proptosis

1. -Dr. venkatesh

2. Age of onset – 3rd to 5th decade
40- 44 and 60 to 64 in females,
45- 49 and 65- 69 in males
Sex: Females:males- 6:1
16 per 1 lakh : 3 per 1 lakh
 more severe in males d/t association
with smoking( 7 times mc)
Chief complaints:

4. Protrusion of eyes:
nature of onset :sudden or insidious
Duration..
progression:
continuous: Tumour or Endocrine
Intermittent postural proptosis
Pulsatile proptosis
 chronology of orbital signs and symptoms:

5. Pain: painless
Double vision: d/t mechanical restriction of
ocular movements
Visual loss: Optic nerve compression
Personal history: H/O SMOKING
H/O Diabetes mellitus
 Myasthenia gravis

7.  History of any drug intake:
steroids or thyroid hormones,
h/o malignancies,
h/o irradiation
 Family history: positive family history of any
autoimmune disorder like pernicious
anaemia,Myasthenia gravis,Rheumatoid
disease,Hashimotos disease

8. systemic exam; café au lait spots
abnormal lymph nodes other neoplasms
FAST/ IRREGULAR PULSE
WARM MOIST SKIN
FINE TREMOR
PALMER ERYTHEMA
HAIR LOSS

34.  Measurement:
Naff-Jagers head bending test.
WORMS VIEW
 Exophthalmometers:
1.Leuddes.
2.Hertels-mirrors to view apex cornea.
3.Gormaz- Plunger Rest upon cornea.
4.Mutch Exophthalmometer
5.Stereo photographic methods.
6.Radiographic exophthalmometry.

36. LEUDDES HERTEL’S
MUTCH

69.  .
 1. Sight-threatening GO:
 dysthyroid optic neuropathy (DON) and or corneal
breakdown. - immediate intervention.
 2. Moderate to severe GO:
any one or more of the following:
 lid retraction ≥2 mm,
 moderate or severe soft tissue involvement,
 exophthalmos ≥ 3 mm above normal for race and
gender,
 inconstant or constant diplopia.

70.  . Mild GO: usually
only have one or more of the following:
minor lid retraction (< 3 mm above normal for race
and gender),
transient or no diplopia,
corneal exposure responsive to lubricants.

71. Lid aperture (distance between the lid margins in mm
with the patient looking in the primary position, sitting
relaxed and with distant fixation)
Swelling of the eyelids (absent/equivocal,
moderate, severe)
Redness of the eyelids (absent/present)
Redness of the conjunctivae (absent/present)
Conjunctival oedema (absent/present)
Inflammation of the caruncle or plica (absent/ present)

72. Exophthalmos ( Hertel exophthalmometer)
Subjective diplopia score (0- no diplopia;
1 - intermittent, i.e. diplopia in primary position
of gaze, when tired or when first
awakening;
2- inconstant, i.e. diplopia at extremes of gaze;
3- constant, i.e. continuous diplopia in primary or
reading position)
Eye muscle involvement (ductions in degrees)
Corneal involvement (absent/punctate keratopathy/
ulcer).
Optic nerve involvement (BCVA, Colour vision, RAPD
plus visual fields
if optic nerve compression is suspected)

74.  Control thyroid function
 To cease smoking
 Topical lubrication for ocular symptoms.
 Oral Selenium
 Periorbital edema: Head elevation at night.
Diuretics - minimal effectiveness in treating soft tissue
edema.
• Eyelid retraction: botulinum toxin to Muller’s muscle.

77.  Steroids: reduce transcription of intra- and
extracellular pro-inflammatory proteins in
orbital fibroblasts and Th1 lymphocytes.
 Most effective - early in active disease
 high-dose intravenous glucocorticoid pulse, with
response rates 80% for parenteral 60% with oral
steroids
• Side effects: weight gain, osteoporosis, blood
sugar elevation, hypertension, mood alteration,
sleep disruption, gastritis, glaucoma, and
cataracts

78.  Steroid-sparing agents:
 Azathioprine (AZT)
 Cyclosporine
 parenteral Rituximab (RTX) (a chimeric
mouse monoclonal anti-human CD20 antibody
that blocks B-cell proliferation and maturation)
 Infliximab and Etanercept (monoclonal
antibodies against TNF-∝)
.

79. • The rationale - both in its nonspecific anti-inflammatory effect and
in the high radiosensitivity of lymphocytes infiltrating the orbit.
typical radiotherapy dose is 2000 Gy,
given in 10 fractions of 200 Gy
• associated with transient exacerbations of inflammation due to release of
TSH receptor antigen and increased inflammatory response , but
avoided with co-coverage with glucocorticoids.
• Cataract, radiation retinopathy, and radiation optic neuropathy are
possible risks.
• Diabetes mellitus, is relative contraindication.

81.  Exposure keratopathy: Intense topical lubricants and
antibiotics
 Compressive optic neuropathy (or dysthyroid optic
neuropathy, DON) -
high dose of systemic steroids
 surgical decompression performed when
the response to medical treatment is inadequate.

86.  • potential complications of the 3 wall decompression
approach –
scarring of the scalp,
and neuralgia of the supraorbital nerve
 The most common complications of orbital decompression
surgery are diplopia and hypoesthesia in the distribution
of the infraorbital nerve.

Other complications include lower eyelid entropion, sinusitis,
CSF leak, NLDO, retrobulbar hemorrhage, and loss of vision.

87.  Restriction of the extraocular muscles will results in the
motility imbalance with both vertical and horizontal
Components ->diplopia.
 The goal of strabismus surgery is to achieve single
binocular vision in primary and downgaze positions
 mc -recession of the
medial rectus or inferior rectus muscle
• The most frequent complication is under correction or
overcorrection.
• Other complications are changes in eyelid position,
ocular ischemia, and globe perforation.

89.  Indications:
ocular discomfort, keratitis, corneal ulceration,
globe subluxation, and chemosis.

Eyelid surgery - after orbital decompression and
EOM surgery,
because both procedures can affect eyelid position.
The most common eyelid abnormality following
transantral decompression is lower eyelid entropion.

90.  • Moderate or severe lower eyelid retraction - placement of a
spacer graft to maintain separation of the tissues
 • The Mc complication of eyelid surgery -unsatisfactory eyelid
appearance.

• Problems with eyelid position, contour, and eyelid
crease position.

Pyogenic granulomata - following a posterior approach to
surgery. The patient c/o FB sensation and discharge. The
conjunctival surface has a pink, fleshy mass. Simple
excision and topical steroid offer prompt relief.

91.  THANK YOU