY NEOPLASIA
INFECTIOUS
•ORBITAL
CELLULITIS
•CAVERNOUS
SINUS
THROMBOSIS
•PARASITIC
•SINUS DISEASE
NON INFECTIOUS
MYOSITIS
IDIOPATHIC
ORBITAL
EYE
DISEASE
SECONDARYPRIMARY
MALIGNANTBENIGN
•CAROTID-
CAVERNOUS
FISTULA
•ARTERIOVENOUS
(A-V)
MALFORMATION
•ORBITAL VARIX
THYROID EYE
DISEASE
(TED)

8. HISTORY
EXAMINATION
INVESTIGATION

9. • Age of patient at onset
• Progression
• Pain
• Visual disturbance
• Laterality(unilateral / bilateral)
• Nature- pulsatile/ intermittent /
variable

10. • redness, dry eye, discomfort
• Lid changes
• Headache, nausea, fever
• Systemic / extra-ocular disease
• Medications
• Previous trauma / surgery to orbit /
face

11. AGE OF ONSET
AT BIRTH
CHILDHOOD/
YOUNG ADULT
MIDDLE AGED/
ELDERLY
UNILATERALBILATERAL
CRANIOFACIAL
DYSOSTOSIS
•CROUZON’S
SYNDROME
•APERT’S
SYNDROME
INTERMITENT/PULSATILE NON PULSATILE
•CEPHALOCELE
•A-V MALFORMATIONS
ORBITAL TUMORS
•Vascular -Capillary
hemangioma
•Teratoma
BIRTH TRAUMA

12. CHILDHOOD/ YOUNG ADULT MIDDLE AGED/ ELDERLY
AGE OF ONSET
PROGRESSION
ACUTE
(hours to a week)
SUB-ACUTE
(1-4 weeks)
CHRONIC
(>6 MONTHS)
PAINFUL with/without
DIMINUTION OF
VISION
INFLAMMATORY
(Immuno-
compromised
state,redness ,
edema,fever)
NON-
INFLAMMATORY
ORBITAL
CELLULITIS
PULSATILE
h/o Trauma,
surgery
(headache,tinnius,
diplopia)
NON
PULSATILE
(h/o trauma)
•A-V FISTULA
•RETROBULBAR
HEMORRHAGE
SUDDEN SPURT IN
PREEXISTING
PROPTOSIS
•Bleed in vascular tumors
•Rupture dermoid or
parasitic cyst
•Lymphangioma

13. CHILDHOOD/ YOUNG ADULT MIDDLE AGED/ ELDERLY
PROGRESSION
ACUTE
(hours to a week)
SUB-ACUTE
(1-4 weeks)
CHRONIC
(>6 MONTHS)
PAINFUL PAINLESS
(+/- DOV , diplopia, redness)
UNILATERAL BILATERAL
INFLAMMARTORY
NON-
INFLAMMATORY
ORBITAL
CELLULITIS
(fever)
(Diplopia)
MYOSITIS
TED
IOID (intermittent/
recurrent)
(Swelling,redness ,+/- DOV)
MALIGNANTM
ETASTASIC
TUMOR
CHILDHOOD/ YOUNG
ADULT
PRIMARY-
Rhabdomyosarcoma
SECONDARY –
Retinoblastoma, sinus
tumor
METASTATIC-Wilm’s
tumour,Neuroblastoma,
AML
MIDDLE AGED/
ELDERLY
•METASTATIC-lung,
breast, prostrate
•SECONDARY –
Intracranial tumor,
sinus tumor
INFLAMMARTORY
+
NON-
INFLAMMATORY
+/-
(Swelling,redness +/-DOV)
CAVERNOUS SINUS
THROMBOSIS
(fever ,
headache,
vomiting)
METASTATIC
TUMOR
•IDIOPATHIC
ORBITAL
INFLAMMATORY
DISEASE
•MALIGNANT
TUMOR
UNILATERAL BILATERAL
MIDDLE AGE/
ELDERLY
THYROID EYE
DISEASE
(diplopia,grittiness,
watering)

14. CHILDHOOD/ YOUNG ADULT MIDDLE AGED/ ELDERLY
PROGRESSION
ACUTE
(hours to a week)
SUB-ACUTE
(1-4 weeks)
CHRONIC
(>6 MONTHS)
PAINFUL PAINLESS
IDIOPATHIC
INFLAMMATORY
ORBITAL
DISEASE
(variable/recurrent)
TED(diplopia)
(Corneal dryness and exposure ,with DOV )
UNILATERAL BILATERAL
LARGE TUMOR/
CYST
WITH DOV WITHOUT DOV
PRECEEDING
PROPTOSIS
OPTIC NERVE
GLIOMA
(children)
FOLLOWING
PROPTOSIS
OPTIC NERVE
MENINGIOMA
BENIGN TUMOR
BENIGN TUMOR
CYST
•Parasitic
•Dermoid
(children,
young adult)
•Capillary
hemangioma
(children)
•Cavernous
hemangioma
(adults)
•Lymphangioma
(intermittent)
VASCULAR
TUMOR OTHER
•Neurofibroma
(pulsatile)
•Schwannoma
•Bone tumor
•Lacrima gland
tumor
•Lymphoma(bilateral)

15. History of systemic / extra-ocular disease
 Diabetes, immunocompromised status
 Sinus , dental and ENT diseases
 Prior nasal surgery
 Previous or current malignancy
 Thyroid dysfunction
 Trauma

16. INSPECTION
PALPATION
MEASUREMENT OF PROPTOSIS
OCULAR EXAMINATION

17. INSPECTION
 Compensatory head posture
 Facial scars, deformity
 Ocular symmetry and position of eye
 Adnexal structure
 Surface of eye
 Pulsations, valsalva maneuver
 Movements

18. POSITION OF EYE
 Forward protrusion without
displacement
AXIAL PROPTOSIS
 Displacement along with proptosis
ABAXIAL PROPTOSIS

19. AXIAL PROPTOSIS
Lesions of intraconal space
Optic nerve glioma
Optic nerve sheath meningioma
Cvernous hemangioma, Orbital
varix
Schwannoma
Neurofibroma
Cystic lesion
Thyroid associated orbitopathy
 Idiopathic orbital inflammation
DOWN AND IN
Orbital mass of
superotemporal quadrant
•Lacrimal gland
tumor
•Dermoid
•Other benign or malignant
neoplasia
DOWN AND OUT
Orbital mass of
superonasal quadrant
•Frontoethmoidal
mucocele
•Fungal granulomas
• Benign or malignant
mass
LATERAL
DISPLACEMENT
•Tumor arising from
ethmoid sinus
•Lacrimal sac tumors
•Lethal midline granuloma
•Nasopharyngeal tumor
UPWARD
DISPLACEMENT
Mass from maxillary sinus
•Neoplasia
•Fungal granuloma
•Dumbbell dermoid
 Cyst or tumor of inferior
quadrant

20. 1.Nafziger’s Method
2.Clear plastic ruler
3. Luedde’s exophthalmometer
4. Hertel’s exophthalmometer
5.Naugle’s exophthalmometer
6.Measure dystopia (2 scale)

21. INSPECTION OF ADNEXAL STRUCTURES
SURFACE LID POSITIONMASS
EYELIDS AND PERIBULBAR TISSUE
COLOUR
EDEMA
SINUS OR
FISTULA
SITE
NUMBER
SIZE
SURFACE
MARGINS
EXTENT
COMPONENT – LID
AND ORBITAL
PTOSIS
LID
RETRACTION
LID LAG

22. REDNESS
Infection and
inflammation
Thyroid eye
disease
Malignant and
metastatic
neoplasm
EDEMA
Reduced venous and
lynphatic drainage by mass
Bluish discoloration- vascular tumor or malformation ,trauma
Sinus and fistula- Orbital abcess, dermoids, mucocele

23. LID POSITION
PTOSIS
LID
RETRACTION LID LAG
Mechanical
Paralytic
Thyroid
eye
disease
Large
orbital
neoplasm
Thyroid
eye
disease
S shaped lid thickening - Plexiform neurofibroma

24.  Pulsation – direct lateral view
• Arteriovenous malformation
• Cephalocele, large mucocele
• Neurofibromatosis
 Valsalva maneuver
Increase in proptosis with valsalva
• AV malformations
• Orbital varix

25. OCULAR MOVEMENTS
 Limitation of ocular motility
due to orbital mass
 Restriction due to invasive
process in muscle
 Paralytic

26. CONJUNCTIVA
Dilated vascular channel at the
canthus with chemosis-
dysthyroid disease
Epibulbar dark-red corkscrew
vessels – increased venous
pressure, AV malformation
Diffuse conjunctival congestion-
orbital inflammatory or infectious
disease
Sectoral congestion and
chemosis- Myositis
Subconjunctival haemorrhage-
Trauma,
infiltrative tumors
Chemosis- inflammation,
lymphatic obstruction
Salmon patch- lymphoma
CORNEA-exposure
Iris- Lisch nodules in
neurofibromatosis

27. EXAMINATION OF NASAL CAVITY
AND ORAL CAVITY IS MANDATORY
IN PRESENCE OF PARANASAL
SINUS INVOLVEMENT

28. • Local Temperature
• Tenderness
•Orbital tonometry, orbital margins
• If mass palpable note
•Position
•Size,surface, attachnents
•Consistency(hard , rubbery, spongy or soft)
•Compressibility/ Reducibility

29. Tenderness
 Orbital infection and inflammation
 Adenoid cystic carcinoma
 Trauma
Temperature
 Rise in temperature of overlying skin seen in orbital
infection and inflammation

30. Consistency of the palpable mass
Compressibility - characteristic of
• Cystic mass
Reducibility- characteristic of mass communicating with
neighbouring cavity
CYSTIC SOFT
FIRMRUBBERY HARD

31. TRANSILLUMINATION
(fluid / air filled)
AUSCULTATION
 Bruits- High flow
arteriovenous fistula

32.  VISUAL ACUITY
 PUPILLARY REACTION
 COLOR VISION
 REFRACTION
 VISUAL FIELD
 OPHTHALMOSCOPY
 INTRA OCULAR PRESSURE

33. Documentation of visual acuity is necessary
Diagnostic and aids in planning management
PUPILS
VISUAL ACUITY
Look carefully for RAPD suggestive
of optic nerve damage

34. COLOUR VISION
 In early compression of optic nerve patient may
not notice defective vision.
 In bilateral cases RAPD may not be elicited.
 Very early optic nerve compression can be
missed in fundus examination
IMPORTANCE

35. RAPD, COLOR VISION
ABNORMALITIES AND VISUAL FIELD
DEFECTS
CAN DETECT COMPROMISE OF THE
OPTIC NERVE EVEN WHEN THE
VISUAL ACUITY IS NORMAL

36. Optic discs – edema, pallor,
atrophy
Choroidal folds - tumours,
dysthyroid ophthalmopathy,
inflammatory lesions
FUNDUS EXAMINATION

37. Retinal vascular changes-
Opticociliary shunt vessels (optic nerve sheath
meningioma, cavernous haemangioma)
Venous dilatation and tortousity (a-v
malformations, carotid cavernous fistula)
Vascular occlusions (orbital cellulitis and optic
nerve tumours

38. GENERAL EXAMINATION
 Look for evidence of malignancy
 Signs of thyroid dysfunction - thyromegaly,
tachycardia, tremors of the hand etc.
 Sites of entry for infection -sinus disease, nasal and
oral infection
 Lymphadenopathy

39. ON THE BASIS OF HISTORY
AND EXAMINATION
DIFFERENTIAL DIAGNOSIS
SHOULD BE MADE

40. IMAGING
SPECIAL INVESTIGATIONS
IMPORTANCE
To know exact location and
extent of lesion
Predict nature of lesion (tumor
or cyst,encapsulated/infiltrating,
Vascular/nonvascular,benign
/malignant/metastatic)
 Plan proper management
strategy

41.  Various imaging modalities in orbital disease
 X-Ray
 Non -contrast and contrast Computed Tomography
 Magnetic Resonance Imaging
 Ultrasound
CT and MRI have largely replaced radiography
Skull X-ray are now performed only in selective cases of
facial fracture

42. THE CHOICE OF IMAGING STUDY
SHOULD BE BASED ON CLINICAL
PRESENTATION AND THE SPECIFIC
PATHOLOGY BEING SUSPECTED

43. FINE NEEDLE ASPIRATION CYTOLOGY
AND BIOPSY
IN CASE OF DOUBT
AIDS IN
ESHTABLISHING
THE DIAGNOSIS
PLAN MANAGEMENT
Biopsy is indicated for histopathological confirmation of
clinical diagnosis

44. DECISION MAKING
GOALS FOR MANAGEMENT
Prevent life threatning condition
Preservation of visual function
Alleviation of pain
Cosmesis

45. MANAGEMENT OPTIONS OF
PROPTOSIS
INFLAMMATORY
NON-
INFLAMMATORY
OTHERS
INFECTIOUS NON-INFECTIOUS
(TED, IOID)
NON-
SURGICAL SURGICAL
•Surgical
drainage of
abcess
•Enucleation/
Exentration
Systemic
•Antibiotics
•Antifungal
ANALGESIC
NON-
SURGICAL SURGICAL
•Non steroid anti
inflammatory
•Steroid
•Immunosuppressent
•Radiotherapy
•Surgical
decompression
•EOM surgery
•Lid surgery
BENIGN MALIGNANT
•Exentration
•Excision
NON-
SURGICAL
SURGICAL
•Observation
•Intralesional/
systemic steroid
Capillary
hemangioma
Excision of
mass
NON-
SURGICAL
SURGICAL
•Radiotherapy
•Chemotherapy
TRAUMA
A-V
MALFORMATION
•Medical
management of
intraocular
pressure
•Closure of
fistula
•Medical
management of
intraocular
pressure
•Surgical
decompression,
exploration
•Fracture repair

46. EVALUATION AND MANAGEMENT
OF PROPTOSIS REQUIRES A
MULTIDISCIPILINARY APPROACH
IF NEEDED ALWAYS TAKE OPINION OF
OTOLARYNGIOLOGIST, NEUROSURGEON,
ONCOLOGIST

50.  Large orbital tumor with pressure on eye
produce
 Irregular quadrantic contractions
 Meningioma- peripheral field affected earlier
than central
 Glioma- Scotoma dispropotionately greater than
proptosis