Work up of proptosis.pptx a useful one .

Proptosis work up

1. Work-up of proptosis MODERATOR : DR. VINnATI KANGALE MAAM PRESENTED BY: DR SONALI SAHU

2. DEFINiTIONS: EXOPHTHALMOS: protrusion of globe secondary to thyroid eye disease DYSTOPIA: Dystopia implies displacement of the globe in the coronal plane, usually due to an extraconal orbital mass such as a lacrimal gland tumour . Proptosis describes an abnormal protrusion of the globe with respect orbit, which may be caused by retrobulbar lesions or, less frequently, a shallow orbit. CRITERIA FOR PROPTOSIS: 1) Proptosis more than 22mm beyond the orbital rim. 2) An asymmetry of more than 2mm between the eyes.

3. PSEUDOPROPTOSIS Pseudoproptosis is either the stimulation of an abnormal prominence of the eye or a true asymmetry that is not caused by a mass, a vascular abnormality, or an inflammatory process. Causes of pseudoproptosis : Myopia Glaucoma Trauma Contralateral ptosis Lid retraction Facial nerve paralysis Contralateral small globe Congential asymmetrical orbital size.

4. HISTORY Age of onset & nature – sudden/gradual Course & duration of proptosis associated symptoms: loss of vision – gradual or sudden Defective color vision scotoma Pain diplopia Any association with cough or straining Any associated known systemic disease Thyroid disease Malignancy (lung, breast, prostate) Any history of trauma Any positive family history Any change in direction or protrusion

5. GENERAL EXAMINATION Age, built, weight Vitals pallor, icterus, clubbing or cyanosis Respiratory, cvs & cns general examination Facial asymmetry, scars , deformities Swelling in thyroid region Signs of trauma Signs of any cranial nerve palsies Any deformity of skull , teeth & bones

6. Ocular examination Visual acuity &BCVA Color vision testing Visual fields measurement of palpebral width (there should be no scleral show) Anterior chamber examination Pupillary reaction Slit lamp biomicroscopy Orbital margins Ocular movements Look for any mechanical ptosis Fullness of eyelids ( enoth sign) Measurements for IPD Diplopia work up

7. inspection Age Any skeletal deformity of skull Asymmetry of face General appearance for any staring looks Proptosis is unilateral or bilateral Any associated squint Versions and ductions in all gazes Direction of displacement of globe Any swelling , chemosis, congestion, lid retraction, lagophthalmos Signs of trauma

8. The following questions should be answered before examination for proptosis : 1) Is the eyeball in normal position ? 2) If so, is the contralateral eyeball sunken ( enophthalmic ) ? 3) Is the eyeball proptosed ?

9. SIGNS OF NORMAL POSITION OF THE GOLBE: 1) upper lids should cover one fifth of upper part of normal cornea or 2mm from upper limbus. 2) lower lids should just touch cornea at lower limbus. 3) no strip of sclera should be visible either above or below the cornea.

10. 4 ) if a straight measuring scale is put in front of eyeball in such a position that upper part rests over mid point of eyebrow and lower part rests on maxilla, then outer margin of upper lid should just touch inner edge of scale. if it pushes scale away, the eyeballs pushed forward. if there is gap between inner edge of scale and lid eyeball is pulled in.

11. Examination of a suspected case of proptosis Patient is made to sit comfortable and examiner stands behind the patient. The patient’s head is tilted back slightly Look at the most prominent part of the upper lid Normally the center of upper lid should be just visible at the level of upper rim of orbit If it protrudes beyond that, the eyeball is proptosed

12. NAFFZIGER’S METHOD: relative protrusion can be obsereved by simple standing behind a seated patient and gazing downward (tangentially) toward chin from forehead to assess protusion of eye beyond orbital rim.

13. WORM’S EYE VIEW: it is similar to Naffziger’s method but the difference is that exminer examines up from below wit the paitent’s head-titled back.

14. OCULAR MOVEMENTS If the ocular movements are restricted: FORCED DUCTION TEST DIFFERNTIAL IOP SACCADIC EYE MOVEMENTS ELECTROMYOGRAPHY

15. FORCED DUCTION TEST How to perform? A. Topical anaesthetic drops are instilled. B. A cotton soaked in anaesthetic solution is inserted into both eyes over the muscles to be tested and left for about 5 minutes. C. The insertion of the muscle in the involved eye is grasped with forceps and the globe is rotated in the direction of limited mobility. D. The test is repeated in the unaffected eye. E. The test is said to be positive when it is difficult to move the eye well in the field of action. This happens in entrapment of muscle, in fracture of orbit or in thyroid myopathy, excessive scarring of conjunctiva. F. The test is said to be negative in neurological paralysis where the globe can be moved with ease.

16. DIFFERENTIAL IOP TEST Intraocular pressure is measured in the primary position of gaze and then with the patient attempting to look into the direction of limited mobility. • Positive result: An increase of 6 mmhg or more denotes resistance transmitted to the globe by muscle restriction ( Braley sign). • Negative result: An increase of <6 mmhg suggests a neurological lesion. The advantages of this test over forced duction is a lesser degree of discomfort and an end-point that is objective rather than subjective.

17. SACCADIC EYE MOVEMENTS In neurological lesions are reduced in velocity, while restrictive defects manifest normal saccadic velocity with sudden halting of ocular movement. EMG is normal to elevated in cases of restrictive lesions Decreased in cases of paralytic lesions EMG ( ELECTROMYOGRAPHY)

18. Finger insertion test Insert the little finger between orbital margin and eyeball Feel for any mass and its consistency Vascular tumors are soft in consistency other are firm to hard

19. RETROPULSION: Paitent is asked to close the lids Apply light pressure on closed lids with palms. Feel the reducibility of globe.

20. BENDING FROWARD AND COUGHING Ask the pt to bend forward and also to cough so as to produce strain Proptosis can be induced in orbital varix after a latent period of 5 seconds Proptosis due to orbital varix is always unilateral and usually left sided due to narrower jugular foramen on the left.

21. VALSALVA MANEUVER Ask the pt to bend forward and also to cough so as to produce strain Proptosis can be induced in orbital varix after a latent period of 5 seconds Proptosis due to orbital varix is always unilateral and usually left sided due to narrower jugular foramen on the left

22. PULSATION AND BRUIT Pulsation is caused either by an arteriovenous communication or a defect in the orbital roof. • In the former, pulsation may be associated with a bruit depending on the size of the communication. • In the latter the pulsation is transmitted from the brain by the cerebrospinal fluid and there is no associated bruit. • Mild pulsation is best detected on the slit-lamp, particularly during applanation tonometry. A bruit is a sign of carotid-cavernous fistula. It is best heard with the bell of the stethoscope and is lessened or abolished by gently compressing the ipsilateral carotid artery in the neck .

23. EXOPHTHALMOMETRY Exophthalmometers measure the distance between apex of cornea and the lateral rim of orbit i.e the severity of proptosis

24. The scale is caliberated in mm, 0 to30 No anesthesia required Pt is asked to sit or lie down and fix his gaze to a distant object The scale is put at right angle to the lateral wall of orbit The apex of cornea is viewed through the transparent scale and reading is taken in mm Normal 15 to 20 mm LUEDDE’S TRANSPARENT SCALE

25. HERTEL EXOPHTALMOMETER

26. GORMAZ EXOPHTHALMOMETER

27. NAUGLE’S EXOPHTALMOMETER In case of acquired or congential asymmetry of the lateral orbital rims a Hertel exophthalmometer is misleading. In these cases, A NAUGLE EXOPHTHALMOMETER is preferred since the referring structure is not the lateral orbital rim but the frontal and infraorbital structures.

28. FUNDUS EXAMINATION

29. LAB INVESTIGATIONS: CBC & ESR FBS PPBS URINE: routine & microscopy, culture & sensitivity STOOL: cyst & ova Lipid renal & liver profile Thyroid profile Casoni’s test for hyadatid cyst ACE enzyme for sarcoidosis ANCA antibody for wegener’s Immunology screening for lupus

30. IMAGING IN PROPTOSIS: Following imaging modalities can be used: X ray USG CT SCAN MRI

31. X RAY ORBIT Helps in localizing orbital pathology: 1. Caldwell view: This shows greater and lesser wing of sphenoid. Superior orbital fissure, most of the paranasal sinuses. 2. Waters' view: This gives details of orbital rim, orbital roof and floor and maxillary sinuses. 3. Lateral view: This shows sphenoid, sphenoid air sinuses, anterior clinoid and sella turcica. 4. Axial (basal view). 5. Optic foramen view: X-ray of both the foramen should be taken for comparison especially in optic nerve glioma.

32. WHAT TO LOOK FOR IN X-RAY ORBIT 1. Size of orbit 2. Symmetry of orbit 3. Bone changes 4. Intraorbital calcification 5. Changes in paranasal sinuses 6. Retained intraorbital foreign body 7. Changes in optic foramen and optic canal 8. Superior orbital fissure width 9. Fracture in the orbital rim 10. Fracture in orbital walls Enlarged Optic Foramen In NF-1

33. USG: Helpful in thyroid Ophthalmopathy where it Demonstrate extra large Lateral and medial recti MRI : non invasive procedure Soft tissue details are better appreciated

34. Computerized Tomography of Orbit Following types of tomography are done in orbital diseases: 1. Axial tomography: This is the most commonly used mode to locate intraorbital / retroorbital lesions. 2. Coronal tomography demonstrates bone erosion in malignant tumours , mostly of lacrimal gland. 3. Lateral tomography is used to see blow out fracture of orbit. Computerized tomography can be done without or with contrast. Contrast tomography is helpful in vascular lesions .

35. Measurement of proptosis The technique for assessment of proptosis using mid-axial orbital CT scan was first described by Hilal and Trokel in 1977. A straight line is drawn between the anterior margins of zygomatic processes, using the mid-axial orbital scan. The distance between the anterior aspect of cornea and the inter-zygomatic line is then measured. Values > 21 mm or an asymmetry greater than 2 mm between the globes, is highly suggestive of proptosis. Another technique of assessing proptosis is by measuring the distance between the inter-zygomatic line and posterior sclera. Less than 1/3rd globe lying behind the inter-zygomatic line is strongly indicative of proptosis. (Figure 2). It is worth noting that the above two methods can be applied to both CT as well as MRI scan.

36. DIFFERENT CAUSES OF PROPTOSIS

37. causes of Axial proptosis: Graves disease Optic nerve glioma and meningioma Hemangioma

38. Causes of nonaxial proptosis: Dermoid Dermolipoma Carcinoma of ethmoid Carcinoma of frontal sinus Carcinoma of maxillary antrum Nasopharyngeal tumor Carcinoma of maxillary antrum Nasopharyngeal tumor

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