Proptosis
Background
- Proptosis (exophthalmos) is forward displacement of the eye from the orbit
- In the ED, the key concern is distinguishing emergent causes requiring immediate intervention from non-emergent etiologies
- Unilateral acute proptosis with pain, vision loss, or elevated IOP is an emergency — consider retrobulbar hemorrhage, orbital cellulitis, or cavernous sinus thrombosis
- Bilateral proptosis is most commonly Graves' disease
- Retrobulbar hemorrhage with elevated IOP requires emergent lateral canthotomy
Clinical Features
Proptosis in a woman with retrobulbar abscess and orbital cellulitis.
History
- Unilateral vs. bilateral
- Onset: acute (hours — retrobulbar hemorrhage, orbital cellulitis) vs. subacute (days — infection, inflammatory) vs. chronic (weeks-months — thyroid, tumor)
- Pain: severe with infection, hemorrhage, or inflammation; painless suggests tumor or thyroid
- Vision changes, diplopia
- Recent trauma or surgery (retrobulbar hemorrhage)
- Fever (orbital cellulitis, cavernous sinus thrombosis)
- Recent sinusitis or dental infection (orbital cellulitis)
- Known thyroid disease
- Immunosuppression, diabetes (mucormycosis risk)
Physical Exam
- Visual acuity (each eye) — decreased acuity indicates optic nerve compromise
- Pupillary exam: RAPD (afferent pupillary defect) indicates optic nerve compression
- Extraocular movements: restricted in orbital cellulitis, cavernous sinus thrombosis, retrobulbar process
- Intraocular pressure (IOP measurement) — elevated >40 mmHg with tense orbit suggests retrobulbar hemorrhage
- Resistance to retropulsion (push gently on closed eyelid — firm/tense orbit is abnormal)
- Assess for chemosis (conjunctival swelling), periorbital edema, erythema
- Fundoscopy: look for optic disc edema, retinal vessel pulsations
- Cranial nerves III, IV, VI (affected in cavernous sinus thrombosis)
- Nasal exam for black eschar (mucormycosis)
Red Flags
- Acute onset with vision loss — retrobulbar hemorrhage (needs emergent canthotomy)
- IOP >40 mmHg with RAPD — retrobulbar hemorrhage
- Fever + proptosis + pain with eye movement — orbital cellulitis
- Bilateral proptosis + CN palsies + fever — cavernous sinus thrombosis
- Immunocompromised + necrotic nasal tissue — mucormycosis
- Pulsatile proptosis with bruit — carotid-cavernous fistula
Differential Diagnosis
Emergent
- Retrobulbar hemorrhage (post-traumatic or post-surgical)
- Orbital cellulitis (frequently from adjacent sinusitis)
- Cavernous sinus thrombosis (bilateral cranial nerve palsies, septic appearance)
- Mucormycosis (immunocompromised, diabetic ketoacidosis)
Urgent
- Carotid-cavernous fistula (pulsatile proptosis, orbital bruit, chemosis)
- Orbital abscess (complication of orbital cellulitis)
- Orbital hematoma (trauma)
Subacute/Chronic
- Graves' disease (most common cause of bilateral proptosis; can be unilateral)
- Orbital tumors (lymphoma, rhabdomyosarcoma in children, meningioma, metastases)
- Orbital pseudotumor (idiopathic orbital inflammation)
- Orbital fractures with soft tissue swelling
Periorbital swelling
Proptosis
- Normal IOP
- Orbital cellulitis
- Orbital pseudotumor
- Orbital tumor
- Increased IOP
- Retrobulbar abscess
- Retrobulbar emphysema
- Retrobulbar hemorrhage
- Ocular compartment syndrome
- Orbital tumor
No proptosis
- Periorbital cellulitis/erysipelas
- Dacryocystitis (lacrimal duct)
- Dacryocele/Dacryocystocele
- Dacryostenosis
- Dacryoadenitis (lacrimal gland)
- Allergic reaction
- Nephrotic Syndrome (pediatrics)
Lid Complications
- Blepharitis (crusts)
- Chalazion (meibomian gland)
- Stye (hordeolum) (eyelash folicle)
Other
- Subperiosteal abscess
- Orbital abscess
- Cavernous sinus thrombosis
- Conjunctivitis
- Contact dermatitis
- Herpes zoster
- Herpes simplex
- Sarcoidosis
- Granulomatosis with polyangiitis
Evaluation
Bedside
- Visual acuity
- IOP measurement (see Tono-Pen use)
- Pupillary exam for RAPD
- Extraocular movements
- POCUS: may identify retrobulbar hemorrhage or abscess
Imaging
- CT orbits with contrast (and maxillofacial cuts): primary imaging modality
- Evaluates for retrobulbar hemorrhage, orbital abscess, sinusitis, fracture, foreign body, mass
- CT angiography if vascular cause suspected (carotid-cavernous fistula)
- MRI/MRV: better for cavernous sinus thrombosis, tumor characterization, optic nerve evaluation (non-emergent)
Laboratory
- CBC, BMP, blood cultures if infection suspected
- ESR, CRP for inflammatory process
- TSH, free T4 if Graves' disease suspected
- HbA1c, glucose if mucormycosis concern (often in DKA patients)
- Coagulation studies if on anticoagulation
Management
Retrobulbar Hemorrhage
- Emergent lateral canthotomy and cantholysis — do not delay for imaging if clinical diagnosis is clear (tense orbit, elevated IOP >40, RAPD, vision loss)
- This is a bedside procedure that can be sight-saving
- Ophthalmology consultation (but do not delay canthotomy for consult)
Orbital Cellulitis
- IV antibiotics: broad-spectrum coverage for sinusitis-related pathogens
- Typical regimen: vancomycin + ceftriaxone +/- metronidazole (or ampicillin-sulbactam)
- Ophthalmology and ENT consultation
- Surgical drainage if subperiosteal or orbital abscess identified on CT
- See Orbital cellulitis for detailed management
Cavernous Sinus Thrombosis
- IV antibiotics (similar to orbital cellulitis)
- Anticoagulation is controversial; consider hematology consultation
- ICU admission
Mucormycosis
- Amphotericin B (liposomal preferred)
- Emergent ENT consultation for surgical debridement
- Correct underlying metabolic derangement (DKA)
- High mortality — aggressive early treatment essential
Graves' Disease
- If mild: artificial tears, head-of-bed elevation, sunglasses
- If sight-threatening (compressive optic neuropathy): high-dose IV corticosteroids, urgent ophthalmology
- Endocrinology referral
Disposition
Admit
- Retrobulbar hemorrhage (post-canthotomy monitoring)
- Orbital cellulitis requiring IV antibiotics
- Cavernous sinus thrombosis (ICU)
- Mucormycosis (ICU)
- Any vision-threatening proptosis
Discharge
- Chronic Graves' ophthalmopathy without acute vision changes — arrange ophthalmology and endocrinology follow-up
- Mild preseptal cellulitis (NOT orbital) — oral antibiotics with close follow-up in 24-48 hours
- Return precautions: vision changes, worsening pain, fever, increasing swelling