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proptosis

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proptosis

  1. 1. EVALUATION OF PROPTOSIS DR. RAKSHYA BASNET 1ST YEAR RESIDENT NAMS,LEI
  2. 2. LAYOUT • Introduction • Clinical anatomy of orbit • Classification of proptosis • Evaluation of proptosis on basis of THE 6 P’S • Investigation
  3. 3. • anterior displacement of globe by >20 mm from lateral orbital rim • >2mm difference between apex of cornea of two eyes
  4. 4. OTHER TERMS 1.Exophthalmos is a term reserved for proptosis due to endocrine cause, but it is used interchangeably 2.Exorbitism decrease in volume of orbit : orbital contents to protrudeforwards
  5. 5. 3.Pseudoproptosis 1. Enlarged globe 2. Asymmetric orbital size 3. Asymmetric palpebral fissure 4. Contralateral enophthalmos
  6. 6. CLINICAL ANATOMY
  7. 7. ORBITALWALLRELATIONS Roof :anterior cranial fossa& frontal sinus above Medial wall : adjacent nasal cavity, ethmoid&posterior sphenoid sinus Lateral wall :adjacent to middle cranial ,temporal&pterygopalatine fossa
  8. 8. ORBIT Below- maxillary sinus • Relationship of orbit & PNS :By its location & venous drainage • orbital venous drainage :devoid of valves – two way communication between orbit and sinuses
  9. 9. SPACES IN RELATION TO ORBIT 1. subperiosteal 2. Peripheral/extraconal 3. Central/intraconal 4. Sub tenon’s 5. subarachnoid
  10. 10. 1.SUBPERIOSTEAL SPACE  Common tumors in this space are Dermoid cyst, epidermoid cyst,mucocele, subperiosteal abscess, myeloma, osteomatous tumour, haematoma and fibrous dysplasia  plain x-rays most useful in this space
  11. 11. • Common tumors in this space: malignant lymphoma, capillary hemangioma, intrinsic neoplasm of lacrimal gland, pseudotumors • Produces non-axial proptosis • Tumors in this space are explored by anterior orbitotomy 2.Peripheral space
  12. 12. • Common tumors include Cavernous hemangioma of adults, solitary neurofibroma, neurilemmomas, nodular orbital meningiomas, optic nerve gliomas • Produces axial proptosis • Tumors in this space explored by lateral orbitotomy 3.Central space
  13. 13. PATHOPHYSIOLOGY Increase in volume within fixed bony orbital contents of the orbit are displaced anteriorly (widest area of orbit) globular protusion of eye ball Proptosis and Exophthalmos
  14. 14. patterns of orbital involvement 1. INFLAMMATORY EFFECT: redness, swelling, pain, heat, and loss of function 2. MASS EFFECT: Displacement with or without signs of involvement of sensory or neuromuscular sign
  15. 15. 3. VASCULAR CHANGE: venous dilation, pulsation, expansion with straining (Valsalva) and haemorrhage 4. INFILTRATIVE CHANGE: evidence of destruction, entrapment, or both
  16. 16. CLASSIFICATION 1) Etiological 2) Onset 3) Direction 4) Axiality 5) Laterality 6) Age of onset
  17. 17. CLASSIFICATION 1.Etiology • Inflammatory • Infectious • Vascular • Neoplastic • Idiopathic
  18. 18. 2.Onset • Acute-several minutes, several hours, or 1 to 2 days • Subacute-period of weeks • Chronic-more insidious onset over several months
  19. 19. 3.DIRECTION • POSITIVE-if the lesion occupies space and pushes orbital structures away eg-intraconal schwannoma • NEGATIVE -if it draws structures toward eg.orbital metastasis of sclerosing carcinoma
  20. 20. 4.AXIALITY --AXIAL Thyroid eye diseaseOptic nerve glioma metastasis
  21. 21. SUPERIOR 1.Maxillary sinus tumours Inferiomedial 2.Dermoid cyst 3.Lacrimal gland tumour Non-axial
  22. 22. INFEROLATERAL •Fronto-ethmoidal mucocele •abscess •Sinus carcinomas •osteomas
  23. 23. 5.LATERALITY • Unilateral Proptosis 1.Congenital 2.Traumatic 3.Inflammatory Lesions 4.Circulatory Disturbances & Vascular Lesions 5.Cysts of orbit: 6.Tumors: 7.Mucocele of PNS:
  24. 24. 1. Developmental Anomalies of Skull 2. Osteopathies 3. Inflammatory Conditions 4. Endocrinal Exophthalmos 5. Tumors 6. Systemic Disease Bilateral proptosis
  25. 25. IN CHILDREN • Unilateral (most common): orbital cellulites • Bilateral (most common):leukemia, metastatic neuroblastoma
  26. 26. 6.PROPTOSIS : ACCORDING TO AGE CAUSES IN INFANT  congenital lesions like craniosynostosis, cephalocele, micropthalmia with cyst, teratoma,  retinoblastoma  capillary hemangioma  juvenile xantho granuloma  metastatic neuroblastoma
  27. 27. CAUSES IN CHILDREN • Orbital cellulitis • Dermoid cyst • Capillary hemangioma • Optic nerve glioma • Rhabdomyosarcoma • Retinoblastoma • Leukemia • Lymphangioma • Metastasis – Metastatic neuroblastoma – Ewing's sarcoma
  28. 28. CAUSES IN ADULTS • Thyroid Exophthalmos • Pseudotumor • Orbital cellulitis • Trauma • Meningioma • Lymphoma • Histiocytoma • Cavernous hemangioma • Osteoma • Varices • Carotid-cavernous fistula • Tumors extending from adjacent areas – Lacrimal gland – Sinuses – lids • Metastasis
  29. 29. 6 P’S 1. Pain 2. Progression 3. Proptosis 4. Pulsation 5. Palpation 6. Periorbital changes
  30. 30. 1.PAIN – Inflammatory disease – Infectious disease – Orbital hemorrhage – Malignant Carcinoma (nasopharyngeal or lacrimal gland) – Metastatic lesions The 6 P’s
  31. 31. 2.PROGRESSION THE SIX P’s (Cont. )
  32. 32. THE SIX P’S (CONT. )2. PROGRESSION Abrupt within hours 1. Bleeding in lymphangioma 2. Orbital emphysema 3. Fracture of medial orbital wall 4. Retrobulbar Haemorrhage 5. Traumatic haematoma 6. Ruptured dermoid 7. Rupture of ethmoidal mucocele 1. Orbital emphysema
  33. 33. Onset occurring over days to weeks • Idiopathic orbital inflammatory disease • Orbital cellulitis • Thrombophlebitis • Rhabdomyosarcoma • Thyroid ophthalmopathy • Neuroblastoma • Metastatic tumour
  34. 34. THE SIX P’S (CONT. ) Onset occurring over months to years • Dermoids • Benignmixed tumours • Neurogenic tumours • Cavernous hemangioma • Lymphoma • Fibrous histiocytoma • Osteoma
  35. 35. Intermittent proptosis • Orbital varices • Haemangioma • Carotid Cavernous fistula
  36. 36. 3.PROPTOSIS i.True or pseudoproptosis ii.Laterality – Unilateral/bilateral iii.Direction of displacement – Axial – Non-axial  Lateral  Inferonasal  Superior The 6 P’s
  37. 37. PROPTOSIS Clinically best appreciated by worm’s eye view -examiner looks up from below with patient’s head tilted back The 6 P’s
  38. 38. Nafziger’s Method
  39. 39. • patient sits in front of examiner, head slightly drawn back & looks downwards • examiner stands behind patient, looks over patient’s forehead by bending over patient’s head • examiner raises patient’s upper lids with his index fingers from sides • examiner compares position of apex of cornea on each side • patient bends his head forward and cornea should disappear at same time.
  40. 40. CLINICAL METHODS FOR MEASUREMENT OF PROPTOSIS: A) PLASTIC RULER: can measure proptosis from the lateral orbital rim to corneal apex,holding ruler parallel to ground
  41. 41. B)LUEDDE’S EXOPHTHALMOMETER: -Transparent plastic mm ruler which is thicker than normal ruler - is better than hertel’s if there is facial asymmetry
  42. 42. C)HERTEL’S Exophthalmometry • Most commonly used • Three types Absolute exophthalmometry - compared with n/lreading (>21mm) Relative exophthalmometry - relative distance of the2 corneas from lateral orbitalrim. Comparative exophthalmometry -exophthalmos of at different times.
  43. 43. Steps of hertel’s exophthalmometry
  44. 44. Stepsof Hertel’s exopthalmometer 1. make sure instrument is ready 2. explain patient 3. ask patient to sit in erect position 4. take a seat one arm away from patient and make sure your eyes and patient’s eyes are at same level 5. ask patient to look at the centre of your forehead 6. place Hertel against lateral walls of patient 7. Measure patient’s left eye with examiner’s right eye 8. move our view so that 2 red lines on prism are are in overlapping position 9. find the position of corneal apex in millimeter scale in prism 10.record proptosis with base reading
  45. 45. Grading: • Mild : 21 – 23 mm • Moderate: 24 – 27 mm • Severe: 28 mm or more
  46. 46. D)Naugle’s exophthalmometer: -Useful in fracture patients when lateral canthus has been displaced -uses frontal and maxillary bone as references
  47. 47. 4.Pulsation Causes:  Pulsating vascular lesions (caroticocavernous fistula)  saccular aneurysm of ophthalmic artery  deficient orbital roof (congenital meningocele or meningoencephalocele, neurofibromatosis, traumatic or operative hiatus) The 6 P’s contd..
  48. 48. Auscultation • Globe/temporal region for bruit
  49. 49. PULSATION Without bruit • Neurofibromatosis • Meningoencephaloceles • Encephaloceles • Result of surgical removal of the orbital roof With bruit • Carotid cavernous fistula • Dural arteriovenous fistula • Orbital arteriovenous fistula
  50. 50. 1. Local Temperature 2. Tenderness 3. orbital margins 4. Retropulsion of globe 5. Regional lymph node 6. If mass palpable note  Position  Size,surface, attachnents  Consistency(hard , rubbery, spongy or soft)  Compressibility/ Reducibility 5.PALPATION The 6 P’s contd..
  51. 51. ORBITAL RIM • Palpation of orbital rim done to note any changes in contour or dehiscence of orbital wall....
  52. 52. RETROPULSION • should be estimated by applying equal digital pressure over two eyes, simultaneously • best done with examiner’s thumb over closed lids-retroocular resistance encountered in presence of solid tumors
  53. 53. LYMPH NODES • regional lymph node preauricular lymph node and metastatic dz. supraclavicular, and cervical nodes.
  54. 54. THE SIX P’S (CONT.) 6. PERIORBITAL CHANGES • S shaped eyelid (plexiform neurofibroma) • Salmon colored mass in cul-de-sac-lymphoma • Eyelid retraction and lid lag-TED
  55. 55. Ecchymosis of eyelid skin-metastatic neuroblastoma,leukemia,amyloidosis Eczematous lesions of eyelid-mycosis fungoides Edematous swelling of lowerlid (meningioma)
  56. 56. -Prominent temple –sphenoid wing meningioma -corkscrew conjunctival vessels –arteriovenous fistula
  57. 57. D. Other tests 1. Transillumination 2. Visual acuity 3. Pupillary reaction 4. Ocular motility 5. Forced duction test 6. Tonometry
  58. 58. 1.TRANSILLUMINATION (fluid / air filled)
  59. 59. 2.Visual acuity:  Loss of vision preceding exophthalmos suggests tumor of optic nerve like glioma in children  Orbital tumors decrease central acuity by --pressing on back of eyeball producing changes in refraction or sallman’s macular folds or optic atropy in late stages
  60. 60. VISION LOSS • Due to involvement of optic nerve by compression, infiltration, vascular compromise, inflammation • Marked proptosis with no visual loss—cavernous hemangioma & neurilemmoma • Marked visual loss with mild to moderate proptosis—optic nerve glioma and optic nerve sheath meningioma
  61. 61. 3.FUNDUS i. Optic disc changes : - Optic disc oedema - Optic atrophy - Optociliary shunt vessels (optic nerve sheath meningioma, cavernous haemangioma)
  62. 62. …. ii. Choroidal folds : - Tumor - Dysthyroid ophthalmopathy - inflammatory lesions iii. Retinal vascular changes - Venous dilatation & tortuosity (arteriovenous communication) - Venous dilatation & disc swelling (orbital mass) - Vascular occlusion (optic nerve tumor)
  63. 63. 4.PUPILLARY REACTIONS -Look carefully for RAPD suggestive of optic nerve damage -Is an indication for plotting visual fields in both eyes
  64. 64. 5.OCULAR MOVEMENTS Limitation of ocular motility due to  Restrictive myopathy (thyroid opthalmopathy)  Splinting of optic nerve(optic nerve sheath meningioma)  Neurological deficit from orbital apex lesions
  65. 65. Differentiation of restrictive from neurological motility defect 6.Forced duction test: Positive result: difficulty or inability to move globe indicates restrictive problem Negative result: no resistance will be encountered indicates neurologic problem
  66. 66. 7.TONOMETRY Raised IOP in TED in upward gaze i.e. positional IOP changes Braley’s sign Positive result: increase of 6mmHg or more indicates due to muscle restriction Negative result: < 6mmHg IOP indicates neurological lesion
  67. 67. • Systemic examination • Café au lait spots • Skin pigmentation • Features of hyperthyroidism • Cutaneous hemangioma elsewhere • Scalp bony lesions • Organomegaly or lumps in abdomen • Otorhinolaryngological examination: paranasal sinus or nasopharyngeal mass • NERVES; Ocular movements (III, IV, VI),Ptosis (III),Lagophthalmos (VII)
  68. 68. Investigations
  69. 69. LAB.. • Haematological studies (TLC, DLC, ESR, VDRL test) • Thyroid function test • Casoni’s test (to rule out hydatid cyst) • Stool examination: cysts, ova • Urine: Bence Jones proteins for multiple myeloma • Serum ACE • Lysozyme • Antineutrophil cytoplasmic antibody
  70. 70. RADIOLOGY 1. X-rays 2. Orbital USG 3. CT scan 4. MRI 5. Angiography Non-invasive invasive 1. Orbital venography 2. Carotid angiography
  71. 71. IMAGING TECHNIQUE: (A)Non-invasive techniques: 1.Plain X-rays: Caldwell view, Water’s view, lateral view & Rhese view (for optic foramina). • Enlargement of orbital cavity & optic foramina, calcification, hyperostosis.
  72. 72. 2. Ultrasonography: • Valuable initial scanning procedure for orbital lesions • Can usually differentiate between solid, cystic, infiltrative & spongy masses • Lesions of posterior orbit can’t be viewed
  73. 73. 3. Computed Tomography: - Most valuable for delineating the shape, location , extent and character of lesions in orbit esp.orbital trauma,bony tumors - Not only bones but foreign body and soft tissues also - Contrast for vascularized tumor,orbital abscess
  74. 74. MEASUREMENT OF PROPTOSIS • By measuring distance from anterior corneal surface to interzygomatic line • Distance from the posterior scleral margin to interzygomatic line. 76
  75. 75. 4. Magnetic resonance imaging (MRI): • Sensitive for detecting differences between normal & abnormal tissues. • Better technique for orbitocranial junction or intracranial,intracanalicular optic nerve
  76. 76. 5. CT and MR angiography: - Arteriovenous malformation - Aneurysms - Arteriovenous fistulas
  77. 77. INVASIVE PROCEDURES Orbital venography: orbital varix suspected Carotid angiography: pulsating exophthalmos & with bruit or thrill
  78. 78. PATHOLOGY The diagnosis of an orbital lesion usually requires analysis of tissue obtained through an orbitotomy. • FNAC • incisional biopsy • Excisional biopsy • Core biopsy
  79. 79. MANAGEMENT Medical Surgical Radiotherapy Chemotherapy Palliative Surgery Depending upon the types of lesions
  80. 80. OPTHALMOLOGIST OTOLARYNGOLOGIST RADIOLOGIST PATHOLOGIST NEUROSURGEON CLINICIANproptosis ONCOLOGIST
  81. 81. BIBLIOGRAPHY • Wolff’s Anatomy of the eye and orbit 7th Edition • AAO • BCSC: Orbit Eyelids and Lacrimal System • Parsons’ Diseases of the eye 22nd edition • Disease of orbit, jack rootman,2nd edition
  82. 82. •Thank you
  • Kommadhanusha

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    Aug. 19, 2019
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    Jul. 31, 2019
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    Jul. 29, 2019
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    Jul. 26, 2019

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