Proptosis

Otolaryngology online
Proptosis
Balasubramanian Thiagarajan
Definition
Proptosis is defined as abnormal protrusion of eye
ball
If protrusion of globe is 18 mm / less it is known as
proptosis
If protrusion of globe is more than 18 mm it is
known as exophthalmos
Proptosis + lid lag = exopthalmos
Exorbitism
This is caused due to decrease in the volume of orbit
causing the orbital contents to protrude forwards
Usually bilateral
Should be differentiated from proptosis /
exophthalmos
Difference between proptosis /
exophthalmos
Anatomy of orbit
Volume of orbit is fixed
30 ml
Increase in soft tissue
volume of 5 ml will
cause 5 mm of proptosis
Anatomy of orbit - 2
Resembles a four sided
pyramid
Rim is 40 mm horizontally
and 35 mm in an adult male
Medial walls are parallel
and 25 mm apart in adults
Lateral orbital walls angle
about 90 degrees from each
other
Orbital rim
Superior orbital rim is formed by frontal bone
Inferior rim is formed by maxillary bone medially
and zygomatic bone laterally
Lateral orbital rim is formed by zygoma
Superior rim contains a notch at the junction of
medial and lateral thirds (supraorbital notch)
Medial portion of the rim is formed by frontal
process of maxilla
Lacrimal fossa
Lodges the lacrimal sac
This fossa is formed by
maxillary and lacrimal
bones
Bounded by anterior and
posterior lacrimal crests
Anterior crest is formed by
maxillary bone
Posterior lacrimal crest is
formed by lacrimal bone
Weber's suture
Lies anterior to lacrimal fossa
Also known as sutura longitudinalis imperfecta
This suture runs parallel to anterior lacrimal crest
Infraorbital nerve artery branches pass through it to
supply nasal mucosa
Bleeding occurs from these vessels during lacrimal
sac surgeries
Embryology
7 bones involved in the formation of orbit are
derived from neural crest cells
Ossification of orbit is complete at birth excepting
its apex
Lesser wing of sphenoid is cartilagenous
Other bones undergo membranous ossification
Orbital roof
Formed by frontal bone
Posterior 1.5 cms of the roof is formed by lesser
wing of sphenoid
Optic foramen contains optic nerve
Optic nerve enters orbit at an angulation of 44
degrees
Lacrimal gland is located at the lateral end of orbital
roof
Medial orbital wall
Formed by frontal process of maxilla, lacrimal bone,
ethmoidal bone and lesser wing of sphenoid
Thinest portion of medial wall is the lamina
papyracea
It separates orbit from the nasal cavity
Infections from ethmoidal sinuses can breach this
bone and spread into the orbit.
Medial wall of orbit applied anatomy
Lacrimal bone at the level of lacrimal fossa is very
thin
This bone can easily be penetrated during
endoscopic DCR
If the maxillary component is predominant then it is
really difficult to breach this bone during endoscopic
DCR since this bone is rather thick.
Fronto ethmoidal suture line
Very important surgical landmark
Marks the approximate level of ethmoidal roof
Dissection above this line will expose the cranial
cavity
Anterior and posterior ethmoidal foramina are
present in this suture line
Anterior and posterior ethmodial arteries pass
throught these foramina
Orbital roof
Roof of orbit is formed by frontal bone
Posterior 1.5 cm of roof is formed by lesser wing of
sphenoid
Optic foramen is located in the lesser wing of
sphenoid
Floor of orbit
It is the shortest of all the walls
Bounded laterally by infraorbital fissure
Medially bounded by maxilloethmoidal strut of bone
Almost entirely formed by orbital plate of maxilla
with minor contribution from orbital plate of
palatine bone posteriorly
Floor is thin medial to infra orbital groove
Infraorbital groove becomes infraorbital foramen
anteriorly
Lateral wall
Formed by greater wing of sphenoid
Zygoma & zygomatic process of frontal bone
minor contribution
Recurrent meningeal branch of middle meningeal
artery is seen in this wall
4-5 mm behind the lateral orbital rim and 1 cm
inferior to the fronto zygomatic suture line lie the
whitnall's tubercle.
Whitnall's tubercle (structures attached)
Lateral canthal tendon
Lateral rectus check ligament
Suspensory ligament of lower eyelid (Lockwood's
ligament)
Orbital septum
Lacrimal gland fascia
Anatomical relationship of orbit with
paranasal sinuses
By its location it is closely related to all paranasal
sinuses
By venous drainage Both these areas share a
common venous drainage
Peculiarities of orbital venous drainage
Entire venous system is devoid of valves hence
two way communication between orbit and sinuses
is a reality
Superior opthalmic vein connects facial vein to
cavernous sinus causing spread of infections from
face to cavernous sinus
Inferior ophthalmic vein communicates with
pterygoid venous plexus and cavernous sinus by its
two branches
Pseudoproptosis
High myopia
Enophthalmos of one eye may cause apparant
proptosis of the other one
Exophthalmometer
Hertel's mirror
exophthalmometer is
used for this purpose
The distance between
the lateral orbital rim
and the corneal apex is
used as a measure for
proptosis
This distance is
normally 18 mm
ENT - Causes
Mnemonic VEIN
V Vascular causes
E Endocrine causes
I Inflammatory causes
N Neoplastic causes
Imaging
CT / MRI may help in
identifying the cause
Fat in the orbit serves as
a contrast medium
3 mm cuts is ideal
Ultrasound A mode /
B mode can be done to
identify the cause
Role of MRI
MRI is sensitive in identifying extraocular muscle
oedema
Increased T2 relaxation time indicates extraocular
muscle oedema, these pts respond well to steroid
therapy
Patients with normal T2 relaxation levels need
orbital decompression
Vascular causes
Classified into arterial and venous
Venous causes are due to dilated veins Positional
proptosis is the classical feature in these patients. It
can also be induced by valsalva maneuver
Initially there may be atrophy of fat in these pts
causing enophthalmos
CT scan after jugular vein compression is diagnostic
Surgery is disastrous in these patients. Conservative
management is the best modality
Proptosis due to dural venous sinus
fistula
Shunt is low flow type
Proptosis is insidiuous and often goes unnoticed
A high index of suspicion is necessary to diagnose
these cases
Carotid cavernous fistula
High flow shunts
Can occur spontaneously / trauma
Subjective bruit / proptosis / chemosis / vision loss
Arterolization of conjunctival vessels causing
corkscrew pattern
Intractable cases shunt must be closed using
balloon / carotid artery ligation
Endocrine proptosis - features
Presence of lid lag / retraction
Presence of temporal flare in upper eyelid
Presence of orbital congestion
Imaging shows enlarged extraocular muscles,
bulging of orbital septum due to fat protrusion
Inflammatory causes
Idiopathic inflammation Pseudotumor of orbit
Due to specific causes of orbital inflammation
These pts have pain during ocular movement
Associated dacryo adenitis +
Perioptic neuritis can cause blindness
Steroids may be helpful
Neoplastic lesions involving nose and
sinuses
Inverted papilloma
Fungal infections
Mucoceles of paranasal sinuses
Fibrous dysplasia of maxilla
Osteomas involving frontal / ethmoidal sinuses
JNA
Management
Low dose irradiation (rarely used)
Surgery
Indications for orbital decompression
Visual disturbance due to proptosis
Failure of steroids to improve vision
If steroids are necessary on a long term basis for
maintaining vision
To preven exposure keratitis
Diplopia
Cosmesis
Risks of orbital decompression
Diplopia
Intractable strabismus
Hypoglobus
Injury to optic nerve due to prolonged globe
retraction
Retrobular hematoma this can cause blindness
Injury to infraorbital nerve
Epistaxis
Orbital decompression (Goals)
To enlarge the confining space of orbit by removing
1-4 of its walls
15 mm of decompression can be achieved by
removing all 4 walls of the orbit
Usually successful surgery causes 3-7 mm
decompression of orbit
Superior orbital decompression
Naffzeiger technique
Superior wall decompression
Complete unroofing of orbit frontal craniotomy
Large amounts of bone can be removed creating
more space
Craniotomy may be needed
Used in pts with orbital trauma
Naffzeiger --- Contd
In collaboration with neurosurgeon
Optic nerve should be visualized to begin with
The roof of the orbit is removed starting from the
optic foramen to the anterosuperior orbital rim
Periosteum should be left intact to prevent injury to
levator muscle
H shaped incision is made over superior periosteum
allowing orbital fat to prolapse through it
Titanium mesh can be used to cover orbital roof
Medial orbital decompression
Also known as Sewell procedure
Coronal incision / external ethmoidectomy incision
Medial canthal tendon is identified and divided
Anterior and posterior ethmoidal arteries identified
and clipped
Complete ethmoidectomy is performed starting from
lacrimal fossa
Bicoronal incision for medial orbital
decompression
Medial canthal tendon can be left intact
Ethmoidectomy is performed from above
Lacrimal sac and trochlea should not be damaged
Medial periosteum is incised and orbital fat is
allowed to prolapse into the nasal cavity
Inferior decompression
Hisch and Urbanek procedure
Artificial creation of blow out fracture of orbital
floor sparing infra orbital nerve
Trans conjunctival / subciliary incision plus
Caldwell Luc procedure
Laterally floor can be removed up to zygoma and
medially up to lacrimal fossa
Posteriorly bone is thick 3 cms of bone can be
removed from this area
Inferior decompression -- Contd
Periosteum is incised to allow orbital fat to prolapse
into the maxillary antrum
Forced duction test should be performed to ensure
orbital muscles are not entrapped.
Lateral decompression
Kronlein procedure
Coronal incision, and lateral extension of subciliary
incision
Extended lateral canthotomy
Lateral orbital rim periosteum is exposed from
zygomatic arch to zygomatico frontal suture
Periosteum incised along lateral orbital rim and
orbital fat is teased out
Combination of approaches
Any of the above said approaches can be combined
for optimal benefit
Combination of apporaches reduces the surgical risk
and provides more increase of space than one
procedure alone
Endoscopic decompression
Inferior and medial orbital walls can be accessed
easily using nasal endoscope
A large middle meatal antrostomy is performed 30
degree endoscope is used to identify the position of
inferior orbital nerve in the roof of maxillary sinus
Total ethmoidectomy is performed
Sphenoid osteum is identified and enlarged
Endoscopic decompression ---Contd
Lamina papyracea is exposed
Position of anterior & posterior ethmoid arteries
noted
If middle turbinate is resected it helps in post op
cleaning. If left behind it prevents excessive
collapse of orbital fat
Lamina papyacea is remove bit by bit using Freer's
elevator. It should be cracked in the middle portion
first
Endocopic decompression --- Contd
Initially periorbita is left intact to prevent orbital fat
prolapse which could obstruct vision
Bone is to be removed up to the roof of the ethmoid
superiorly, face of the sphenoid posteriorly, the
nasolacrimal duct anteriorly.
Inferiorly it can be removed up to maxillary
antrostomy
Small piece of bone is retained over frontal recess
area to prevent orbital fat obstruction frontal sinus
drainage
contd
Starting posteriorly periorbita is incised
Sickle knife is kept superficial to avoid injury to
extraocular muscles
Mutliple cuts are made in the periorbita allowing
orbital fat to prolapse into the nasal cavity
Exophthalmos of up to 3.5 mm can be corrected by
endoscopic decompression
Nasal packing is to be avoided to prevent optic nerve
compression
Tips
Nose blowing is to be avoided for 2 weeks following
surgery
Bilateral decompression should be done within an
interval of a week
For mild exophthalmos 2-3 mm any of the
approaches would suffice
For moderate 3-5mm inferior decompression is
sufficient
For severe ones 5-7 mm three wall decompression
is preferred
Thank You

Proptosis

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Proptosis

Transféré par

Droits d'auteur :

Formats disponibles

Otolaryngology online

Vous aimerez peut-être aussi