Proptosis

1
Proptosis

• Mounir Bashour, M.D., C.M.

2
What is proptosis?

• Forward protrusion of one or both eyeballs
• Unilateral asymmetric protrusion of one eye by at
  least 2 mm
• Normal upper limits
• 22 mm in Caucasians
• 24 mm in African-Americans

3
How is proptosis diagnosed?

• Globes from above
• Measured with an exophthalmometer
• lateral orbital rim
• CT scan

4
List common problems associated with proptosis

• 1. Exposure keratopathy
• poor blink mechanism
• corneal abrasions and ulcers
• 2. Diplopia
• displacement of the globes
• extraocular muscle function
• 3. Optic nerve compression
• decreased visual acuity
• RAPD
• color vision deficit
• visual field defect
• prompt therapeutic intervention

5
Most common cause of unilateral proptosis?

• Thyroid eye disease (Graves' ophthalmopathy)

6
Most common cause of bilateral proptosis?

• Thyroid eye disease

7
What are other causes of proptosis?

• Orbital inflammatory pseudotumor
• Orbital infectious cellulitis
• Orbital tumors (benign or malignant)
• Lacrimal gland tumors
• Trauma (retrobulbar hemorrhage)
• Orbital vasculitis (i.e., polyartentts nodosa,
  Wegener's granulomatosis)
• Mucormycosis
• Carotid-cavernous fistula
• Orbital varix

8
List the causes of pseudoproptosis

• 1. Unilateral high axial myopia
• A-Scan
• 2. Actual enophthalmos of other eye
• 3. Upper lid retraction

9
Which neuroimaging test is best to evaluate the
etiology of proptosis?

• CT scans are superior in most cases
• MRI may be desirable in certain cases when optic
  nerve dysfunction is present

10
Unilateral or bilateral painless proptosis,
eyelid retraction, eyelid lag, and motility
disturbances?

• Thyroid ophthalmopathy
• multisystem. autoimmune disorder
• hyperthyroid, hypothyroid, euthyroid
• inflammation and enlargement EOM
• IRgtMRgtSRgtLR
• fusiform enlargement sparing the tendon
• peribulbar tissues.
• Proptosis
• Eyelid retraction
• Corneal problems
• Diplopia
• Optic nerve compression
• Treatment depending on the severity
• Systemic and laboratory evaluation is mandatory

11
Unilateral proptosis, pain, conjunctival
injection, and motility disturbances in an adult?

• Orbital inflammatory pseudotumor
• nonspecific idiopathic inflammatory
• localized to muscle, lacrimal gland, sclera vs.
  diffuse
• eyelid erythema or edema
• palpable mass
• decreased vision
• uveitis
• hyperopic shift
• optic nerve edema
• Bilateral disease more common in children
• CT scan
• thickening 1 EOM (inc. tendons)
• lacrimal gland enlargement
• thickening of the posterior sclera
• Treatment corticosteroids /- radiation

12
Unilateral proptosis, pain, fever, decreased
ocular motility, erythema, and edema of the
eyelids?

• Infectious orbital cellulitis
• usually bacterial
• extended posterior to orbital septum
• meningitis
• cavernous sinus thrombosis
• staphylococci. streptococci. anaerobes, and
  Haemophilus influenza (in children under 5 years
  of age)
• most common source -- ethmoid sinusitis
• intravenous antibiotics

13
Persistent proptosis or progression of infection
despite adequate antibiotic Rx

• Orbital subperiosteal abscess
• CT scan
• confirm diagnosis
• locate the abscess
• surgical drainage and continued intravenous
  antibiotics

14
Child lt 6 y.o. with gradual, painless,
progressive, unilateral axial proptosis with
visual loss?

• Optic nerve glioma (juvenile pilocytic
  astrocytoma)
• slow-growing tumor
• Decreased visual acuity with a RAPD
• CT scan or MRI
• fusiform enlargement of the ON
• associated with NF1 Dx if bilateral
• Systemic evaluation and genetic counselling for
  NF is essential

15
Child with rapidly progressive unilateral
proptosis, displacement of the globe inferiorly,
and edema of upper eyelid?

• Rhabdomyosarcoma
• most common primary orbital malignancy of
  childhood
• malignant growth of striated muscle tissue
• rapidly progressive mass in the superior orbit
  with proptosis, globe displacement, and eyelid
  swelling
• average age of presentation is 7 years
• Prompt diagnosis with orbitotomy and biopsy is
  crucial
• overall mortality is 60 once the disease has
  extended to orbital bones
• Current Rx with radiation chemo have lowered
  mortality rates to 5 to 10

16
Most common benign orbital tumor in adults that
causes unilateral proptosis?

• Cavernous hemangioma
• slow-growing vascular tumor
• usually diagnosed in young adulthood to middle
  age
• CT scan
• intraconal well-defined orbital mass
• Visual acuity is often not affected.
• Treatment observation or surgical excision

17
Most common malignant orbital tumor in adults
that causes unilateral proptosis?

• Orbital lymphomas
• typically superior orbit
• slow onset and progression
• subconjunctival salmon-colored" mass in the
  fornix
• CT scan
• poorly defined mass conforming to the shape of
  the orbital bones and globe without bony erosion
• orbital biopsy
• definitive treatment is radiation
• associated with systemic lymphoma therefore
  medical consult and systemic evaluation are
  necessary for all patients

18
Tumors that are encapsulated or appear well
circumscribed on neuroimaging

• Cavernous hemangioma
• Schwannoma
• Fibrohistiocytoma
• Neurofibroma
• Hemangiopericytoma