|Year : 2017 | Volume
| Issue : 3 | Page : 149-154
Clinical analysis of proptosis in a tertiary care hospital of South India
Soujanya Kaup1, HT Venkategowda2
1 Department of Ophthalmology, Yenepoya Medical College, Yenepoya University, Mangalore, Karnataka, India
2 Department of Ophthalmology, Adichunchanagiri Institute of Medical Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||9-Aug-2017|
2-98/11, “Shreeshaila,” Gurunagar, Maryhill, Mangalore - 575 008, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Comprehensive data on various etiologies of proptosis is a necessity in guiding the ophthalmologists and physicians for early diagnosis and treatment.
AIMS: This study aimed to describe the clinical presentation, spectrum of etiology, treatment modality, and outcome among patients with proptosis.
Settings And Design: A longitudinal study was conducted in the department of ophthalmology of a tertiary care hospital, Karnataka, from December 2010 to December 2011.
Participants And Methods: All the study participants who satisfied inclusion and exclusion criteria were interviewed with a pretested and validated schedule. Detailed clinical evaluation of proptosis was done after obtaining informed consent. Every case was followed up till the end of treatment.
Statistical Analysis Used: Data were analyzed using Statistical Package for Social Sciences for Windows, Version 16.0. (SPSS Inc., Chicago, IL, USA). Results were expressed as frequencies and proportions for categorical variables and mean and standard deviations for continuous variables.
Results: Fifty patients completed the study and nearly half were in the age group of 41–60 years. Axial proptosis was the most common type. Nearly one-third required surgical treatment and was significantly high (P < 0.01) in neoplastic proptosis. More than one-third resolved completely.
Conclusions: Thyroid eye disease and other inflammatory disorders were the major etiology of proptosis. Extremes of age and unilaterality and eccentricity of proptosis clearly distinguish neoplastic causes from that of inflammatory. Considering the diverse etiology of the diseases causing proptosis, definitive management varies accordingly. The site of lesion causing proptosis is of prognostic value during orbitotomies with higher complications occurring with intraconal lesions.
Keywords: Etiology, orbitotomy, outcome, proptosis
|How to cite this article:|
Kaup S, Venkategowda H T. Clinical analysis of proptosis in a tertiary care hospital of South India. Int J Health Allied Sci 2017;6:149-54
|How to cite this URL:|
Kaup S, Venkategowda H T. Clinical analysis of proptosis in a tertiary care hospital of South India. Int J Health Allied Sci [serial online] 2017 [cited 2018 Mar 17];6:149-54. Available from: http://www.ijhas.in/text.asp?2017/6/3/149/212586
| Introduction|| |
Proptosis describes an abnormal protrusion of the globe., The anatomical position of the orbits, their relative inaccessibility, and variety of lesions giving rise to proptosis make it a difficult yet interesting problem.
Orbital surgery has become safer owing to advances in diagnostic instrumentation and surgical techniques. Although over the years many authors have assessed proptosis and its causes, there exists a disparity in the incidence of reported lesions. Comprehensive data on etiologies of proptosis is a necessity in guiding ophthalmologists toward clinical suspicion for early diagnosis and treatment.
| Participants and Methods|| |
This longitudinal study was conducted in the department of ophthalmology of a tertiary care hospital, Karnataka, from December 2010 to December 2011. The study hospital is attached to a medical college and research institute, which is recognized by the Medical Council of India with facility to teach Ophthalmology for both under- and post-graduates.
The study sample comprised patients with proptosis who presented at ophthalmology outpatient department and inpatients referred from other departments of the study hospital.
Cases of pseudoproptosis, debilitated and bedridden patients, uncooperative, and those who were not willing to participate were excluded from the study.
All the study participants who satisfied inclusion and exclusion criteria were interviewed with a pretested and validated schedule, and clinical evaluations of proptosis were done, after taking informed consent. Every case was followed till the end of treatment.
Clinical evaluation included detailed history (including onset, duration, and rate of progression of proptosis), visual acuity, color vision, pupillary reaction, extra-ocular movements, intraocular pressure, slit-lamp biomicroscopy, and fundoscopy. The amount of proptosis was measured using Luedde's exophthalmometer and was graded as mild (21–23 mm), moderate (24–27 mm), and severe (28 mm or more). Proptosis was classified as axial or eccentric depending on the direction of proptosis. Other specific tests such as Valsalva maneuver, testing for ocular pulsations, and auscultation for bruit were done. Routine blood investigations were done in all cases. Radiological investigations of the orbit were done and results were noted. Histopathological study including fine-needle aspiration cytology of the orbital swelling and excision biopsy were done in relevant cases. Other selective investigations included T3, T4, and thyroid-stimulating hormone levels. ENT surgeon and neuro-surgical opinion was obtained and evaluated in relevant cases.
Final diagnosis was based on clinical, histopathological, laboratory, and radiological findings. Based on the final diagnosis, treatment was planned. Cases which required further evaluation and management were referred to higher centers and patients were asked to follow-up, after the management at higher centers.
Data were analyzed using Statistical Package for the Social Sciences for Windows, Version 16.0. (SPSS Inc., Chicago, IL, USA). Results were expressed as frequencies and proportions for categorical variables and mean and standard deviations for continuous variables. Pearson's Chi-squared test was applied to capture the gender- and etiology-wise differences in proportions of proptosis across outcome variables. Yates's Chi-squared test was considered if more than 20% of the cells had an expected count of <5. A two-sided P< 0.05 was considered statistically significant.
Institutional Review Board and Ethics Committee of Rajiv Gandhi University of Health Sciences, India, approved the study protocol. Informed written consent was taken from all the study participants in local language Kannada.
| Results|| |
A total of 56 cases satisfying study criteria were included in the study; however, 6 of them did not complete the study and therefore, attrition rate was 10.7% and attritions were excluded from the analysis. Out of the fifty study participants, 64% (n = 32) were males. Mean ages of males and females were 42.2 ± 16.2 and 43.6 ± 18.9 years, respectively (range: 9–77 years). Gender-wise differences in mean ages were statistically nonsignificant (P = 0.785). Majority (46%) of patients with proptosis were in the age group of 41–60 years [Table 1]. Four patients were aged <13 years.
|Table 1: Age- and gender-wise distribution of study participants with proptosis in a tertiary care hospital (n=50)|
Click here to view
[Table 2] shows the various etiologies of proptosis among the study participants. Thyroid eye disease (n = 21, 42%) and orbital cellulitis (n = 10, 20%) were the most common etiologies. Nearly two-third (64%) of the patients presented with unilateral proptosis. Axial proptosis was the most common type (76%) [Table 3]. Almost equi-proportional distribution was seen in laterality and duration of proptosis presentation. More than half of the proptosis were mild (21–23 mm). Nearly one-third of males and one-fourth of females required surgical treatment. Gender-wise differences across various clinical parameters of proptosis were statistically nonsignificant (P > 0.05) [Table 3].
|Table 2: Etiology of proptosis among study participants in a tertiary care hospital (n=50)|
Click here to view
|Table 3: Gender-wise variations in clinical features, etiology, and treatment modality of proptosis among study participants in a tertiary care hospital (n=50)|
Click here to view
In the present study, neoplasms constituted 26% (n = 13) of all the cases. Of these, 69.2% (n = 9) were benign and 30.8% (n = 4) were malignant. Neoplastic proptosis displayed bimodal age distribution, i.e., <20 and >60 years. Thyroid eye disease was quite common in 20–60 years' age group. Other inflammatory causes predominated in 40–60 years' age group [Figure 1]. All the neoplastic proptosis were unilateral. Significantly (P < 0.05) a higher proportion of neoplastic proptosis were eccentric when compared to thyroid and other inflammatory causes [Table 4]. Among neoplastic proptosis, lacrimal gland tumor and cavernous hemangioma were the common etiologies.
|Table 4: Clinical features and treatment modality according to etiology of proptosis in a tertiary care hospital (n=50)|
Click here to view
Over one-third (n = 15) of the proptosis required surgical treatment. Proportion of proptosis requiring surgical treatment was statistically significantly high (P < 0.01) in neoplastic group. Orbital cellulitis with retained intraocular foreign body, intraorbital abscess, and fronto-ethmoidal mucocele were the nonneoplastic proptosis that needed surgical treatment (n = 4). Orbitotomy [Figure 2] was the most common surgery performed followed by exenteration [Figure 3] and frontoethmoidectomy. Visual loss (n = 1), extra-ocular movement restriction (n = 2), and ptosis (n = 1) were the complications observed following orbitotomy. Observed proportional differences of proptosis in other outcome variables such as duration and severity of presentation were statistically insignificant (P > 0.05).
|Figure 2: Patient with axial proptosis with intraconal mass – Schwannoma – who underwent lateral orbitotomy|
Click here to view
|Figure 3: Patient with mucoepidermoid carcinoma of lacrimal gland who underwent exenteration|
Click here to view
More than one-third of proptosis (38%) resolved completely. Although 44% of the patients did not show improvement in proptosis, they became symptomatically better. Almost one in every ten patients who underwent surgery developed surgery-related complications. About 4% of them resolved with sequel and the remaining 6% were referred to higher center for management.
| Discussion|| |
Despite low incidence, ocular proptosis needs a special mention and detailed evaluation owing to its unfavorable outcome including loss of vision and death. A wide range of local and systemic conditions have been enlisted as causes of proptosis. Familiarity with common conditions in their local setting would obviously aid the ophthalmologists in clinical diagnosis. In this regard, this longitudinal study was conducted to provide comprehensive data on proptosis in local setting.
Overall in this study, inflammatory orbital disorders (thyroid eye disease and other inflammatory diseases) were the major etiology of proptosis. Age group of 20–60 years was most commonly affected with steady decline in extreme ages. These findings are corroborated by the studies conducted by Dallow et al., Rootman, Henderson's orbital series, Wilson and Grossniklaus, and Mallajosyula. On the contrary, extremes of age (<20 and > 60 years) and unilaterality and eccentricity of proptosis are more likely to have neoplastic etiology. Similar to our study, bimodal distribution and benign nature of neoplasms were described by Dallow et al. and Rootman.,
Available evidences suggest that thyroid eye disease causing proptosis peaks in the middle age and has a female dominance., Mallajosyula  also showed that inflammatory diseases constituted 37.1% of the orbital diseases in Indian population. However, this female dominance decreases with age. Lack of association of proptosis with female gender in this study could be explained by higher mean age of the patients (60% were aged 40 years and above) and relatively small study sample. Temporal onset of proptosis is a good indicator of etiology. In this study, acute, subacute, and chronic onsets were dominated by inflammatory, neoplastic, and thyroid eye diseases, respectively. Similar temporal onset was reported by Rootman.
According to this study and study by Krásný et al. orbitotomy and exenteration appear to be the common surgical approaches for proptosis. Vision can be threatened after orbital surgery due to direct or surgical damage to optic nerve. One case of postoperative loss of vision in our study was due to compressive optic neuropathy. Bonavolontà  noted postoperative blindness of 0.44% out of 1593 cases. In the present study, all the complications occurred while operating for intraconal tumors. Purgason and Hornblass  and Salem and Qahtani  also reported that location of the tumor appeared to be the most crucial factor associated with complications of orbital tumor surgeries.
| Conclusions|| |
In the local study setting, corroborating with other studies, thyroid eye disease and other inflammatory disorders were the major etiology of proptosis. Extremes of age and unilaterality and eccentricity of proptosis clearly distinguish neoplastic causes from that of inflammatory. This study reaffirms that detailed history and clinical evaluation give valuable hints to the etiology of proptosis. Considering the diverse etiology of the diseases causing proptosis, definitive management varies accordingly. In patients requiring orbitotomy, the site of the lesion can have a prognostic significance, with intraconal lesions having higher complication rate.
Relatively small study sample and only one tertiary care hospital as source of data may question the external validity of the findings. Investigation such as thyroid auto-antibodies could not be done due to nonavailabilty in the study setting and paucity of the funds. Nonetheless, it provides valuable information to doctors in local setting regarding proptosis to streamline the investigations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Karcioglu ZA. Clinical evaluation of the orbit. In: Orbital Tumors: Diagnosis and Treatment. New York: Springer Science Business Media; 2005.
Sihota R, Tandon R. Diseases of the orbit. In: Parson's Diseases of the Eye. 20th
ed. Philadelphia: Elsevier; 2007.
Mohan H, Gupta AN. Proptosis – A clinical analysis of 141 cases. J All India Ophthalmol Soc 1968;16:91-7.
Dutton JJ. Orbital diseases. In: Yanoff M, Duker JS, editors. Ophthalmology. 2nd
ed. Philadelphia: Elsevier; 2004.
Dallow RL, Pratt SG, Green JP. Approach to orbital disorders and frequency of disease occurrence. 2nd
ed. In: Albert and Jakobiec's Principles and Practice of Ophthalmology. Philadelphia: WB Saunders; 2000.
Kanski JJ, Bowling B. Orbit. In: Clinical Ophthalmology: A Systematic Approach. 7th
ed. Philadelphia: Elsevier; 2011.
Rootman J. Distribution and differential diagnosis of orbital diseases. In: Diseases of Orbit. 2nd
ed. Philadelphia: JB Lippincott; 1988.
Henderson JW, Farrow GM. Frequency of Orbital Diseases. 3rd
ed. New York: Revan Press; 1994.
Wilson MW, Grossniklaus HE. Orbital diseases in North America. Ophthalmol Clin North Am 1996;9:539-47.
Mallajosyula S. Clinical approach to proptosis. In: Surgical Atlas of Orbital Diseases. 1st
ed. New Delhi: Jaypee Brothers Medical Publishers; 2009.
Krásný J, Sach J, Brunnerová R, Konvicka J, Jankovská M, Srp A, et al.
Orbital tumors in adults – A 10-year study. Cesk Slov Oftalmol 2008;64:219-27.
Bonavolontà G. Postoperative blindness following orbital surgery. Orbit 2005;24:195-200.
Purgason PA, Hornblass A. Complications of surgery for orbital tumors. Ophthal Plast Reconstr Surg 1992;8:88-93.
Salem M, Qahtani F. Risk factors associated with complications of orbital surgery in children. J Pediatr Ophthalmol Strabismus 2001;38:335-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]