Differential Diagnosis of ProptosisAbdullatiff Sami Al-RashedMovement Block 4.4 (Opthalmology Week)212516770College of Medicine, King Faisal University Al-Ahsa, Saudi Arabia

Introduction• Proptosis, or exophthalmos, is a protrusion of the eye

caused by a space occupying lesion.

• Can be either bilateral or unilateral.

• Measurement of the degree of exophthalmos is performed using an exophthalmometer.

Exophthalmometer

A difference of prominence of more than 2 mm between the two eyes is

significant.

Graves disease

Introduction

• Autoimmune disorder with orbital involvement and associated with thyroid dysfunction.

• Women are affected more than men.

• Proptosis could be unilateral or bilateral

Symptoms

Eyelid Signs in Graves Disease

Dalrymple sign:

Upper eyelid is retracted with visible sclera

superior to the limbus and widened palpebral

fissure with developing exposure keratitis

(overactive muscle of Müller)

Eyelid Signs in Graves Disease

Gifford sign:

Upper eyelid is difficult to evert (due to eyelid

edema)

Eyelid Signs in Graves Disease

Von Graefe sign:

Upper eyelid retracts when the eye

depresses (overactive muscle of Müller)

Eyelid Signs in Graves Disease

Stellwag Sign (Rare blinking)

Eyelid Signs in Graves Disease

Kocher sign ( Fixed Gaze )

Diagnosis

Treatment• Methylcellulose or hypromellose eyedrops:

– To aid lubrication and improve comfort.

• Systemic steroids (prednisolone 30–120 mg daily):– usually reduce inflammation if more severe symptoms are

present.

• Surgical decompression of the orbit:– Particularly if pressure of orbital contents on the optic nerve

threatens vision.

• Lid surgery:– Protect the cornea if lids cannot be closed.

Orbital cellulitis

Introduction

• Acute inflammation of the contents of the orbital cavity with the cardianl symptoms of limited motility and general malaise.

• Orbital cellulitis is the most frequent cause of exophthalmos in children.

Symptoms

Symptoms

InvestigationsTest Results

CBC Leukocytosis

ESR Increased

Blood culture To detect specific organisms

Nasal swap For gram stain

CT scan orbit

MRI For orbital abscess and evaluating for cavernous sinus disease

Complications

Optic neuritis Cavernous sinus thrombosis

Treatment

• High-dose intravenous antibiotic therapy:– Infants are treated with ceftriaxone and school-age

children with oxacillin combined with cefuroxime in the appropriate doses.

• Treatment of underlying sinusitis– Indicated in applicable cases.

Orbital Hemingioma

Hemangioma • Hemangiomas are the most common benign orbital

tumors in both children and adults.

• They usually occur in a nasal superior location.

• Capillary hemangiomas are more common in children (they swell when the child screams)

• Cavernous hemangiomas are more common in adults.

Hemangioma

• Treatment is only indicated where the tumor threatens to occlude the visual axis with resulting amblyopia or where there is a risk of compressive optic neuropathy.

• Capillary hemangiomas in children can be treated with cortisone or low-dose radiation therapy.

Other causes of proptosis

References