Proptosis 3

ORBIT EVALUATION

1. PROPTOSIS Dr Nikita Jaiswal

2. GLOSSARY INTRODUCTION TYPES DIFFERENTIAL DIAGNOSIS INVESTIGATIONS

3. CASE SUMMARY

4. 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. Pseudoproptosi s:this is a clinical appearance of proptosis where dere is no forward displacement of the globe.

5. 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.

6. Measurements Proptosis > 21 mm Enophthalmos < 10–12 mm

7. 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.

8. CLASSIFICATION LATERALITY TYPE DURATION NATURE UNILATERAL & BILATERAL AXIAL OR ECCENTRIC ACUTE ,CHRONIC & INTERMITTENT PULSATILE OR NON PULSATILE

9. AXIAL PROPTOSIS Axial proptosis is caused by any space occupying lesion in the muscle cone or any diffuse orbital inflammatory or neoplastic lesions.

10. ECCENTRIC PROPTOSIS Proptosis caused by any extraconal lesion or fracture displacement of orbital bones protruding inwardly.

11. NON AXIAL PROPTOSIS Downward: Fibrous dysplasia Fibrous mucocele Lymphoma Neuroblastoma Neurofibroma Schwannoma Subperiosteal hematoma Upward : Tumors of floor of orbit Maxillary tumors Lymphoma Lacrimal sac tumors Down & in : Lacrimal gland tumors Sphenoid wing meningoma lateral: Ethmoidal mucocele, Frontal mucocele, Lacrimal sac tumors

12. Newborn Orbital sepsis Orbital neoplasm Neonates Osteomyelitis of maxilla Infants Dermoid cyst Dermolipoma Hemangioma Histocytosis X Orbital extension of retinoblastoma Children Dermoid cyst Teratoma Capillary hemangioma Lymphangioma Orbital nerve glioma Plexiform neurofibroma Rhabdomyosarcoma Acute myeloid leukemia Histocytosis Neuroblastoma Wilms’ tumor Ewing’s tumor Adults : Thyroid orbitopathy Cavernous hemangioma Orbital varices Optic nerve meningoma Schwannoma Fibrous histocytoma Lymphoma Secondaries from breast, lung, prostate carcinoma

13. GROSSLY Infection congenital Inflammation Inflammatory Traumatic Metabolic Vascular Tumors Tumors Systemic disorders Unilateral Bilateral

14. Unilateral proptosis 2. Traumatic Vascular Haemorrhage Aneurysm of ophthalmic artery Carotico-cavernous fistula Orbital varix Haemangioma Tumours Dermoid Glioma of optic nerve Meningioma of optic nerve sheath Retinoblastoma Rhabdomyosarcoma Secondaries Leukaemia Lacrimal gland tumours Systemic disorders Ocular Graves’ disease (dysthyroid orbitopathy) Blood disorders Sarcoid Storage disorders Cysts and parasites: Cysticercosis Hydatid cyst Inflammation or infection Orbital cellulitis Cavernous sinus thrombosis Orbital abscess Pseudo-tumour Parasites

15. Bilateral proptosis Inflammatory Cavernous sinus thrombosis Pseudo-tumours Wegener’s granuloma, tuberculosis and fungal granuloma Metabolic Ocular Graves’ disease and sarcoid Tumours Retinoblastoma Lymphoma Lymphosarcoma Leukaemia

16. EXAMINATION OF PROPTOSIS

17. HISTORY DURATION NATURE EXAMINATION

18. 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

19. 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.

20. 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.

21. DYSTOPIAS

22. PULSATIONS /BRUIT

23. Investigation in proptosis Haematological for blood dyscrasia Otorhinological Nasopharynx 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

24. 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

25. ULTRASONOGRAPHY/B-SCAN

26. MRI

27. CT SCAN

28. CHECK LIST VISION PUPIL IOP OCULAR-MOTILITY & ALIGNMENT PROPTOSIS PALPRABERAL FISSURE HEIGHT CONJUNCTIVAL CHEMOSIS CORNEA FUNDUS

29. DIFFRENTIALS : THYROID EYE DISEASE PSEUDOTUMOUR

30. TED THYROID ORBITOPATHY THYROID ASSOCIATED OPHTHALMOPATHY GRAVES DISEASE

31. PATHOGENESIS INFLAMMATION OF THE EOM INFLAMMATORY CELLULAR INFILTRATION

32. Diagnostic criteria Eyelid retraction to the level of upper limbus along with: Thyroid abnormalities Exophthalmos Optic neuropathy

33. CLASSIFICATION HISTORICAL CURRENTLY

34. HISTORICAL N : no signs & symptoms O : only signs S : soft tissue involvement(odema & conjestion) P :proptosis E :extra ocular muscle involvement C :corneal involvment S :sight loss

35. 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,irritation

36. Clinical features Signs & symptoms Clinical signs

37. SIGNS & SYMPTOMS c/f Extraocular muscles Eyelid signs Optic neuropathy Soft tissue

38. Soft tissue features Inflammatory cells & odema cause soft tissue involvement Epiphora ,chemosis Dull aching pain around the eye Fat prolapse Pushing sensation Enlarged palprabral fissure Periocular edema

39. SIGNS & SYMPTOMS c/f Extraocular muscles Eyelid signs Optic neuropathy Soft tissue

40. 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.

41. SIGNS & SYMPTOMS c/f Extraocular muscles Eyelid signs Optic neuropathy Soft tissue

42. EYELID SIGNS Lid abnormalities Fibrosis & contractures of tissues Drooping of normal eye lid if the retraction is asymmetric

43. SIGNS & SYMPTOMS c/f Extraocular muscles Eyelid signs Optic neuropathy Soft tissue

44. OPTIC NEUROPATHY Crowding of orbital apex Elderly patients mostly RAPD VISUAL FIELD ANALYSIS

45. CLINICAL SIGNS FACIAL UPPER LID LOWER LIDS EYELIDS CONJUNCTIVAL PUPILLARY EXTRAOCULAR MUSCLES

46. FACIAL JOFFROYS SIGN: ABSENT CREASES ON THE FOREHEAD ON UPWARD GAZE

47. EYELID SIGN KOCHERS SIGN VIGOUROUX SIGN ROSENBACH’S SIGN: TREMORS OF EYELID REISMAN ‘S SIGN: BRUIT OVER THE EYELIDS

48. UPPER EYELID SIGN Von grafe’s sign Dalrymple’s sign

49. 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

50. LOWER LID SIGN Enroth’s sign Edema of lower lid Griffith’s sign Lower lid lag on upward gaze

51. 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

52. Conjunctival & pupillary Names Signs Goldzeiher’s Conjunctival injection Kneis Uneven dilatation in dim light Cowen’s Jerky contractions of pupil to light

53. IMAGING CT SCAN:

54. Systemic signs

55. 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)

56. 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

57. 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

58. Thank you Have a good day