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|Year : 1964 | Volume
| Issue : 4 | Page : 160-165
Ophthalmic Hospital, Madras, India
Ophthalmic Hospital, Madras
|How to cite this article:|
Balkrishnan E. Uniocular proptosis. Indian J Ophthalmol 1964;12:160-5
Meticulous observation and corelation of physical signs are important steps in the diagnosis of proptopsis. The following cases of uniocular proptopsis are diagnosed by their specific clinical signs and are reported for their rare occurrence.
| I. Aneurysm of Ophthalmic Artery with Angioma Orbit|| |
A male aged twenty four years was admitted for proptopsis of the right eye of eighteen months' duration. It was gradual, painless and without loss of vision. He denied injury to the head or orbit. (Plate 1)-[Figure - 1]
The right eye vision was 6/6, the -lobe was proptosed directly forwards. the anterior segment of the eye and movements of the globe were normal. No mass could be palpated in the orbit to account for the proptopsis. Vessels over the skin of the lids and conjunctiva were normal and no bruit could be heard on auscultation. Retinal vessels were tortuous and bright and the optic disk appeared to be slightly hyperaemic.
The left eye vision was 6/6 and no abnormality of any kind was detected on external and ophthalmoscopic examinations. The fields by quantitative perimetry of both eyes were found to be normal.
Inspite of a large proptopsis, absence of cranial nerve palsy had to be explained. On a careful inspection, the proptopsed eye was found to be feebly pulsatile. It synchronised with the arterial pulse. Digital pressure over the right common carotid artery reduced the proptopsis. So an aneurysm connected with the internal carotid artery, most probably the Ophthalmic artery was suspected. (Plates 2 and 3)-[Figure - 2],[Figure - 3].
A plain x'ray of the skull and right orbit were normal; no calcified mass was seen. Cytological examination of blood was normal. Serological tests for venereal disease were negative. A right carotid angiogram done at the neuro-surgical department showed an aneurysmal dilatation of the right ophthalmic artery with an angiomatous mass in the right orbit visible during the arterial phase. (Plate 4)-[Figure - 4].
A preliminary ligature of the right common carotid artery was done. For a few days the proptopsis was reduced completely but returned later. The patient refused further treatment and left the hospital.
A male aged thirty years was admitted for a complaint of frequent bleeding from the right eye of three years' duration. He was not able to see with that eye since childhood.
In the right eye there was no perception of light. The eyeball was proptosed. The conjunctiva and cornea were keratinised. An angiomatous mass, three inches in diameter originating from the bulbar conjunctiva covered the cornea all round. The proptosed eye was pulsatile synchronising with the arterial pulse. Pressure over the right carotid region reduced the proptosis.
Left Eye vision was 6/6, fundus and fields were normal.
Right carotid angiography done at the neurosurgical dept. showed that the right ophthalmic artery was dilated and an angiomatous mass in the right orbit was seen during the arterial phase.
The neurosorgeon applied two silver clips to the dilated ophthalmic artery. The eyeball receded, only to recur The eyeball receded, only to reproptose after a few weeks. Seven years later the patient was admitted for severe headache with giddiness and sudden loss of ivsion in the left eye.
The left eye vision was reduced to perception of light, the pupil was dilated and sluggishly reacting to light. An oedema of the optic disc, five dioptres high was seen. A large prehyaloid haemorrhage in the lower quadrant and flame-shaped haemorrhages all over the retina were present. From the previous investigation and with the present fundus appearance a leak from the aneurysm was suspected. The patient's general condition deteriorated and was taken home against medical advice.
Sugar and Meyer (1940) divided cases of pulsating exophthalmos into true pulsating and pseudopulsating exopthalmos. True pulsating exopthalmos may be caused by (1) carotid-cavernous fistula, (2) intra-orbital aneurysm, either arteriovenous or of the opthalmic artery, (3) arteriovenous aneurysms between the internal carotid artery and the internal jugular vein at the entrance of the carotid canal, which is rare and (4) simple aneurysm of the internal carotid artery.
Pseudopulsating exopthalmos may be caused by orbital angioma, meningocele and absence of a large part of the orbital roof. The cases reported were of true pulsating exopthalmos, as pressure on the carotid region reduced the proptosis. This is a useful sign in differentiating arterial aneurysm from carotid-cavernous fistula or arteriovenous aneurysm or orbital varix where the pressure on the carotid region will be followed by increased proptosis due to pressure on the internal jugular vein. The second was a long standing case of aneurysm of the opthalmic artery where angimatous vessels developed even over the conjunctiva followed by rupture and bouts of bleeding. An intracranial leak was suspected.
| II. Lymphoma Orbit (2 cases)|| |
I. A female aged forty five years was admitted for a complaint of gradual and painless proptosis of her left eye of three years' duration. (Plate 6)-[Figure - 6].
Vision in the left eye was 6/36. The proptosis was forwards, downwards and laterally. A soft, diffused and nonpulsatile mass was palpable in the upper medial quadrant of the orbit. It could be pushed back when the eyeball would displace more forwards and downwards. The cranial nerves, visual fields and fundi were normal.
Vision in the right eye was 6/6 and nothing abnormal was detected in that eye.
X'ray examinations of the skull, the left orbit and of the long bones revealed no abnormality. Blood tests for venereal diseases were negative. Urine was normal. Total white blood cell count 8000, Polymorphs 63, Lymphocytes 33, Eosinophiles 3, Mononuclears 1. Total red blood cells were 3 million per c. mm. Haemoglobin 8.5 grams, platelets 286,00 per c.mm. Total proteins 6.5 grams, of which albumin was 3.66 grams, globulin 0.40 grams, alpha 0.74, beta 0.4, gamma 1.3 gms. Lymph glands were not enlarged.
Since the tumour was slowly growing, soft but not cystic and was opaque to transillumination and as there was no evidence of inflammation, like pain, tenderness or adhesions to surrounding structures, it was suspected to be a lymphoma or angioma. With our previous experience of having seen lymphomas constantly occupying the upper part of the orbit we arrived at our clinical diagnosis of lymphoma in this case.
Under general anaesthesia, anterior orbitotomy was done. A pale lobulated soft mass filled up the orbital cavity. A portion of it was exised. On pathological examination it was found to be a lymphoma (Plate 7)-[Figure - 7]. After protecting the cornea, deep X'rays of five thousand Roentgen units were given to the tumour through the upper quadrant. The proptosis regressed completely. Vision improved to 6/9. The fundus and fields were normal.
II. A male aged fifty years was admitted for proptosis of the right eye of three months' duration. It was gradual, painless and without loss of vision (Plate 8)-[Figure - 8].
Vision in the right eye was 6/6. There was fullness at the supraorbital margin with mechanical ptosis. The eyeball was pushed slightly forwards and downwards. A soft diffused and non-pulsatile mass could be palpated in the upper quadrant and could be pushed back into the orbit. The fundus and fields were normal. (Plate 8)-[Figure - 8].
The left eye vision was 6/6, and no abnormality was detected.
Skiagrams of the skull and right orbit were normal.
Blood test for venereal disease was negative. Total white blood cells were 8000 per c.mm., polymorphs 64, lymphocytes 34, and eosinopheles 2. No abnormal cells were detected. Urine analysis normal. Lymph glands, liver and spleen were not enlarged.
A clinical diagnosis of lymphoma was made on the same lines as in the previous case.
Under general anesthesia through an anterior orbitotomy the tumour was excised by Dr. T. T. Ramalingam. The mass was pale, lobulated and soft. Histopathological examination of the excised tumour proved it to be a lymphoma.
Since the entire mass was excised the patient was not submitted to radiotherapy. After the operation the proptosis receded and the vision remained 6/6 and the fundus and fields normal.
According to Stout's (1942) classification, lymphomatous tumours are divided into lymphocytic-cell type and giant follicular type. In addition Hodgkins disease and lymphatic leukemia are included. The cases reported here were of the lymphocytic cell type. In the first case the tumour resolved under radio therapy and in the second case it was completely excised.
| III. Caveronous Angioma of Orbit|| |
A male aged 52 years was treated for schizophrenia in a mental hospital. He was referred to the ophthalmic hospital for proptosis of his right eye. It was of six years' duration, gradual and painless. He had hemoptysis, one year back. His parents had died of pulmonary tuberculosis when he was a small boy.
The right eve vision was 6/18. The eyeball was proptosed forwards and upwards- A localised mass was sandwiched between the globe and floor of the orbit. It was palpable through the lower fornix, and was firm in consistency, not pulsatile, not reducible, and it extended posteriorly behind the globe. A few dilated vessels were seen in the lower fornix. In the lower quadrant movements of the globe were limited due to the mass. The fundus and fields were normal.
The left eye vision was 6/6. The rondos and fields were normal.
X'ray examination of the skull, right orbit and lung revealed no abnormality.
Total W. B. C. count was 7,200/ cmm., Polymorphs 64% Lymphocytes 33%, Eosinophiles 2%, Monocytes 1%. Blood test for venereal disease was negative.
A provisional diagnosis of chronic granuloma of the right orbit was made. A biopsy was attempted under general anesthesia. During induction with ethylchloride and ether the patient coughed out blood and the operation was postponed. Fearing tuberculosis. he was sent for a check up but was found to he free from tuberculous infection.
Biopsy was done under local anesthesia. On incising the orbital septum, a chocolae coloured mass, well-encapsulated, with dilated blood vessels on its surface, suggestive of angioma was seen. A portion was excised after applying a purse string suture. There was frank bleeding which was controlled by tightening the suture and with hot packs. Within four weeks the proptosis was completely reduced and vision improved to 6/9. The pathologist described the section as one of a cavernous angioma. (Plate 9)-[Figure - 9].
Cavernous angioma is more often noted in the older age group than haemangiomas in general. In this case the tumour occupied the apex and floor of the orbit, as stated by Byers (1924) that the muscle cone is the commonest site for cavernous angioma. Reese (1951) has stated that the thickness of the capsule may influence the consistency of the tumour and the ease with which it can be excised. In this case the tumour was firm in consistency sshieh was mistaken for granuloma and the leak from the angioma was mistaken for haemoptysis. Probably the leak occured from the pterygoid plexus of veins into the nasopharynx due to hack pressure from the cavernous angioma through the inferior orbital veins. The increased pressure could have been caused by either mechanical pressure on the application of the face mask or by increased venous pressure during induction of anaesthesia with ether, when the patient was struggling and holding the breath.
| Summary|| |
Five cases of uniocular proptosis are described. Two were of Aneurysm of opthalmic artery with angiomatous mass in the orbit, two were of Lymphoma orbit and one was of cavernous angioma of the orbit.
I thank Dr. B. Ramamoorthy the neurosurgeon. Govt. General Hospital Madras and his assistants for all the help and cooperation. I thank Dr. T. T. Ramalingam the superintendent of Govt. Ophthalmic Hospital for permitting me to report his cases. I thank Kumaradevan for the clinical photographs.
| References|| |
|1.||Byers W. G. M. (1924) quoted in 4. p. 413. |
|2.||Duke. Elder Sir J. W. (1961) System of Ophthalmology, Vol. It. Henry Kimpton, London. p. 478. |
|3.||Reese A. B. (1951) Tumours of the Eye. 2nd edition. Paul B. Hoeber Inc. New York. p. 412. |
|4.||Sorby A. (1958) Systemic Ophthalmology. 2nd edition. Butterworth and Co. Ltd. London pp. 526, 580. 581. |
|5.||Stout A. P. (1942) as quoted in 4. p. 453. |
|6.||Sugar and Meyer (1940) as quoted in 4. p 956 |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]