Proptosis

Key question…

1

Proptosis

Proptosis

IsLid Retraction

present?

2

Proptosis

Proptosis

IsLid Retraction

present?

Yes NoYour thought is…

If the answer is…

3

Proptosis

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

4

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

5

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pt has lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely.

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

6

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pt has lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely.

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

7

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pt has lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely.

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

8

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

9

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely

There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

10

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely

There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravistwo words

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

11

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely

There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

12

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely

There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis

What one word best characterizes the clinical course of ptosis in MG?Variable. That is, one would expect the degree of ptosis to vary from exam to exam

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

13

How common is lid retraction in Graves disease?It is ubiquitous, with greater than 90% of Graves pts manifesting it at some point. Because of this ubiquity, lid retraction is a key diagnostic finding in Graves dz—if a pthas lid retraction plus laboratory evidence of thyroid dysfunction, the diagnosis of Graves dz is made.

Does the absence of lid retraction rule out Graves?No, but it make it much less likely

There is an important exception to the ‘absence of lid retraction indicates it isn’t Graves dz’ contention--in fact, such pts can present with ptosis. Under what circumstance might a Graves pt present with no lid retraction, or even frank ptosis?If the pt has concurrent myasthenia gravis

What one word best characterizes the clinical course of ptosis in MG?Variable. That is, one would expect the degree of ptosis to vary from exam to exam.

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

14

What if it’s not Graves dz? What else can cause proptosis + lid retraction?An abnormally large globe as in high axial myopia, or buphthalmos. Of course, such cases would not consist of lid retraction + proptosis; rather, they would consist of lid retraction + pseudoproptosis.

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

15

What if it’s not Graves dz? What else can cause proptosis + lid retraction?An abnormally large globe as in high axial myopia, or buphthalmos. (Of course, such cases would not consist of lid retraction + proptosis; rather, they would consist of lid retraction + pseudoproptosis.

ProptosisProptosis

IsLid Retraction

present?

Yes No

Graves dzYour thought is…

If the answer is…

16

What if it’s not Graves dz? What else can cause proptosis + lid retraction?An abnormally large globe as in high axial myopia, or buphthalmos. (Of course, such cases would not consist of lid retraction + proptosis; rather, they would consist of lid retraction + pseudoproptosis.)

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

If the answer is…

Your thought is…

Yes

Graves dz

17

(over here now)

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

18

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

Key question…

19

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

Is there a Mass

present?

20

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

Is there a Mass

present?

Yes NoIf the answer is…

Your DDx is…

21

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

Is there a Mass

present?

Yes NoIf the answer is…

Your DDx is…

--Cavernous hemangioma--ON sheath meningioma--ON glioma--Rhabdomyosarcoma--Metastatic disease--Varix--Lymphangioma

22

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

Is there a Mass

present?

Yes NoIf the answer is…

Your DDx is…

If the answer is…

Your DDx is…

--Cavernous hemangioma--ON sheath meningioma--ON glioma--Rhabdomyosarcoma--Metastatic disease--Varix--Lymphangioma

23

ProptosisProptosis

IsLid Retraction

present?

NoIf the answer is…

Your thought is…

CT (as in, I need to order a CT)

If the answer is…

Your thought is…

Yes

Graves dz

Is there a Mass

present?

Yes NoIf the answer is…

--Cavernous hemangioma--ON sheath meningioma--ON glioma--Rhabdomyosarcoma--Metastatic disease--Varix--Lymphangioma

Your DDx is…

If the answer is…

Your DDx is…

--CCF--AVM--Orbital inflammation--Lymphoproliferative dz

24

(CCF = carotid-cavernous sinus fistula)(AVM = arteriovenous malformation)

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Proptosis: Fill in the blanks

Your first thoughtshould be…

Your first thoughtshould be…

25

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks

Bears repeatingfor emphasis!

26

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks27

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks28

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Are we talking about unilateral proptosis, or bilateral proptosis?It can be either

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks29

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Are we talking about unilateral proptosis, or bilateral proptosis?It can be either

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks30

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Where does TED rank as a cause of unilateral proptosis in adults?#1

Are we talking about unilateral proptosis, or bilateral proptosis?It can be either

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks31

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Where does TED rank as a cause of unilateral proptosis in adults?#1

Are we talking about unilateral proptosis, or bilateral proptosis?It can be either

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks32

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Are we talking about unilateral proptosis, or bilateral proptosis?It can be either

Where does TED rank as a cause of unilateral proptosis in adults?#1

Where does TED rank as a cause of bilateral proptosis in adults?#1

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks33

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Are we talking about unilateral proptosis, or bilateral proptosis?It can be either

Where does TED rank as a cause of unilateral proptosis in adults?#1

Where does TED rank as a cause of bilateral proptosis in adults?#1

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks34

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Q

What about in the pediatric population--is the relationship between proptosis and Graves dz as strong?

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks35

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

Q/A

What about in the pediatric population--is the relationship between proptosis and Graves dz as strong?No. Graves is rare in children, and when it does occur, only about 10% of pts present with proptosis. (Rule of thumb: In children, proptosis is more likely to be infection or neoplastic than to be inflammatory.)

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

Graves disease

Imaging

Proptosis: Fill in the blanks36

^= Graves disease

Note: Some authorities argue that, in adults, all proptosis (ie, whether or not lid retraction is present) is Graves dz until proven otherwise!

A

What about in the pediatric population--is the relationship between proptosis and Graves dz as strong?No. Graves is rare in children, and when it does occur, only about 10% of pts present with proptosis. (Rule of thumb: In children, proptosis is more likely to be infection or neoplastic than to be inflammatory.)

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Graves disease

Imaging

reassuring? or cause for concern?

Proptosis: Fill in the blanks37

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Graves disease

Imaging

highly suspicious for an orbital process

Proptosis: Fill in the blanks38

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Ask the patient to ______--if proptosis worsens, it’s probably an ______________

Graves disease

Imaging

highly suspicious for an orbital processsimple

maneuver

cause of proptosis

Proptosis: Fill in the blanks39

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Ask the patient to ______--if proptosis worsens, it’s probably an ______________

Graves disease

Imaging

highly suspicious for an orbital process

Valsalvaorbital venous anomaly

Proptosis: Fill in the blanks40

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Ask the patient to ______--if proptosis worsens, it’s probably an ______________

In evaluating proptosis, always consider contralateral ________

Graves disease

Imaging

highly suspicious for an orbital process

Valsalvaorbital venous anomaly

pathologic condition

Proptosis: Fill in the blanks41

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Ask the patient to ______--if proptosis worsens, it’s probably an ______________

In evaluating proptosis, always consider contralateral ________

Graves disease

Imaging

highly suspicious for an orbital process

Valsalvaorbital venous anomaly

enophthalmos

Proptosis: Fill in the blanks42

Q

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Ask the patient to ______--if proptosis worsens, it’s probably an ______________

In evaluating proptosis, always consider contralateral ________

Auscultate for a ____ (indicates ___ or ____)

Graves disease

Imaging

highly suspicious for an orbital process

Valsalvaorbital venous anomaly

enophthalmospathologic

sound dx dx

Proptosis: Fill in the blanks43

A

Proptosis + lid retraction = ________ Proptosis w/o lid retraction = ________

If one suspects orbital disease, a 2 mm disparity on exophthalmometry--the so-called ‘limit of normal’—is ____________________

Ask the patient to ______--if proptosis worsens, it’s probably an ______________

In evaluating proptosis, always consider contralateral ________

Auscultate for a ____ (indicates ___ or ____)

Graves disease

Imaging

highly suspicious for an orbital process

Valsalvaorbital venous anomaly

enophthalmos

bruit CCF AVM

Proptosis: Fill in the blanks44

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

45

Q

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

46

A

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

47

Q

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?----If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

48

Q/A

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

three words

three words

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

49

A

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

50

Q

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

51

A

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis? Rhabdomyosarcoma Optic nerve glioma

52

Q

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

If a child presents with ocular stigmata of orbital cellulitis but is systemically healthy and happy, what diagnosis should you consider?Rhabdomyosarcoma

All of the following are likely to produce rapid proptosis in a child except: Lymphangioma Orbital cellulitis Rhabdomyosarcoma Optic nerve glioma

53

A

Under what clinical circumstances might a lymphangioma be expected to expand rapidly?--If the pt as an upper-respiratory tract infection --If the lesion undergoes spontaneous intralesional hemorrhage

How will a child with orbital cellulitis present?S/he will usually be toxic—ill-appearing, febrile, and in pain, in addition to the ocular stigmata of proptosis, chemosis, etc

If a child presents with ocular stigmata of orbital cellulitis but is systemically healthy and happy, what diagnosis should you consider?Rhabdomyosarcoma