Proptosis evaluation
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Transcript of Proptosis evaluation
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EVALUATION OF PROPTOSIS
Presented by DR.Tasmia Ibrahim
DR. MD. Dedarul HassanDO student(LEI&H)
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PROPTOSIS
Is defined as abnormal protrusion of the eyeball along
with lids & orbital contents.
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CLASSIFICATION
Proptosis can be divided into following clinicalgroups:
• 1. Unilateral /Bilateral proptosis• 2.Axial / Eccentric proptosis• 3. Acute /Intermittent proptosis• 4. Pulsatile/Non-pulsatile proptosis
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Causes of Proptosis• UNILATERAL (Axial) Thyroid associated orbitopathy Optic nerve glioma Lymphoma Lymphangioma Orbital cellulitis Retinoblastoma Idiopathic orbital inflammatory disease Optic nerve sheath meningioma Cavernous haemangioma Deep dermoid
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Cont….
• UNILATERAL (Non axial )
Lacrimal gland tumour Deep dermoid Neurofibroma Ethmoidal mucocele
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Cont….Bilateral Thyroid associated orbitopathy Lymphoma Secondary metastasis
Congenital Dermoid Teratoma Congenital cystic eyeball
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Cont…
Painful proptosis Pseudotumour Tolosa-Hunt syndrome Orbital cellulities Acute dacryoadenitis
Pulsating proptosis Meningocele Meningoencephalocele
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Pseudoproptosis
It is a false impression of proptosis.
Causes : High myopia Buphthalmos Ipsilateral lid retraction Contralateral enophthalmos Facial asymmetry
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Severity of Proptosis
Can be measured with a plastic rule resting on the lateral orbital margin or by an exophthalmometer. Reading greater than 20 mm indicates proptosis and a difference of atleast 2 mm between the two eyes is suspicious regardless of the absolute value.
Mild proptosis : 21-23 mm Moderate proptosis : 24-27 mm Severe proptosis : 28 mm or more
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Why vision detoriates in proptosis
Optic nerve compression Exposure keratopathy Astigmatism Choroidal fold
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APPROACH
HISTORYLOCAL
EXAMNSYSTEM.EXAMN
INVESTIGATION
SIMAGIN
G
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History
• Age of onset , duration , progression• Constant or intermittent• Variation with posture / strain• Decreased vision • Associated field defects• Pain • Double vision • Trauma• Fever , chills ,systemic symptoms• H/O thyroid disease ,TB , DM ,HTN ,HIV , Syphilis
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Examination
Examinations : General Systemic Complete ocular examination Local examinations
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Inspection:Facial asymmetryBulging of eye Orbital rim Palpebral fissure is widen or not Oral and nasal orifice Thyroid moves with deglutition or not Any skull deformity Fine tremor in fingers Hircshberg reflex
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Cont…. Three Measurements :I. Anterior-posterior measurementII. Horizontal measurementIII. Vertical measurement
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Primary position Ant-posterior measurement
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Horizontal measurement Vertical measurement
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Palpation: Palpation of orbital rim Reducibility(in vascular lesions) Compressibility(in capillary haemangioma) Temperature Tenderness Any thrill present or absent
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Cont… Others Naffziger’s sign Ocular motility- decreased in thyroid
orbitopathy,extensive tumor growths and neurological deficit
Pupillary reaction-RAPD suggests optic nerve compression
Pretibial myxoedema-Thyroid eye disease Valsalva manauver Fundus examination- reveal hemorrhages ,
papilloedema , optic atrophy , choroidal folds, optico-ciliary shunt
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Routine & Systemic Investigations CBC PBF Thyroid function test : T3,T4,TSH USG of thyroid Thyroid scanning FNAC X-ray soft tissue neck Incisional biopsy
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Investigations : Cont…..
Imaging
CT scan of brain and orbit MRI of brain and orbit MRA and MRV
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InterpretationsCT scan findings in different orbital lesions:
TAO : Enlargement of muscle belly with well defined margin.
IOID : Ill defined orbital opacification with loss of definite contents.
Carotid cavernous fistula : Enlargement of extra ocular muscle and superior ophthalmic vein.
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Cont….
Lacrimal gland carcinoma : Globular lesions with irregular serrated edges, bony erosion and calcification present.
Dermoid : Well-circumscribed cystic lesions.
Lymphoma : Diffuse enlargement of peri orbital tissue, can follow the curvature of eyeball.
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General management of proptosis Intensive medical therapy : Systemic steroid Radiotherapy Combined : Radiotherapy,chemotherapy,Steroid Surgical decompression Orbital surgery Follow up
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Take home message
o Proptosis is an alarming conditiono Localized or systemic causes are presento Proper approach should be takeno Thorough examination & investigation is musto Proper management results good prognosis
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References
Clinical Ophthalmology-A systematic approach By Jack J Kanski & Bowling
American academy of ophthalmology
Clinical examination of Ophthalmic cases By ML Agarwal & Sanjeev Agarwal
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MEASUREMENT OF PROPTOSIS
• Measured by a group of instruments called exophthalmometer or proptometer
• All instruments are meant to measure the distance b/w thw apex of cornea and lateral wall of orbit
• OPTICAL- Lueddes scale and Hertels exophthalmometer
• MECHANICAL – Gormaz exophthalmometer
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• Proptosis with white reflex – retinoblastoma• U/L fast progressing proptosis , fever , toxic
child , pain – orbital cellulitis• U/L axial proptosis with early vision loss –
optic nerve glioma• B/L proptosis , fever and toxemia – cavernous
sinus thrombosis• Pale child , bleeding from gums , U/L or B/L
proptosis – leukemia• U/L proptosis ,pain ,fever,hazy cornea and
loss of vision - panophthalmitis