Common Causes
Proptosis is the medical term for bulging eyes. Graves disease is the most common cause of proptosis, but other, more serious causes, exist as well.
Related Conditions
The proptosis can be axial or nonaxial, depending on the position of the mass. In some patients, the disease may present bilaterally (an exception to the rule that orbital tumors are usually unilateral). Most commonly, you see lymphoid tumors arising in the superior orbital quadrants.
What is proptosis?
Exophthalmos means the same thing, and this term is usually used when describing proptosis due to Graves disease. Disorders that may cause changes in the appearance of the face and eyes that resemble proptosis but are not include hyperthyroidism without infiltrative eye disease, Cushing disease, and severe obesity.
Is proptosis axial or nonaxial?
Thyroid eye disease is the most common cause of unilateral or bilateral proptosis. As we said, at least briefly, consider this diagnosis in all patients with proptosis. Without looking at other signs and symptoms, you are more often correct about this diagnosis than any other. Thyroid eye disease affects women five to six times more often than men.
Is exophthalmos the same as proptosis?
What is the most common cause of bilateral proptosis?
What is axial and eccentric proptosis?
A lesion in the intraconal region produces axial proptosis, whereas lesion in the extraconal region produces eccentric proptosis. Eccentric proptosis may be due to lesion within the orbit itself or due to the lesion in the neighbouring structures like cranial cavity, paranasal structures etc.
What is non axial proptosis?
Pneumosinus Dilatans (PD) is a rare condition characterized by abnormal enlargement of one or more paranasal sinuses that can lead to different functional and cosmetic presentations.
What are the types of proptosis?
Acute unilateral proptosis suggests infection or vascular disorder (eg, hemorrhage, fistula, cavernous sinus thrombosis). Chronic unilateral proptosis suggests tumor. Do CT or MRI and thyroid function testing when Graves disease is suspected.
How is non axial proptosis measured?
Measurement of dystopia: -In an eccentric or non axial proptosis, the horizontal & vertical dystopia of globe is to be measured. -Horizontal dystopia :is measured by the distance from the midline of bridge of nose to the nasal limbus, compared bilaterally.
What are the causes of proptosis?
What are the most common causes of proptosis? The most common cause of bulging eyes is an autoimmune disorder in which the body's immune system attacks cells in the thyroid gland and the tissue behind the eye. Proptosis in people with thyroid issues is also called thyroid eye disease.
What is the difference between proptosis and exophthalmos?
Proptosis can describe any organ that is displaced forward, while exophthalmos refers to only the eyes. Proptosis can include any directional forward displacement.
Can bulging eyes go back to normal?
Eye protrusion Although less variable than eyelid retraction, the protrusion of the eye can return to normal on its own.
What medical condition causes bulging eyes?
Hyperthyroidism (particularly Graves disease) is the most common medical cause of bulging eyes. With this condition, the eyes do not blink often and seem to have a staring quality. Normally, there should be no visible white between the top of the iris (the colored part of the eye) and the upper eyelid.
How does an MRI detect proptosis?
The reference line for measurement of proptosis is the interzygomatic line (a line is drawn at the anterior portions of the zygomatic bones): the upper limit of normal distance from this line to the anterior surface of the globe is 23 mm, above which indicates proptosis.
Can proptosis be cured?
In many cases, supportive treatment may be all that's needed. About 66 percent of mild cases resolve within 6 months. About 95 percent of people with thyroid-related proptosis heal without permanent vision loss, but about 5 percent of people develop permanent double vision or visual impairment.
What is normal proptosis?
It is suggested that the following "upper limits of normal" be used when clinically estimating proptosis: 19 and 21 mm for white female and male patients, respectively; and 23 and 24 mm for black female and male patients, respectively.
What is the most common cause of unilateral proptosis?
Thyroid eye disease. Estimated to have an annual incidence of 16 women and 3 men per 100,000 people,27 thyroid eye disease (TED) is the most common cause of unilateral or bilateral proptosis.
What is the most common cause of unilateral proptosis?
Thyroid eye disease. Estimated to have an annual incidence of 16 women and 3 men per 100,000 people,27 thyroid eye disease (TED) is the most common cause of unilateral or bilateral proptosis.
Can proptosis be cured?
In many cases, supportive treatment may be all that's needed. About 66 percent of mild cases resolve within 6 months. About 95 percent of people with thyroid-related proptosis heal without permanent vision loss, but about 5 percent of people develop permanent double vision or visual impairment.
What can cause unilateral proptosis?
The causes of unilateral proptosis include trauma followed by endocrine ophthalmopathy, orbital haemangioma, malignant lymphomas, pseudotumour, lacrimal gland epithelial tumours, meningioma, lymphangioma, glioma of optic nerve, metastatic malignant tumours [1].
How does an MRI detect proptosis?
The reference line for measurement of proptosis is the interzygomatic line (a line is drawn at the anterior portions of the zygomatic bones): the upper limit of normal distance from this line to the anterior surface of the globe is 23 mm, above which indicates proptosis.
What is the term for the protrusion of the eyeball?
DR P. MARAZZI/SCIENCE PHOTO LIBRARY. Proptosis is protrusion of the eyeball. Exophthalmos means the same thing, and this term is usually used when describing proptosis due to Graves disease. Disorders that may cause changes in the appearance of the face and eyes that resemble proptosis but are not include hyperthyroidism without infiltrative eye ...
What does sudden unilateral onset mean?
Sudden unilateral onset suggests intraorbital hemorrhage (which can occur after surgery, retrobulbar injection, or trauma) or inflammation of the orbit or paranasal sinuses. A 2- to 3-week onset suggests chronic inflammation or orbital inflammatory pseudotumor (non-neoplastic cellular infiltration and proliferation); slower onset suggests an orbital tumor.
How to treat Graves exophthalmos?
Lubrication to protect the cornea is required in severe cases. When lubrication is not sufficient, surgery to provide better coverage of the eye surface or to reduce proptosis may be required. Systemic corticosteroids (eg, prednisone 1 mg/kg orally once a day for 1 week , tapered over ≥ 1 month) are often helpful in controlling edema and orbital congestion due to thyroid eye disease or inflammatory orbital pseudotumor. Other interventions vary by etiology. Graves exophthalmos is not affected by treatment of the thyroid condition but may lessen over time. Tumors must be surgically removed. Selective embolization or, rarely, trapping procedures may be effective in cases of arteriovenous fistulas involving the cavernous sinus.
Overview
Proptosis is the bulging of one or both or your eyes from their natural position. The condition can affect your appearance, leaving you with a startled expression that doesn’t go away.
Symptoms and Causes
The most common cause of bulging eyes is an autoimmune disorder in which the body’s immune system attacks cells in the thyroid gland and the tissue behind the eye. Proptosis in people with thyroid issues is also called thyroid eye disease.
Diagnosis and Tests
Your healthcare provider will ask about your symptoms and medical history to determine potential causes for your symptoms.
Management and Treatment
Artificial tears, including drops or gel to relieve dry eyes and protect the cornea.
Living With
Protruding eyes can affect your appearance and cause issues with your confidence and self-esteem. If it affects your vision, you may experience unexpected changes in your daily life. These changes can leave you feeling upset, anxious or depressed.
Which direction does proptosis occur?
Direction of proptosis. Proptosis can be axial, when it occurs in the anteroposterior direction or can be in the direction opposite to the causative lesion . Thus, a lesion in the upper-lateral aspect of the orbit, such as a lacrimal gland tumour, will push the eyeball downwards and medially.
How to measure proptosis?
The severity of proptosis can be measured by various methods. The Hertel exophthalmometer uses a system of prisms to project a lateral view of the eye forward. A millimetre-scale is superimposed on this view and is read by the opposite eye of the examiner. The patient is made to sit at the eye level of the examiner. The two ends of the instrument are placed at the lateral orbital margins of each eye. Subsequently, the observer uses his opposite eye to look at the distance of the apex of the cornea on the scale by excluding parallax. A millimetre-scale is provided on the top of the instrument to measure the distance between the lateral orbital margins of the two eyes; this reading can be noted for future reference. Errors in measurement are caused by thickness of subcutaneous tissue over the bone, facial asymmetry, parallax and examiner skills. 6,31 Apart from Hertel’s exophthalmometer, a simple plastic scale at the lateral orbital margin, or a Luedde exophthalmometer, can be used. The latter is a thick plastic ruler with a notch to fit in the lateral orbital margin and markings in millimetres on both sides of the scale to avoid parallax. In exophthalmometry, normal readings are taken as less than 21 mm between the lateral orbital rim and apex of the cornea, or a difference of less than 2 mm between the two eyes. 1,6
What is P roptosis?
Overview. P roptosis is an abnormal prominence of the eyeball beyond the confines of the bony orbit. It can appear in various systemic, as well as orbital or peri-orbital, disorders. Not only is proptosis potentially vision-threatening, but also it could be a manifestation of life-threatening conditions, such as metastatic carcinomas.
What is the term for an abnormal protrusion of the eyeball beyond the boundaries of the bony orbit?
Article: An abnormal protrusion of the eyeball, beyond the boundaries of the bony orbit, is termed ‘proptosis ’. A similar appearance, seen in endocrine dysfunction, especially thyroid disorders, is called ‘exophthalmos’.
Why does my eyeball protrude forward?
Because of the relatively small amount of space between the orbital walls and the eyeball, an expanding lesion within the orbit, or a shallow bony orbit, as often seen in congenital disorders, causes protrusion of the eyeball forwards.
What are the methods of investigating proptosis?
The methods for investigating proptosis have been classified into primary, secondary, pathological and laboratory techniques. The article extensively discusses thyroid eye disease, including the current hypothesis of pathophysiology, mechanisms, stages, clinical features, classification and management of this disease.
Why is time important in proptosis?
In certain situations, time is of vital importance to prevent optic nerve compression and permanent loss of vision. This review provides a simplified pathway to approach proptosis and to improve patient care and outcomes. 16
What causes proptosis in children?
The most common cause in children is orbital cellulitis . Table. Some Causes of Proptosis.
What is the name of the protrusion of the eyeball?
Proptosis is protrusion of the eyeball. Exophthalmos means the same thing, and this term is usually used when describing proptosis due to Graves disease. Disorders that may cause changes in the appearance of the face and eyes that resemble proptosis but are not include hyperthyroidism without infiltrative eye disease, Cushing disease, ...
What does sudden unilateral onset mean?
Sudden unilateral onset suggests intraorbital hemorrhage (which can occur after surgery, retrobulbar injection, or trauma) or inflammation of the orbit or paranasal sinuses. A 2- to 3-week onset suggests chronic inflammation or orbital inflammatory pseudotumor (non-neoplastic cellular infiltration and proliferation); slower onset suggests an orbital tumor.
How to treat Graves exophthalmos?
Lubrication to protect the cornea is required in severe cases. When lubrication is not sufficient, surgery to provide better coverage of the eye surface or to reduce proptosis may be required. Systemic corticosteroids (eg, prednisone 1 mg/kg orally once a day for 1 week , tapered over ≥ 1 month) are often helpful in controlling edema and orbital congestion due to thyroid eye disease or inflammatory orbital pseudotumor. Other interventions vary by etiology. Graves exophthalmos is not affected by treatment of the thyroid condition but may lessen over time. Tumors must be surgically removed. Selective embolization or, rarely, trapping procedures may be effective in cases of arteriovenous fistulas involving the cavernous sinus.
Where does proptosis originate?
The causes of proptosis are broad and include a wide range of mass lesions that originate within the cranium, sinuses, paranasal spaces, and orbit 3:
What causes uni/bilateral proptosis?
The causes of proptosis are broad and include a wide range of mass lesions that originate within the cranium, sinuses, paranasal spaces, and orbit 3: thyroid orbitopathy (the most common cause of uni/bilateral proptosis in adults) infection. orbital cellulitis.
What is the difference between proptosis and exophthalmos?
proptosis and exophthalmos are often used interchangeably. exophthalmos used to refer to severe (>18 mm) proptosis 5. exophthalmos used to refer to endocrine-related proptosis 6. Proptosis can also be used for other viscera (although rarely seen in contemporaneous usage), but exophthalmos only for the eyes.
What is the term for forward protrusion of the globe with respect to the orbit?
Proptosis (rare plural: proptoses) refers to forward protrusion of the globe with respect to the orbit. There are many causes of proptosis which can be divided according to location and it is worth remembering that it is not just orbital disease processes that cause proptosis.
What is the reference line for measuring proptosis?
The reference line for measurement of proptosis is the interzygomatic line (a line is drawn at the anterior portions of the zygomatic bones ):
Can proptosis be used for other viscera?
Proptosis can also be used for other viscera (although rarely seen in contemporaneous usage), but exophthalmos only for the eyes.
What are the characteristics of orbital problems that are most helpful in developing a differential diagnosis?
Pain and progression are the characteristics of orbital problems that are most helpful in developing the differential diagnosis. Pain is caused by inflammation, infection, acute pressure changes, or bone or nerve involvement. Once you become familiar with the common orbital disorders, you find that the presence or absence of pain is very helpful in developing a differential diagnosis.
What is the term for the eye being pushed down by a mass?
Proptosis implies an anterior displacement of the globe. An orbital mass not centered within the orbit displaces the eye off the axis, as well. Globe ptosis is the term used when the eye is pushed down by a mass (also known as hypoglobus ). As you perform the orbital examination, look for signs of axial and nonaxial globe displacement of the eye to help you locate the mass that is displacing the globe.
What is orbital lymphoma?
Lymphoid lesions of the orbit are among the most common orbital tumors that you see in adults. A gradual onset with slow progression of a painless orbital mass, often anterior and superior, is typical of the orbital lymphoid lesions. About 25% of patients have a previous diagnosis of lymphoma. Lymphoid lesions occur most commonly in elderly patients but may occur in middle-aged patients.
What is orbitopathy?
Thyroid orbitopathy is an idiopathic inflammatory condition affecting the orbit, primarily the extraocular muscles. The eye is spared from intraocular involvement. Although the exact mechanism is not well known, presumably antibodies attach to tissue in both the thyroid gland and extraocular muscles that are recognized as foreign. The associated immune response stimulates the thyroid gland to produce thyroid hormone. Similarly, the local inflammatory response causes the muscles and orbital fat to enlarge. Most patients are hyperthyroid at the time of diagnosis of the eye condition. Only a small percentage of patients remain euthyroid throughout the disease course. Most patients assume that serum normalization of the thyroid levels helps the orbital disease. Reduction in serum thyroid hormone levels is achieved by reducing the output of the thyroid gland by administration of radioactive iodine to destroy the gland, medical treatment to suppress the gland, or surgical resection of the gland. Few patients easily understand that the medical treatment of serum thyroid levels recommended by the endocrinologist has little or no effect on controlling the orbitopathy. This is something about which many patients have questions.
Do you need orbital imaging for proptosis?
Almost all patients with proptosis require orbital imaging. One exception to this may be the patient with findings typical of stable Graves’ disease in whom the diagnosis is so apparent that no imaging is needed to confirm your clinical suspicion. CT scanning is used as the primary imaging technique for evaluation of any patient with proptosis. You should order a magnetic resonance imaging (MRI) scan of the orbit in special cases, primarily those situations in which imaging of the orbital apex and chiasm is required.
How to diagnose proptosis?
The plan for evaluation of the patient with proptosis is to take the history and perform the physical examination followed by imaging of the orbit. Usually, at this point, you can make a differential diagnosis. You can generally narrow down the choices to one of the general pathologic categories such as neoplasm or infection. Remember thyroid orbitopathy is the most common cause of unilateral, bilateral proptosis. If a mass is diagnosed, incisional or excisional biopsy is usually needed to confirm the diagnosis. Treatment is based upon the pathology results.
What is the term for the eye being pushed down by a mass?
Proptosis implies an anterior displacement of the globe. An orbital mass not centered within the orbit will displace the eye off axis as well. Globe ptosis is the term used when the eye is pushed down by a mass. As you perform the orbital examination, look for signs of axial and nonaxial globe displacement of the eye that will help you locate the mass that is displacing the globe.
What are the tissues in the orbit?
Think of all the different tissue types that are found in the orbit—nerves, muscle, veins and arteries, glandular tissue, and connective tissue, to name a few. In addition to these tissues, pigment cells and red and white blood cells are present. A primary orbital neoplasm may arise from any of these tissue types or cells. Now consider the tissues surrounding the orbit—bones of the face and skull, the brain, the sinus and nasal tissues, and the soft tissues of the face. Each of these structures may develop a problem that extends into the orbit as a secondary orbital condition. Given the almost infinite number of processes that can involve the orbit, it is important for you to develop an approach to investigating the patient with a proptotic eye.
Can you get a biopsy for proptosis?
For some causes of proptosis, such as orbital cellulitis, medical treatment will be initiated without biopsy. For other patients, an incisional biopsy will be required to obtain the diagnosis, for example the biopsy of a suspected lymphoid lesion to determine if the mass is benign or malignant.
Do you need orbital imaging for proptosis?
Almost all patients with proptosis will require orbital imaging. One exception to this may be the patient with findings typical of stable Graves’ disease in whom the diagnosis is so apparent that no imaging is needed to confirm your clinical suspicion.
Can you diagnose proptosis based on pain?
History as a clue to the pathologic process. It is impossible to diagnose every cause of proptosis based on pain and progression only, but you will be surprised how easy it is to develop a differential diagnosis of a general pathogenesis. Consider the types of pathologic processes that affect the body as a whole.
What is the definition of proptosis?
On scans, proptosis is defined as globe protrusion greater than 21 mm anterior to the interzygomatic line on axial scans at the level of the lens. Proptosis without displacement (axial) is due to intraconal, most commonly dysthyroid, eye disease.
How is proptosis measured?
Proptosis is measured using an exophthalmometer. This device takes a millimeter measurement of the distance between the anterior cornea and the temporal orbital rim for each eye. For an individual patient the measurement base is the distance between the two temporal orbital rim margins. Thus a consistent measurement of proptosis or enophthalmos ...
What is the term for the anterior displacement of one or both eye globes within the bony orbit?
Proptosis is the anterior displacement of one or both eye globes within the bony orbit. The term exophthalmos is sometimes used, particularly when the proptosis is related to thyroid dysfunction. The normal amount of ocular protrusion as measured (with an exophthalmometer) from the lateral orbital rim to the corneal apex is 14–21 mm in adults; protrusion greater than 21 mm or a 2-mm change is abnormal. On scans, proptosis is defined as globe protrusion greater than 21 mm anterior to the interzygomatic line on axial scans at the level of the lens.
What is an exophalmometer?
Exophalmometer readings are particularly useful to monitor changes from thyroid eye disease or orbital mass. Enophthalmos can be indicative of orbital floor fracture or a cicatrizing lesion such as metastatic breast cancer. The data are expressed as “x” millimeters right eye, “y” millimeters left eye, with a base of “z” millimeters.
How to check for periorbital deformities?
The function of the infraorbital nerve should also be checked by gently stroking the upper cheek below the eye with a cotton swab or similar item. Infraorbital hypesthesia, crepitus, enophthalmos, and orbital deformity may indicate the presence of an orbital blow-out fracture.
Where is the enlargement of the muscle?
Enlargement is maximal in the middle of the muscle and tapers toward the end (infiltrative, not inflammatory disease).
Can toothed forceps be used to manipulate canalicular lacerations?
The use of toothed forceps to manipulate canalicular lacerations should be avoided, as further tissue damage can follow.
