Transcript Proptosis

Proptosis
Mounir Bashour, M.D., C.M.
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What is proptosis?
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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
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How is proptosis
diagnosed?
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Globes from above
Measured with an exophthalmometer
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lateral orbital rim
CT scan
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List common
problems associated
with
proptosis
1. Exposure keratopathy
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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
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Most common cause
of unilateral
proptosis?
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Thyroid eye disease (Graves'
ophthalmopathy)
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Most common cause
of bilateral proptosis?
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Thyroid eye disease
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What are other causes
of proptosis?
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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
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List the causes of
pseudoproptosis
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1. Unilateral high axial myopia
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A-Scan
2. Actual enophthalmos of other eye
3. Upper lid retraction
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Which neuroimaging
test is best to evaluate
the etiology of
proptosis?
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CT scans are superior in most cases
MRI may be desirable in certain cases
when optic nerve dysfunction is
present
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Unilateral or bilateral
painless proptosis, eyelid
retraction, eyelid lag, and
motility disturbances?
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Thyroid ophthalmopathy
 multisystem. autoimmune disorder
 hyperthyroid, hypothyroid, euthyroid
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inflammation and enlargement EOM
• IR>MR>SR>LR
• fusiform enlargement sparing the tendon
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peribulbar tissues.
Proptosis
Eyelid retraction
Corneal problems
Diplopia
Optic nerve compression
Treatment depending on the severity
Systemic and laboratory evaluation is mandatory
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Unilateral proptosis, pain,
conjunctival injection, and
motility disturbances in an
adult?
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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
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thickening 1+ EOM (inc. tendons)
lacrimal gland enlargement
thickening of the posterior sclera
Treatment corticosteroids +/- radiation
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Unilateral proptosis, pain,
fever, decreased ocular
motility, erythema, and
edema of the eyelids?
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Infectious orbital cellulitis
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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
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Persistent proptosis or
progression of
infection despite
adequate antibiotic Rx
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Orbital subperiosteal abscess
CT scan
confirm diagnosis
 locate the abscess
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surgical drainage and continued
intravenous antibiotics
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Child < 6 y.o. with gradual,
painless, progressive,
unilateral axial proptosis with
visual loss?
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Optic nerve glioma (juvenile pilocytic
astrocytoma)
slow-growing tumor
 Decreased visual acuity with a RAPD
 CT scan or MRI
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“fusiform” enlargement of the ON
associated with NF1 Dx if bilateral
 Systemic evaluation and genetic
counselling for NF is essential
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Child with rapidly progressive
unilateral proptosis, displacement
of the globe inferiorly, and edema
of upper eyelid?
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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%
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Most common benign
orbital tumor in
adults that causes
unilateral
proptosis?
Cavernous hemangioma
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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
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Most common
malignant orbital tumor
in adults that causes
unilateral
proptosis?
Orbital lymphomas
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typically superior orbit
slow onset and progression
subconjunctival “salmon-colored" mass in the
fornix
CT scan
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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
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Tumors that are
encapsulated or appear
well circumscribed on
neuroimaging
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Cavernous hemangioma
Schwannoma
Fibrohistiocytoma
Neurofibroma
Hemangiopericytoma
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