A Young Man with Unilateral Proptosis

Presented by: Dr. Md. Kamal Hossen

Asstt. Registrar Dept. of Neurosurgery, MMCH

“A Young Man with Unilateral Proptosis”

ChairpersonProf ( Dr.) M A Gafur Miah

Professor & HeadDepartment of Surgery

Mymensingh Medical College

CoordinatorDr Saumitra Sarkar

Assistant Professor & HeadDeptt. of Neurosurgery

Mymensingh Medical College

Particulars of the patient

Particulars of the Patient:

Name : Md. Shafayet Age : 27 years Sex : Male Religion : Islam Address :Purbadhola, Netrokona Marital status : Unmarried Occupation : Unemployed Date of admission : 21st November 2011 Date of examination : 21st November 2011

Presenting complaints :(Pre-Operative)

Irritation and watering of the left eye for 10 month.

Forward displacement of left eye ball for 3 months

Gradual dimness of vision in left eye for 3 months

According to the statement of the patient he was

reasonably well about 10 months back. Then he

complained about irritation and watering of the left eye

which was prominent in day time. In last 3 months he

developed forward displacement of left eye ball,

History of present illness :-

which was gradually increasing and not

associated with pain and pulsation. He also

complained gradual dimness of vision in left

eye and occasional double vision for 3 months.

History of present illness :-

Patient had no history of Headache, vomiting,

vertigo, fever, night sweats, weight loss, cough

or haemoptysis, haematuria or per rectal

bleeding, bone pain. There was no history of

trauma.

History of present illness (Cont.)

H/O of Past illness – The patient has a history

of jaundice 2 years back.

Personal history – The patient is a smoker. He

took 5 sticks per day .

Immunizations History – Completed immunization.

Family history – No such diseases found in the

other family members.

At first he was treated by Ophthalmologist at BNSB,

Mymensingh for watering and irritation and he used eye

drop and took some medicine for his illness but he

couldn’t mention any name. Then he got treatment at Dr.

Muktadir Eye Hospital, Gauripur and After doing the CT

scan, the patient was referred to a Neurosurgeon of

Dhaka. But, according to the advise of a physician he

got admitted in the Neurosurgery dept. of MMCH.

Treatment History

General Examination (Preoperative)

Appearance – ill looking Body build – Average Anemia – Absent Cyanosis – Absent Jaundice – Absent Oedema – Absent Dehydration – Absent Lymph nodes – not

palpable

Thyroid gland – not enlarged

Neck vein – not engorged Clubbing – Absent Koilonychia – Absent Leukonychia – Absent Pulse – 76/min B.P – 130/80 mm of Hg Temp – Normal Respiration – 16/min

Local Examination (Preoperative)

Local Examination of the Left Eye

- Inferonasal globe displacement and fullness of the

superotemporal lid and orbit.

- Proptosis – 4 mm

- A S-shaped contour to the upper lid.

- Tenderness absent.

- Motility of the left globe restricted in superior and lateral

direction.

- Intraocular pressure (IOP)- Not measured

- Preauricular lymphadenopathy - Absent

Systemic examination (Preoperative)

Nervous system examination –

Higher Psychic function – Normal Speech – Normal Gait – Normal

Systemic examination (Preoperative)

Nervous system examination – Examination of cranial nerve Olfactory nerve – sense of smell is intact Optic nerve – Visual acuity : 6/6 (Rt) Finger

counting at 2 feet (Lt)

Field of vision : reduced

Color vision : normal Ophthalmoscopic examination :

Disc swelling on left eye Light reflex : normal

Systemic examination (Preoperative)

Nervous system examination – Oculomotor nerve : normal Trochlear nerve : normal Abducent nerve : normal Trigeminal nerve : normal Facial nerve : normal

Systemic examination (Preoperative)

Nervous system examination – Vestibule-cochlear nerve : normal Glossopharyngeal nerve : normal Vagus nerve : normal Accessory nerve ( spinal part) : normal Hypoglossal nerve : normal

Systemic examination –

Motor function Upper limbs – Lt. Rt.

Bulk of muscle – Normal Normal Tone of muscle – Normal Normal Muscle Power – Grade ‘5` G - 5

Lower limbs – Lt. Rt. Bulk of muscle – Normal Normal Tone of muscle – Normal Normal Muscle Power – Grade ‘5` G - 5

Systemic examination –

Co ordination of movement : Finger nose test – intact Heel shin test – intact Involuntary movement : absent

Systemic examination –

Jerks

All jerks are Normal

Planter response: Flexor (B/L)

Clonus- Absent (B/L)

Systemic examination –

Sensory function test : Pain, touch, temperature – intact Joint position sense – intact Vibration sense – intact

Autonomic function

Normal

Systemic examination –

Signs of meningeal irritation : Neck rigidity : absent Kerning’s sign : negative Brudzinski’s sign : negative

Systemic examination –

Cardiovascular system

Nothing abnormalities are detected Respiratory system

Nothing abnormalities are detected Alimentary system

Nothing abnormalities are detected

Salient feature

A young man, 27 years of age right handed

hailing from Purbadhola, Netrogona

presented with irritation and watering of the

left eye for 10 months, forward displacement

of left eye ball for 3 months and gradual

dimness of vision in left eye for 3 months.

Salient feature (Cont.)

He complained about irritation and watering of the

left eye which was prominent in day time. In last 3

months he noticed forward displacement of left eye

ball which was gradually increasing and not

associated with pain and pulsation. He also

complained gradual dimness of vision in left eye

and occasional double vision .

Salient feature (Cont.)

The patient had no history of Headache,

vomiting, vertigo, fever, night sweats, weight

loss, cough or haemoptysis, haematuria or

per rectal bleeding, bone pain. There was no

history of trauma.

Salient feature (Cont.)

On examination, the patient was ill looking and his pulse

was 76/min & BP was 130/80 mm Hg . On local examination

of the left eye he was found Inferonasal globe displacement

and fullness of the superotemporal lid and orbit with 4mm

proptosis of left eye and A S-shaped contour to the left

upper lid. Tenderness was absent. The motility of the left

globe restricted in superior and lateral direction with

absent preauricular lymphadenopathy.

Salient feature (Cont.)

He was found with visual acquity 6/6 (Rt),

finger counting from 2 feet (Lt) & with

restricted field of vision. He was found disc

swelling in left eye.

Provisional Diagnosis

Left sided Retrobulbar Benign Tumour

Diferential Diagnosis

PseudotumourMalignant Retrobulbar tumourCarotido- Cavernous Fistula

Orbital vein thrombosisHaemangiomaNeurofibroma

Optic Nerve Glioma

Investigation

Investigations (Preoperative)

CBC :

TC – 10,300/cmm DC – N 68%

L 26%

M 02%

E 04%

Hb% - 12 gm/dl

ESR – 18 mm in 1st hour

Serum creatinine - 1.2 mg/dl

RBS- 5.4 mM/L

Urine R/M/E- Normal

ECG – Within normal limit

CXR P/A - Within normal limit

Investigations (Cont…)

CT Scan of Brain

Clinical Diagnosis

Retrobulbar solid tumour on left orbit

Clinical Diagnosis

Transcranial Orbitotomy and Removal of

the Tumour was done under G/A on 11th

December, 2011

Treatment

Operative Procedure

Confirm Diagnosis by Histopathology

Pleomorphic Adenoma