2. LAYOUT
• Introduction
• Clinical anatomy of orbit
• Classification of proptosis
• Evaluation of proptosis on basis of THE 6 P’S
• Investigation
3. • anterior displacement of globe by >20 mm from lateral orbital rim
• >2mm difference between apex of cornea of two eyes
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
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. SPACES IN RELATION TO ORBIT
1. subperiosteal
2. Peripheral/extraconal
3. Central/intraconal
4. Sub tenon’s
5. subarachnoid
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. • 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. • 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. 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. 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. 3. VASCULAR CHANGE: venous dilation, pulsation,
expansion with straining (Valsalva) and haemorrhage
4. INFILTRATIVE CHANGE: evidence of destruction,
entrapment, or both
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. 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
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. Onset occurring over days to
weeks
• Idiopathic orbital inflammatory disease
• Orbital cellulitis
• Thrombophlebitis
• Rhabdomyosarcoma
• Thyroid ophthalmopathy
• Neuroblastoma
• Metastatic tumour
34. THE SIX P’S (CONT. )
Onset occurring over months to years
• Dermoids
• Benignmixed tumours
• Neurogenic tumours
• Cavernous hemangioma
• Lymphoma
• Fibrous histiocytoma
• Osteoma
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. 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
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.
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. Grading:
• Mild : 21 – 23 mm
• Moderate: 24 – 27 mm
• Severe: 28 mm or more
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. 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. ORBITAL RIM
• Palpation of orbital rim done to note any changes in
contour or dehiscence of orbital wall....
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. LYMPH NODES
• regional lymph node preauricular lymph node and
metastatic dz. supraclavicular, and cervical nodes.
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. Ecchymosis of eyelid skin-metastatic neuroblastoma,leukemia,amyloidosis
Eczematous lesions of eyelid-mycosis fungoides
Edematous swelling of lowerlid (meningioma)
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. 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
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. 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. 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. • 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)
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. 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. MEASUREMENT OF PROPTOSIS
• By measuring distance from anterior corneal
surface to interzygomatic line
• Distance from the posterior scleral margin to
interzygomatic line.
76
75. 4. Magnetic resonance imaging (MRI):
• Sensitive for detecting differences between normal
& abnormal tissues.
• Better technique for orbitocranial junction or
intracranial,intracanalicular optic nerve
78. PATHOLOGY
The diagnosis of an orbital lesion usually requires analysis of
tissue obtained through an orbitotomy.
• FNAC
• incisional biopsy
• Excisional biopsy
• Core biopsy
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
