jump to first page proptosis mounir bashour, m.d., c.m
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ProptosisMounir Bashour, M.D., C.M.
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What is proptosis? 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? Globes from above Measured with an exophthalmometer
lateral orbital rim CT scan
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List common problems associated with proptosis 1. Exposure keratopathy
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? Thyroid eye disease (Graves'
ophthalmopathy)
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Most common cause of bilateral proptosis?
Thyroid eye disease
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What are other causes of proptosis? 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 1. Unilateral high axial myopia
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? 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? Thyroid ophthalmopathy
multisystem. autoimmune disorder hyperthyroid, hypothyroid, euthyroid
inflammation and enlargement EOM• IR>MR>SR>LR
• fusiform enlargement sparing the tendon 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? 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
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? Infectious orbital cellulitis
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 Orbital subperiosteal abscess CT scan
confirm diagnosis locate the abscess
surgical drainage and continued intravenous antibiotics
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Child < 6 y.o. with gradual, painless, progressive, unilateral axial proptosis with visual loss?
Optic nerve glioma (juvenile pilocytic astrocytoma) slow-growing tumor Decreased visual acuity with a RAPD CT scan or MRI
“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?
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
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
typically superior orbit slow onset and progression subconjunctival “salmon-colored" mass in the fornix CT scan
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 Cavernous hemangioma Schwannoma Fibrohistiocytoma Neurofibroma Hemangiopericytoma