1 Proptosis
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Proptosis Key question… 1 Proptosis
Transcript of 1 Proptosis
Proptosis
Key question…
1
Proptosis
Proptosis
IsLid Retraction
present?
2
Proptosis
Proptosis
IsLid Retraction
present?
Yes NoYour thought is…
If the answer is…
3
Proptosis
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
4
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
5
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pt has lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely.
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
6
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pt has lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely.
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
7
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pt has lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely.
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
8
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
9
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely
There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
10
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely
There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravistwo words
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
11
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely
There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
12
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely
There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis
What one word best characterizes the clinical course of ptosis in MG?Variable. That is, one would expect the degree of ptosis to vary from exam to exam
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
13
How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.
Does the absence of lid retraction rule out Graves?No, but it make it much less likely
There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis
What one word best characterizes the clinical course of ptosis in MG?Variable. That is, one would expect the degree of ptosis to vary from exam to exam.
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
14
What if it’s not Graves dz? What else can cause proptosis + lid retraction?An abnormally large globe as in high axial myopia, or buphthalmos. Of course, such cases would not consist of lid retraction + proptosis; rather, they would consist of lid retraction + pseudoproptosis.
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
15
What if it’s not Graves dz? What else can cause proptosis + lid retraction?An abnormally large globe as in high axial myopia, or buphthalmos. (Of course, such cases would not consist of lid retraction + proptosis; rather, they would consist of lid retraction + pseudoproptosis.
ProptosisProptosis
IsLid Retraction
present?
Yes No
Graves dzYour thought is…
If the answer is…
16
What if it’s not Graves dz? What else can cause proptosis + lid retraction?An abnormally large globe as in high axial myopia, or buphthalmos. (Of course, such cases would not consist of lid retraction + proptosis; rather, they would consist of lid retraction + pseudoproptosis.)
ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
If the answer is…
Your thought is…
Yes
Graves dz
17
(over here now)
ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
18
ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
Key question…
19
ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
Is there a Mass
present?
20
ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
Is there a Mass
present?
Yes NoIf the answer is…
Your DDx is…
21
ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
Is there a Mass
present?
Yes NoIf the answer is…
Your DDx is…
--Cavernous hemangioma--ON sheath meningioma--ON glioma--Rhabdomyosarcoma--Metastatic disease--Varix--Lymphangioma
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ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
Is there a Mass
present?
Yes NoIf the answer is…
Your DDx is…
If the answer is…
Your DDx is…
--Cavernous hemangioma--ON sheath meningioma--ON glioma--Rhabdomyosarcoma--Metastatic disease--Varix--Lymphangioma
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ProptosisProptosis
IsLid Retraction
present?
NoIf the answer is…
Your thought is…
CT (as in, I need to order a CT)
If the answer is…
Your thought is…
Yes
Graves dz
Is there a Mass
present?
Yes NoIf the answer is…
--Cavernous hemangioma--ON sheath meningioma--ON glioma--Rhabdomyosarcoma--Metastatic disease--Varix--Lymphangioma
Your DDx is…
If the answer is…
Your DDx is…
--CCF--AVM--Orbital inflammation--Lymphoproliferative dz
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(CCF = carotid-cavernous sinus fistula)(AVM = arteriovenous malformation)
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Proptosis: Fill in the blanks
Your first thoughtshould be…
Your first thoughtshould be…
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A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks
Bears repeatingfor emphasis!
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Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks27
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks28
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Are we talking about unilateral proptosis, or bilateral proptosis?It can be either
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks29
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Are we talking about unilateral proptosis, or bilateral proptosis?It can be either
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks30
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Where does TED rank as a cause of unilateral proptosis in adults?#1
Are we talking about unilateral proptosis, or bilateral proptosis?It can be either
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks31
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Where does TED rank as a cause of unilateral proptosis in adults?#1
Are we talking about unilateral proptosis, or bilateral proptosis?It can be either
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks32
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Are we talking about unilateral proptosis, or bilateral proptosis?It can be either
Where does TED rank as a cause of unilateral proptosis in adults?#1
Where does TED rank as a cause of bilateral proptosis in adults?#1
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks33
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Are we talking about unilateral proptosis, or bilateral proptosis?It can be either
Where does TED rank as a cause of unilateral proptosis in adults?#1
Where does TED rank as a cause of bilateral proptosis in adults?#1
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks34
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Q
What about in the pediatric population--is the relationship between proptosis and Graves dz as strong?
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks35
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
Q/A
What about in the pediatric population--is the relationship between proptosis and Graves dz as strong?No. Graves is rare in children, and when it does occur, only about 10% of pts present with proptosis. (Rule of thumb: In children, proptosis is more likely to be infection or neoplastic than to be inflammatory.)
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
Graves disease
Imaging
Proptosis: Fill in the blanks36
^= Graves disease
Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!
A
What about in the pediatric population--is the relationship between proptosis and Graves dz as strong?No. Graves is rare in children, and when it does occur, only about 10% of pts present with proptosis. (Rule of thumb: In children, proptosis is more likely to be infection or neoplastic than to be inflammatory.)
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Graves disease
Imaging
reassuring? or cause for concern?
Proptosis: Fill in the blanks37
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Graves disease
Imaging
highly suspicious for an orbital process
Proptosis: Fill in the blanks38
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Ask the patient to ______--if proptosis worsens, it’s probably an ______________
Graves disease
Imaging
highly suspicious for an orbital processsimple
maneuver
cause of proptosis
Proptosis: Fill in the blanks39
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Ask the patient to ______--if proptosis worsens, it’s probably an ______________
Graves disease
Imaging
highly suspicious for an orbital process
Valsalvaorbital venous anomaly
Proptosis: Fill in the blanks40
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Ask the patient to ______--if proptosis worsens, it’s probably an ______________
In evaluating proptosis, always consider contralateral ________
Graves disease
Imaging
highly suspicious for an orbital process
Valsalvaorbital venous anomaly
pathologic condition
Proptosis: Fill in the blanks41
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Ask the patient to ______--if proptosis worsens, it’s probably an ______________
In evaluating proptosis, always consider contralateral ________
Graves disease
Imaging
highly suspicious for an orbital process
Valsalvaorbital venous anomaly
enophthalmos
Proptosis: Fill in the blanks42
Q
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Ask the patient to ______--if proptosis worsens, it’s probably an ______________
In evaluating proptosis, always consider contralateral ________
Auscultate for a ____ (indicates ___ or ____)
Graves disease
Imaging
highly suspicious for an orbital process
Valsalvaorbital venous anomaly
enophthalmospathologic
sound dx dx
Proptosis: Fill in the blanks43
A
Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________
If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________
Ask the patient to ______--if proptosis worsens, it’s probably an ______________
In evaluating proptosis, always consider contralateral ________
Auscultate for a ____ (indicates ___ or ____)
Graves disease
Imaging
highly suspicious for an orbital process
Valsalvaorbital venous anomaly
enophthalmos
bruit CCF AVM
Proptosis: Fill in the blanks44
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
45
Q
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
46
A
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
47
Q
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?----If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
48
Q/A
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
three words
three words
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
49
A
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
50
Q
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
51
A
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis? Rhabdomyosarcoma Optic nerve glioma
52
Q
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
If a child presents with ocular stigmata of orbital cellulitis but is systemically healthy and happy, what diagnosis should you consider?Rhabdomyosarcoma
All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma
53
A
Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage
How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc
If a child presents with ocular stigmata of orbital cellulitis but is systemically healthy and happy, what diagnosis should you consider?Rhabdomyosarcoma
