PROPTOSIS :

INVESTIGATION & MANAGEMENT

Dr Ramchandra D Hendge

Proptosis

Definition :

Abnormal protrusion of globe

Displacement of globe relative to orbital rims

Exophthalmos : abnormal protrusion of eye balls in

endocrine disorders specially in thyroid dysfunction

Classification

1) Based on direction

2) Based on severity

3) Based on presentation

4) Based on etiology

5) Based on movement

Etiology

Axial Proptosis- Eccentric/Abaxial Proptosis

Optic nerve tumours Thyroid orbitopathy

Intra conal haemangioma Dermoid cyst

Infections & Inflammations

Neurofibroma

Lacrimal gland tumour

Approach to diagnosis

History Clinical exam Investigations

Inspection Blood Ix

Palpation Imaging

Percussion X-ray

Auscultation USG

Tests CT

MRI

Angiography

Histopathology

FNAC

Biopsy

History

Onset , duration, progress

DOV, colour vision defect

Diplopia

Discoloration of lids

Association with straining

Postural variation

Oral hygiene

Clinical Examination

Inspection

Palpation

Percussion

Auscultation

Clinical Tests

Auscultation

Globe/temporal region for bruit

Differential Tonometry

Useful in fibrosis of muscles & lesions compressing globe

Rise in IOP >6mmHg suggestive of pathology

Rise in IOP due to mechanical compression of globe

Gaze- Upward for muscles & in direction of mass in

space occupying lesions

Ruler Test

Exophthalmometry/ Proptometry

1) Clinical

2) Stereo Photographic

3) Radiographic

Clinical Exophthalmometry

1. Hertel

2. Luedde

3. Naugle

4. Gormaz

Hertel Exophthalmometer

Measures distance of corneal apex from lateral orbital rim

Lateral orbital rim serves as reference point

Difficult to use in lateral wall fracture or surgery

Leudde Exophthalmometer

Light weight, cheaper, easier

allows accurate measurement of proptosis by viewing at right

angle

Naugle Exophthalmometer

Uses fixation points slightly above and below superior &

inferior orbital rims

Measures difference in proptosis of two eyes rather than

absolute proptosis

Useful in lateral

orbital wall fracture

or surgery

Gormaz Exophthalmometer

Measure distance between two lateral orbital

margins

Require topical anaesthesia

Blood Investigations

Complete haemogram

ESR

FBS/PPBS

Thyroid function tests

Serum c-ANCA levels

Serum ANA levels

Other Investigations

Sputum for AFB

Montoux test

X -ray

Should be the first screening imaging investigation

Useful specially for bony pathology

Useful in detecting :

Benign tumours

Calcification( Meningioma, retinoblastoma,

lacrimal gland carcinoma)

Hyperostosis( Meningioma, fibrous dysplasia,

osteoblastic secondaries)

Caldwell view/General view

Structures seen-

Medial wall ,

orbital rim

Water’s view/Orbital view

Structures

seen-

anterior

2/3rd of

orbital

floor

Lateral

Structures

seen-

Orbital

roof

Ultra sonography

Rapid, non invasive , simple, no radiations

Compact & Portable

Can be done in OPD & before surgery by ophthalmologist

No need to depend upon radiologists

Gives information about characteristics of lesions

Size of lesion can be measured

Principle- Piezo electric effect

Probes- Sound waves-6-20 MHz

Lower frequencies-> lower resolution->better penetration

Higher frequencies-> higher resolution->lesser penetration

Gives echogenicity based on reflectivity of structure

TYPES

A scan/Amplitude scan

B scan/ Brightness scan Trans ocular

C scan/ Coronal scan Para ocular

D scan / 3D scan

Hydatid cyst

• Double wall sign

• Un-echoic space

Vascular tumor

• Well

demarcated, intra-

conal lesion with

high internal

reflectivity

Orbital Cellulitis

Well defined ,

encapsulated

lesion

CT Scan

Is superior to X ray & USG

Gives shape , size , location & nature of lesion

Resolution ~0.5 mm

8 slices required to scan orbit

Causes radiation exposure but its comparable with orbital X

ray

HRCT with 1mm sections gives information about optic nerve

tumours

Sections

Axial section-

shows both globes,

horizontal recti ,

optic nerves, orbital

soft tissue & bony

structures

Coronal section-

Anterior- Globe with

recti muscles

Posterior – all recti

muscles, oblique

muscles, optic nerve &

soft tissue of orbit

Thyroid orbitopathy

Fusiform

dilatation of belly

of recti muscles

Hematoma

Meningioma

Iso-dense with

optic nerve

Takes contrast

Tram track sign

on axial CT

Non enhancing

dot sign on coronal

CT

Pseudotumour of orbit

Generalised

enlargement of

muscles

MRI

Most sensitive modality for soft tissue lesions

No radiation exposure

Specially useful in optic nerve lesions, pseudo tumour, orbital

metastasis & tumours having intra cranial expansion

Metallic implants/ metallic foreign bodies are the only

absolute contraindications

T1/T2 weighting- refers to methods of measuring the

relaxation times of excited protons after magnetic field is

switch off.

T1- Fat-Bright

Vitreous- Dark

T2- Fat-Dark

Vitreous- Bright

Cavernous Hemangioma

T1- Iso-intese

with muscle, if

thrombosis-hyper

intense

T2- Hyper intense

with muscle

Contrast-

Irregular

enhancement with

delayed wash out

Lacrimal gland tumor

Pleo-morphic adenoma-

T1,T2- Intermediate

intensity

Contrast- bright

enhancement

Pseudotumor

T1,T2- Hypo

intense

Contrast-

Diffuse

enhancement

Angiography

Orbital Venography :

Useful in diagnosis of orbital varix, cavernous sinus

thrombosis & obstruction of ophthalmic vein by external mass

Dye is injected in frontal or angular veins & sequential X

rays are taken in AP view.

not used now a days

Orbital Arteriography :

Useful in diagnosis of A-V malformations , carotid-cavernous

fistula , aneurysms etc

Contrast dye is injected in ipsi-lateral common or internal

carotid artery and sequential X rays are taken.

Contrast medium may cause allergic reactions

Not used now a days due to CT,MRI & MR Angiography.

Ophthalmic artery Anurysm

Hyper lucent

mass in orbit

Histopathology

Definitive diagnosis is by histopathology

Biopsy Techniques :

FNAC

Core biopsy

Incisional biopsy

Excisional biopsy

FNAC

Minimal invasive

Rapid diagnosis

USG/CT guided FNAC

Accuracy >80%

Indications :

Lymphoma,melanoma,meningioma

Scanty material, difficult to evaluate

Risk of globe perforation,h’age

Core biopsy –better than FNAC

Inscisional biopsy- sample obtained under direct visualisation

Excisional biopsy- Best method for tissue sampling

Both diagnostic &therapeutic

Pathology Techniques

1. Cytology

2. Gross examination

3. Routine histopathology

4. Histochemistry-Sudan black(Fat)

5. Immuno-histochemistry –HMB45 for melanomas, S100 for

schwannomas & neurofibromas

6. Electron microscopy

Management of proptosis

Local measures

Medical therapy

Radiation

Surgical options

Local measures

Sun glasses

Sleep in supine position with head elevated

Taping of lids at night

Prisms in diplopia

Medical therapy

Topical tear substitutes

Systemic diuretics - minimal role

Parenteral antibiotics

Pain killers

Corticosteroids

Corticosteroids

Indications

Compressive optic neuropathy

Prior to orbital decompression

Pseudo tumor

Traumatic optic neuropathy

Hydatid cyst

Corticosteroids - regimen

60-100mg(1mg/kg) orally prednisolone in divided

doses

Pulse intravenous therapy of methyl prednisolone

1gm on alternate days for 3-5days

Local steroid injections have no role

Complications

Weight gain

Gastrointestinal irritation

Reactivation infections (tuberculosis)

Cataract

Glaucoma

Osteoporosis

Adrenal gland suppression

Immunosuppressive

Indications-

Refractory cases of thyroid orbitopathy, pseudotumour,

sarcoidosis , hematological malignancies etc

Commonly used drugs- Cyclosporin, methotrexate,

azathioprine, cyclophosphamide etc

Anti tumor necrosis factor drugs – infiximab

Radiation Therapy

Indications-

Pseudotumour

Lymphoma

Rhabdomyosarcoma

Meningioma

Thyroid orbitopathy

Surgical management

Orbital decompression

Strabismus surgery

Eye lid surgery

Orbital decompression

Done in stable cases

Severe exophthalmos

Exposure keratopathy

Optic nerve compression

Cosmetic purpose

Surgical approaches to orbit

(1) Lateral orbitotomy (Krönlein procedure)

(2) Superior decompression via craniotomy(Naffziger procedure)

(3) Medial wall removal and ethmoidectomy

(4) Orbit floor removal

(5) Combined ethmoidectomy

and medial orbit floor

Complications: Orbital Decompression

Diplopia

Hyper aesthesia in distribution of infra orbital nerve

Nasolacrimal duct obstruction

Cerebrospinal fluid leak

Frontal lobe hematoma

Strabismus surgery

Indications :

Done in stable inactive thyroid orbitopathy

Angle of deviation stable for at least 6–12 months

Goal :

To minimize diplopia in primary position

Eye lid surgeries

Mild eyelid retraction- no surgeries

Main indication is exposure keratopathy

Conclusion

Proptosis is an important manifestation of a large number of

orbital diseases. Thorough clinical examination coupled with

appropriate investigations clinches the diagnosis and helps in

management.

THANK YOU