|Year : 1968 | Volume
| Issue : 2 | Page : 91-97
Proptosis - a clinical analysis of 141 cases
Hari Mohan1, AN Gupta2
1 Department of Ophthalmology, Irwin Hospital, India
2 Department of Ophthalmology, Safdarjang Hospital, India
Department of Ophthalmology, Irwin Hospital
|How to cite this article:|
Mohan H, Gupta A N. Proptosis - a clinical analysis of 141 cases. Indian J Ophthalmol 1968;16:91-7
The anatomical position of the orbits, their relative inaccessibility for clinical examination and the variety of lesions that can involve them giving rise to proptosis make it a difficult yet interesting problem not only to he ophthalmologist but also to the neurosurgeon, the rhinologist and the internist. There is a gross disparity as to the incidence of various lesions reported in different studies. This is primarily due to variable approach to the subject. Thus in pathological studies REESE (1951), in 355 cases, found haemangioma to be the most frequent lesion in contradiction to FORREST (1949) who reported mixed tumour of lacrimal gland as the commonest orbital tumour in 222 cases.
In radiological studies the reports of PFEIFFER (1943), 200 cases, and BULLOCK AND REEVES (1959), 138 cases, are amongst the largest in the series. Mucocele was the commonest etiological cause noted in both these studies - a cause not noted at all in either of the pathological series. Reports from the neurosurgeons attributed meningioma as the commonest cause (DANDY, 1941, and von BUREN PAPPEN and Horax 1957).
O'BRIEN AND LEINFELDER (1934) from the medical records of University of Iowa found malignant neoplasms to be the commonest cause of unilateral proptosis whereas SCHULTZ, RICHARDS AND HAMILTON (1961) from the same institution found endocrine exophthalmos as the commonest cause. DRESCHER AND BENEDICT (1950) from Myo Clinic also found `exophthalmic goitre' as the commonest cause in 177 cases of proptosis. MOSS (1962) reporting on 230 cases of expanding lesions of the orbit found `exophthalmic ophthalmopathy' as the commonest cause closely followed by haemangioma. DAS (1963) reporting on the primary tumours of the orbit found mixed tumour of Lacrimal gland and dermoid cysts as the commonest tumours.
| Present study|| |
One hundred forty one cases of proptosis which had been seen in the past 5 years at Irwin Hospital, New Delhi have been analysed. The diagnosis was made by clinical, radiological and laboratory examinations confirmed histologically in a large majority of these cases. The cases were divided into 3 age groups i.e. the paediatric age group (from birth to 15 years age), the adult age group (from 16 years to 50 years age) and the elderly age group (above 50 years age). The first group had 42 cases, the second group 84 cases and the third 15 cases.
In the paediatric age group [Table - 1] though all cases of retinoblastoma had not been included they still formed a large majority (38%) leading to proptosis. The next in order of frequency in this group were benign neoplasms with angiomatous tumours heading the list followed by haemopoietic system tumours, inflammatory granulomata and metastatic deposits.
In the adult age group [Table - 2] the malignant primary orbital tumours headed the list forming about 29% of cases closely followed by benign tumours (20%). The tumours from the nose, nasopharynx and paranasal sinuses which were conspicious by their absence in the pediatric age group formed about 16% of cases in this group. Inflammatory and traumatic lesions leading to proptosis in this group were approximately twice and 1½ times commoner respectively than in the first group. In 4 cases (4.8%) no definite diagnosis could be made.
In the elderly age group [Table - 3] the main bulk of cases were those of malignant tumours (60%) either from the orbit or from the adjoining region i.e. nose and para-nasal sinuses. Inflammatory granulomata accounted for 20% of cases and 2 cases (13.3%) remained undiagnosed.
Overall, primary malignant neoplasms accounted for a large majority (36%) of cases of proptosis. The next in order of frequency were benign orbital tumours (19%), Secondary extension of malignant growth from paranasal sinuses (12%) metastases in the orbit (5%) cysts (3.5%) and trauma (2.8%). Other causes such as endocrinal disorder, vascular disease, lipodystrophy and craniostenosis constituted about 4% of cases. In 6 cases (4%) no exact diagnosis could be made.
The management of specific groups of lesions in these cases and the result of treatment have been summarized in [Table - 5],[Table - 6],[Table - 7],[Table - 8],[Table - 9],[Table 10],[Table 11] and [Table 12].
| Discussion|| |
The disparity in the reported incidence of various causes of proptosis are attributable to variations in the approach to the subject. The diagnosis of space-occupying lesions of the orbit may be made clinically, radiologically or surgically (lateral and anterior orbitotomy by the ophthalmologist and transfrontal orbitotomy by the neurosurgeon) with or without histological examination. The anatomical situation of the orbits results in lesions which are of interest to neurosurgeon as well as rhinologist. Thus the different series by various investigators are bound to be subject orientated and unbalanced.
The present series is conspicious by the exceptionally low incidence of endocrine exophthalmos. It is because these cases are usually referred to ophthalmologists by the internist and vice versa and so are lost from the ophthalmic records.
As regards the management, inflammatory cases and benign orbital neoplasms were most amenable to satisfactory treatment, medical or surgical while malignant primary tumours if detected early could be eradicated with fair chances of success. Surgically results were more encouraging in cases of retinoblastoma, glioma of optic nerve and lacrimal gland tumours than in other highly malignant and infiltrative growths where deep x-ray therapy was the only possible recourse for palliative and temporary improvement. Anterior orbitotomy with ethmoidectomy was the most satisfactory approach for anteriorly situated neoplasms. Kronlein's approach was found most suitable for tumours situated behind the eyeball and lateral to the optic nerve while transfrontal approach gave better accessibility for tumours situated medial to the optic nerve while transfrontal approach gave better accessibility for tumours situated medial to the optic nerve or extending intracranially. Palliative decompression of the orbit (Naffzieger's operation) through this route was found most effective.
Thus in surgical management our single procedure cannot be adjudged as good or bad since the approach depends on the site of origin, the location and the extension of the growth.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9]