Proptosis

1. dr:bushra a/rahman manhal hospital hargeisa proptosis

2. P roptosis

3. It is defined as forward displacement of the eyeball beyond the orbital margins. Though the word exophthalmos (out eye) is synonymous with it; but somehow it has become customary to use the term exophthalmos for the displacement associated with thyroid disease.

4. CLASSIFICATION Proptosis can be divided into following clinical groups: 1. Unilateral proptosis 2.Bilateral proptosis 3. Acute proptosis 4. Intermittent proptosis 5. Pulsating proptosis

5. ETIOLOGY Important causes of proptosis in each clinical group are listed here: A. Causes of unilateral proptosis include: 1 . Congenital conditions . These include: Dermoid cyst , congenital cystic eyeball, and orbital teratoma. 2 . Traumatic lesions 3 . Inflammatory lesions

6. 4 . Circulatory disturbances and vascular lesions 5 . Cysts of orbit 6 . Tumours of the orbit 7 . Mucoceles of paranasal sinuses

7. B. Causes of bilateral proptosis include 1 . Developmental anomalies of the skull : craniofacial dysostosis e.g., oxycephaly ( tower skull). 2. Osteopathies 3 . Inflammatory conditions : Mikulicz’s syndrome and late stage of cavernous sinus thrombosis. 4. Endocrinal exophthalmos (eg;thyrotoxicosis).

8. 5 . Tumours : These include symmetrical lymphoma or lymphosarcoma, 6 . Systemic diseases : Histiocytosis, systemic amyloidosis , xanthomatosis and Wegener’s granulomatosis, thyroid diseases

9. C. Causes of acute proptosis. It develops with extreme rapidity (sudden onset). Its common causes are : orbital emphysema, fracture of the medial orbital wall , orbital haemorrhage and rupture of ethmoidal mucocele.

10. D. Causes of intermittent proptosis : This type of proptosis appears and disappears of its own, Its common causes are: orbital varix, periodic orbital oedema , recurrent orbital haemorrhage and highly vascular tumours.

11. E. Causes of pulsating proptosis: It is caused by pulsating vascular lesions such as caroticocavernous fistula and saccular aneurysm of ophthalmic artery. Pulsating proptosis also occurs due to transmitted cerebral pulsations in conditions associated with deficient orbital roof. These include congenital meningocele or meningoencephalocele, neurofibromatosis and traumatic or operative hiatus.

12. Investigation of a case of proptosis I. Clinical evaluation (A) History . It should include: age of onset, nature of onset, duration, progression, chronology of orbital signs and symptoms. (B) Local examination . It should be carried out as follows:

13. 1. Inspection . ( i ) To differentiate proptosis from pseudoproptosis which is seen in patients with buphthalmos , axial high myopia, retraction of upper lid and enophthalmos of the opposite eye. (ii) to ascertain whether the proptosis is unilateral or bilateral; (iii) to note the shape of the skull;and (iv) to observe whether proptosis is axial or eccentric .

14. 2. Palpation It should be carried out for retrodisplacement of globe to know compressibility of the tumour, for orbital thrill, for any swelling around the eyeball, regional lymph nodes and orbital rim. 3 . Auscultation It is primarily of value in searching for abnormal vascular communications that generate a bruit, such as caroticocavernous fistula.

15. 4. Transillumination . It is helpful in evaluating anterior orbital lesions. 5. Visual acuity . Orbital lesions may reduce visual acuity by three mechanisms: refractive changes due to pressure on back of the eyeball, optic nerve compression and exposure keratopathy.

16. 6 . Pupil reactions . The presence of Marcus Gunn pupil is suggestive of optic nerve compression. 7. Fundoscopy . It may reveal venous engorgement, haemorrhage , papilloedema and optic atrophy. Choroidal folds and opticociliary shunts may be seen in patients with meningiomas.

17. 8 . Ocular motility It is restricted in thyroid ophthalmopathy , extensive tumour growths and neurological deficit.

18. 9 . Exophthalmometry It measures protrusion of the apex of cornea from the outer orbital margin ( with the eyes looking straight ahead ). Normal values vary between 10 and 21 mm and are symmetrical in both eyes . A difference of more than 2 mm between the two eyes is considered significant. The simplest instrument to measure proptosis is Luedde’s exophthalmometer . the Hertel’s exophthalmometer ( is the most commonly used instrument . Its advantage is that it measures the two eyes simultaneously.

19. C) Systemic examination . A thorough examination should be conducted to rule out systemic causes of proptosis such as thyrotoxicosis, histiocytosis, and primary tumours elsewhere in the body ( secondaries in orbits). Otorhinolaryngological examination is necessary when the paranasal sinus or a nasopharyngeal mass apears to be a possible etiological factor.

20. II. Laboratory investigations These should include : Thyroid function tests, Haematological studies (TLC, DLC, ESR, VDRL test ), …. Casoni’s test (skin test to rule out hydatid cyst ),. Stool examination for cysts and ova, and Urine analysis for Bence Jones proteins for multiple myeloma.

21. III. Imaging Technique (A) Non-invasive techniques 1. Plain X-rays . 2 . Computed tomography scanning 3 . Ultrasonography 4 . Magnetic resonance imaging (MRI).

22. (B) Invasive procedures 1. Orbital venography 2 . Carotid angiography . 3 . Radioisotope studies.

23. IV. Histopathological studies ; The exact diagnosis of many orbital lesions cannot be made without the help of histopathological studies,which can be accomplished by following techniques. 1 . Fine-needle aspiration biopsy (FNAB ). 2 . Incisional biopsy . 3. Excisional biopsy.

24. MANAGEMENT OF PROPTOSIS REMOVE THE UNDERLYING CAUSES!!!!!!!!!!!!!!.