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ARTICLE
Year : 1964  |  Volume : 12  |  Issue : 4  |  Page : 160-165

Uniocular proptosis


Ophthalmic Hospital, Madras, India

Date of Web Publication13-Feb-2008

Correspondence Address:
E Balkrishnan
Ophthalmic Hospital, Madras
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Balkrishnan E. Uniocular proptosis. Indian J Ophthalmol 1964;12:160-5

How to cite this URL:
Balkrishnan E. Uniocular proptosis. Indian J Ophthalmol [serial online] 1964 [cited 2020 Oct 20];12:160-5. Available from: https://www.ijo.in/text.asp?1964/12/4/160/39093

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 Top


(2 cases)

I

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]

Examination

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].

Investigations

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].

Treatment

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.

II

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.

Examination

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.

Investigations

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.

Treatment

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.

Examination

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.

Comment

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) Top


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.

Investigations

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].

Examination

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.

Treatment

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.

Comment

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 Top


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.

Investigations

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].

Comment

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.[6]


  Summary Top


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 Top

1.
Byers W. G. M. (1924) quoted in 4. p. 413.  Back to cited text no. 1
    
2.
Duke. Elder Sir J. W. (1961) System of Ophthalmology, Vol. It. Henry Kimp­ton, London. p. 478.  Back to cited text no. 2
    
3.
Reese A. B. (1951) Tumours of the Eye. 2nd edition. Paul B. Hoeber Inc. New York. p. 412.  Back to cited text no. 3
    
4.
Sorby A. (1958) Systemic Ophthal­mology. 2nd edition. Butterworth and Co. Ltd. London pp. 526, 580. 581.  Back to cited text no. 4
    
5.
Stout A. P. (1942) as quoted in 4. p. 453.  Back to cited text no. 5
    
6.
Sugar and Meyer (1940) as quoted in 4. p 956  Back to cited text no. 6
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]



 

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