PROPTOSIS:

How to approach?
History, clinical examination, investigations
and differntial diagnosis

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 DEFINITION:
• PROPTOSIS: Forward displacement of bulging
especially that of eye.
• Abnormal protrusion of the globe beyond the
orbital margins with the patient looking
straight ahead
• Word EXOPHTHALMOS synonymous – but is
more specific for the. eye

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 Causes of pseudoproptosis:
Simulation of abnormal protrusion of the eye or a true
abnormal protrusion of eye or a true abnormal
protrusion that doesn’t originate from a mass,
inflammation or a vascular disorder
1.u/l high axial myopia
2.u/l congenital glaucoma
3.u/l secondary glaucoma resulting from ocular trauma
during childhood
4.shallow c/l orbit as in crouzon’s ds(craniosynostosis)
5.hypoplastic supra-orbital ridges as in trisomy18
6.assymetry of body of orbits
7.facial asymmetry
8. Lid retraction, ptosis or enopthalmos.

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 CLASSIFICATIONS
Time of onset
Etiology childhood-congenital
dysthyroid orbitopathy acquired
inflammatory adulthood
tumours & cysts Duration
Laterality Acute
unilateral Subacute
bilateral
chronic
Direction.
Clinical course
Axial Stationary
non-axial Progressive
Regressive
Pulsating
Intermittent
positional

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 CAUSES OF PROPTOSIS:
• Inflammation • Vascular disorders
Acute-orbital cellulitis -collagen ds-SLE or PAN
-cranial arteritis
Chronic(nongranulomatous)- -allergic vasculitis
pseudotumour -thrombophlebitis
-AV aneurysm or varices
Chronic(granulamatous)
TB,sarcoid,syphilis,parasites,Aspergill Systemic disease
osis -Thyroid disorder
-Myasthenia gravis
Benign lymphoepithelial -Acute intracranial
lesion (Mikulicz’s ds) hypertension
Injuries
-foreign body
-orbital hemorrhage

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 TUMOURS
PRIMARY SECONDARY
a.Dermoid
b.Hemangioma
c.lymphangioma • 1.Direct extension from-
d.Phakomatoses a.intraocular region:malignant
1.neurofibromatoses melanoma,retinoblastoma
2.Sturge-weber ds
b.eyelid:bcc,scc,malignant
3.tuberous sclerosis
e.Lipoma melanoma,mucoepidermoid ca
f. Fibrous xanthoma c.conjunctiva:scc,malignant
g.Rhabdomyosarcoma melanoma,mucoepidermoid ca
h.Amputation neuroma d.intracranium:meningioma
I.Neurilemmoma e.PNS:frontal,ethmoid,maxillary
j.Glioma of optic nerve tumours
k.Meningioma
• 2.Metastatic lesion
l.Lacrimal gland lesions
m. Lymphoma &leukemia
-neuroblastoma(child)
n.Hand-Schuller-Christian ds -primary in lung,
o.Juvenile xanthogranuloma breast,prostrate(adults)
-malignant melanoma of skin

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 EVALUATION OF THE PATIENT
• HISTORY
-Age of onset
-nature of onset
-duration
-progression
-symptoms
-associated symptoms/systemic
symptoms

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 AGE OF ONSET:
• NEWBORN • 1-5 Yrs OF AGE
-orbital sepsis -dermoid
-orbital neoplasm -orbital extension of
retinoblastoma
NEONATAL -hemangioma
-infections of maxilla -metastatic
neuroblastoma
EARLY CHILDHOOD(upto 1 yr) -glioma of optic n.
-dermoid
-hemangioma
-orbital extension of
retinoblastoma
-Hand-Schuller-Christian ds

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• Young Adult • Old age:
-pseudotumour -pseudotumour
-thyroid ophthalmopathy -sino-orbital mucocele
-mucocele -malignant lymphomas&
-meningioma leukemias
-fibrous dysplasia -meningioma
-osteoma -ca of palpebral or
epibulbar region
-undifferentiated
sarcoma -metastatic ca
-lacrimal gland tumour

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 NATURE OF ONSET:
Sudden onset
-orbital emphysema
-rupture&infection of ethmoidal mucocele
-retrobulbar hemorrhage&infection
Gradual onset
-benign tumour
-ASPERGILLOSIS
Rapidly expanding orbital masses
-rhabdomyosarcoma,neuroblastoma,eosinophilic granuloma,
capillary hemangioma,traumatic hematoma, orbital
cellulitis/abcess,pseudotumour

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 PROGRESSION:
Continuous progression Variable
-tumours & endocrinal • pseudotumours&angiomas
exophthalmos

Pulsating
Intermittent proptosis -carotidocavernous
-orbital varices aneurysm
-recurrent hemorrhage -large frontal mucocele
-vascular neoplasm -meningoencephalocele
-lymphangioma -blow out fracture of roof
of orbit

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 SYMPTOMATOLOGY:
PAIN:
orbital inflammatory disorders,traumatic cases with orbital
hematoma, malignancy
DIPLOPIA:
common symptom in orbital disorders related to paralysis of
extraocular muscles or restriction of ocular movements.

OPTHALMIC EXAMINATION
VISUAL ACUITY—provides an indicator of extent of orbital
ds.&decreased vision suggests either exposure keratitis or
involvement of optic n. Loss of vision prior to proptosis in children
suggests optic n. glioma.

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 INSPECTION

• Important to look at the entire face in order to get a

sense of facial proportion & symmetry.
1.whether proptosis is true or false
2.whether proptosis unilateral or bilateral.

Inspection of eyelids-diagnostic clues

• Swelling of lids with ecchymosis & chemosis of
conjunctiva-orbital cellulitis
• Pediatric disorders that cause eyelid ecchymosis—
neuroblastoma,ewing’s sarcoma,leukemia, eosinophilic
granuloma,lymphangioma,traumatic hematoma

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Conjunctiva • Direction of displacement

-dysthyroid orbitopathy-hyperemia • Ethmoidal sinus mucocele

near insertions of recti muscles displaces globe laterally
-orbital vascular malformation or • Mass in lacrimal fossa-downward
caroticocavernous fistula-
dilated,slightly tortuous larger & nasal displacement
vessels that extend to
corneoscleral limbus • Axial proptosis-mass inside
muscle cone eg.optic n. glioma
-idiopathic orbital inflammation- ,meningioma, grave’s
marked diffuse injection of
smaller conjunctival &episcleral
blood vessels • Maxillary sinus growth-superior
displacement

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 Differential Diagnosis:
Causes of u/l proptosis Causes of b/l proptosis
•
• Developmental anomalies of skull-
Congenital-dermoid cyst,orbital teratoma etc.
craniofacial dysostosis eg.
Oxycephaly(tower skull)
• Traumatic -orbital hemorrhage,traumatic
aneurysm,foreign body etc.
• Osteopathies-
osteitis deformans, rickets,acromegaly
• Inflammatory -orbital
cellulitis/absess,cavernous sinus
• Inflammatory conditions-Mikulicz’s
thrombosis(proptosis is intially u/l then syndrome,late stage of cavernous sinus
becomes b/l),fungal, pseudotumours thrombosis

• Vascular lesions-orbital varix • Endocrinal exophthalmos-thyrotoxic or

&aneurysm(saccular aneurysm of ophthalmic thyrotropic
artery,carticocavernous fistula)
• Tumours-
• Cysts of orbit-haematic cyst,parasitic lymphoma,lymphosarcoma,secondaries
cyst(hydatid cyst,cysticercosis)
• Systemic ds-histiocytosis,systemic
• Tumours-primary,secondary or metastatic amyloidosis,xathomatosis&wegener’s
granulomatosis

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• PALPATION:
• Retrodisplacement of globe should be estimated
• Resistance: painful/hard
• In orbital varices-complete reducibility of eyeball which
comes back on valsalva or bending of head
• Thrill palpable in CCF or AV malformations
• Palpation of orbital rims – to note any change in
contour or dehiscence of any orbital wall
• AUSCULTATION:
• for abnormal vascular communications that generate a
bruit
• LYMPHADENOPATHY-preauricular,cervical neck nodes
• ENT EXAMINATION
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• Pupillary reactions-presence of Marcus Gunn pupil –optic n.
compression

• Fundoscopy-venous engorgement,hemorrhage, papilledema

or optic atrophy is observed

• Ocular motility-restriction of ocular movements may be

caused by restrictive myopathy as in thyroid
ophthalmopathy,splinting of optic n. in optic sheath
meningioma &neurological deficit resulting from orbital apex
lesions.

• Forced duction test- to differentiate defective ocular

movements due to neurological lesions from those caused by
mechanical obstuction.

• Tonometry-IOP is usually raised in thyrotropic exophthalmos

esp. in upward gaze(positional iop changes)

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 Exophthalmometry(proptometry)
• Worm’s eye view
• Standard Hertal’s
exophthalmometer-measures
both eyes simultaneously with
lateral orbital rim as reference
point
• Leudde’s exophthalmometer-
measures each eye separately
with lateral orbital rim as
reference pt.
• Mutch exophthalmometer-
measures each eye separately
with cheek or brow as
reference pt.
Normal values: 10-21 mm
Absolute reading of >21mm suggests proptosis
Difference of >2mm between eyes also indicates proptosis
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 VEP

Flash VEP
Pattern VEP-
full field
hemi field
central field
partial field
Chromatic patterned stimuli-best method of separating
red, green , and blue coloured channels. Helpful in
detecting colour blindness.
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 Normal Data:
• P 100 LATENCY ( m sec ) = 102  5
• Amplitude (μV) =10  4.2
• Duration = 63  8.7

Criteria for abnormailty

LATENCY CRITERIA
• PROLONGATION > 3 SD
• INTEROCULAR LATENCY OF P100>10 msec,
LONGER LATENCY ABNORMAL

AMPLITUDE CRITERIA
• INTEROCULAR AMPLITUDE RATIO>2
• ABNOMALLY LOW OR HIGH AMPLITUDE
• ABSENCE OF IDENTIFIABLE VEP FROM
MIDLINE AND LATERAL OCCIPITAL SITES.

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General systemic examination Lab investigations

conducted to rule out complete hemogram,

proptosis (esp. when b/l) peripheral blood smear &
associated with systemic BM examination
ds such as thyroid function tests
amylodosis,histiocytosis
or wegener’s
granulomatosis

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 RADIOLOGICAL INVESTIGATIONS:
X-ray orbit PA view(caldwell • X-ray pns (waters’ view)
view) -for visualisation of orbital
-orbital fractures floor ant. 2/3&maxillary
-calcification inside sinus
tumours- meningioma -better picture of orbital
-phleboliths-varices blow out fractures
-erosion of bony walls- X-ray optic foramen
malignancies view(Rhese view)
-paranasal comparison of both optic
sinusitis/mucocele foramen-enlargement of
foramina occurs in gliomas,
X-ray lateral view meningiomas,neurofibroma
orbital roof fracture,pituitary s etc.
ds,frontal sinus ds

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 Ultrasonography:

• Non-radiational,non-invasive,well tolerated
• A-scan-unidimensional image
• B-scan-2D picture,better anatomical display. 4
patterns.
• C-scan-for visualizing soft tissue of orbit in coronal
plane
• USG patterns of pathological lesion depends mainly
on displacement of orbital fat.

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 CT SCAN MRI
• Most valuable,non-invasive • Superior in evaluating
method in diagnosis of intracanalicular,chiasmal&p
orbital&related lesions---
axial&coronal planes ost chiasmal extension of
• Size,shape,extent of any tumours
orbital mass lesion is seen • Added adv of not being
clearly
• hampered by bone&proves
Bony involvement is seen
clearly to be more sensitive in
• PNS pathology is seen delineating subtle
clearly differences in fat content &
• Main disadv-inability to hydration of neural tissues
distinguish b/w pathological
soft tissue masses which are
radiological isodense

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Carotid angiography Orbital Venography
Done in selected cases- • Limited indications
-suspected vascular shunts • Invasive
or intracranial vascular
anomaly, tumour. • Sup opthalmic vein-= most
consistent landmark.
-should be performed in all
cases of pulsating
exophthalmos&in cases
associated with bruit/thrill
Eg: angiofibroma,carotid
cavernous fistula.

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 HISTOPATHOLOGICAL STUDIES:
FNAC
• under direct vision in an obvious mass;CT or USG
guided in retrobulbar mass
• D/v-scanty cellular material
CORE BIOPSY
•3 part instrument consists of a trephine,an
obturator&a tissue fixator.

Endoscopic biopsy

Incisional Biopsy
•Not preferred
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 Excisional biopsy:
• Preferred to incisional biopsy in orbital masses which
are well encapsulated or circumscribed
• Anterior orbitotomy:mass in ant part of orbit is
reached either by transcutaneous or
transconjunctival approach
• Lateral orbitotomy:mass in post part(retrobulbar)or
at apex of orbit
• Transcranial approach :when tumour extends into
cranial cavity

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