An Algorithmic Approach in Diagnosis and Management of Proptosis: Demographic Patterns, Frequency and Aetiology of Proptosis

Aisha Rafique; Syeda Alishba Zehra; Ammarah Ashraf; Ubaid Ullah Yasin; Abid Hassan Naqvi

doi:10.51253/pafmj.v76iSUPPL-6.14074

Authors

Aisha Rafique Department of Ophthalmology, Armed Forces Institute of Ophthalmology/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Syeda Alishba Zehra Department of Ophthalmology, Foundation University, Rawalpindi Pakistan
Ammarah Ashraf Department of Ophthalmology, Armed Forces Institute of Ophthalmology/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Ubaid Ullah Yasin Department of Ophthalmology, Armed Forces Institute of Ophthalmology/National University of Medical Sciences (NUMS), Rawalpindi Pakistan
Abid Hassan Naqvi Department of Ophthalmology, Armed Forces Institute of Ophthalmology/National University of Medical Sciences (NUMS), Rawalpindi Pakistan

DOI:

https://doi.org/10.51253/pafmj.v76iSUPPL-6.14074

Keywords:

Algorithmic Approach, Hertel, Proptosis, Thyroid.

Abstract

Objective: To evaluate the demographic patterns, frequency, and etiological profile of proptosis in patients presenting to a tertiary care eye hospital, and to develop an algorithmic approach for its diagnosis and management.

Study Design: Cross-sectional study.

Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi Pakistan, from Aug 2024 to Aug 2025.

Methodology: Two hundred participants presenting with proptosis over one year were divided into two age groups: 0-30 years, and 30 years and above. All patients underwent detailed ophthalmological examinations, including a comprehensive proptosis assessment, neuroimaging correlation, and systemic evaluation. Data collected included age, gender, visual acuity, pupil response, diplopia, laterality, symptom duration, clinical features, imaging findings, and final diagnosis. An evidence-based diagnostic and management algorithm was developed and implemented to streamline clinical decision-making.

Result: Of 200 patients with proptosis, 170(85%) were males and 30(15%) were females. Fifty (25%) were under 30 years of age, while 150(75%) were aged above 30 years. Aetiology comprised endocrinological causes 40(20%), followed by inflammatory 36(18%), systemic 34(17%), arteriovenous malformation 30(15%), pseudo-proptosis 28(14%), infective 26(13%), and idiopathic 6(3%). Surgical intervention was indicated in 68(34%) of patients, while conservative management was employed in 118(59%). Patients underwent both surgical and conservative treatments comprised 14(7%).

Conclusion: Endocrinological, inflammatory, and systemic causes were most frequently identified. The suggested diagnostic and management algorithm demonstrated effectiveness in facilitating efficient clinical decision-making.

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References

1. Kikkawa DO, Pornpanich K, Cruz RC Jr, Levi L, Granet DB. Graded orbital decompression based on severity of proptosis. Ophthalmology 2002; 109(7): 1219-1224.

https://doi.org/10.1016/S0161-6420(02)01068-0

2. Salmon JF. Kanski’s Clinical Ophthalmology: A Systematic Approach. 9th ed. Elsevier Health Sciences; 2019. Available from:

https://www.elsevier.com/books/kanskis-clinical-ophthalmology/salmon/978-0-7020-7711-1

3. Zahir SI, Khan MU, Ahmad M, Hussain I, Hamayun J. Etiological pattern, clinical presentation and outcome of patients with proptosis in a tertiary care hospital. Pak Armed Forces Med J 2023; 72(6): 2113-2116.

https://doi.org/10.51253/pafmj.v72i6.6097

4. Bartalena L, Gallo D, Tanda ML, Kahaly GJ. Thyroid eye disease: epidemiology, natural history, and risk factors. Ophthalmic Plast Reconstr Surg 2023; 39(6S): S2-8.

https://doi.org/10.1097/IOP.0000000000002467

5. Heller RS, David CA, Heilman CB. Orbital reconstruction for tumour-associated proptosis: quantitative of postoperative orbital volume and final eye position. J Neurosurg 2019; 132(3): 927-932. https://doi.org/10.3171/2018.12. JNS181385

6. Manzoor A, Taimur F, Saad M, Ahmad S, Tahir F, Khan S. Frequency And Unusual Clinical Manifestation Of Orbital Xanthogranulomas: An Overview. J Rawalpindi Med Coll 2024: 28(3). https://doi.org/10.37939/jrmc.v28i3.2516

7. Nair GR, Senthil MS. Evaluation of orbital volume in unilateral orbital fracture using computed tomography. Natl J Maxillofac Surg 2022; 13(2): 223-228.

https://doi.org/10.4103/njms.njms_379_21

8. Idris M, Yaqoob H, Khan MA, Zar A, Ullah S. Pattern of orbital diseases at a tertiary oculoplastic centre. Pak J Ophthalmol 2020; 37(1): 70–74. https://doi.org/10.36351/pjo.v37i1.1154

9. Sharma B, Sharma A, Thatte S. Etiological prevalence of proptosis: a prospective study. J Med Sci Clin Res 2018; 6(8): 482–488. https://doi.org/10.18535/jmscr/v6i8.76

10. Zahir SI, Khan MU, Ahmad M, Hussain I, Hamayun J. Etiological pattern, clinical presentation and outcome of patients with proptosis in a tertiary care hospital. Pak Armed Forces Med J 2022; 72(6): 2113-2116.

https://doi.org/10.51253/pafmj.v72i6.6097

11. Topilow NJ, Tran AQ, Koo EB, Alabiad CR. Etiologies of proptosis: a review. Intern Med Rev 2020; 6(3): 852.

https://doi.org/10.18103/imr.v6i3.852

12. Tamhankar MA, Raza S, Brutsaert E, Urdániz E, Vainilovich Y, Heyes A, et al. The burden of illness in thyroid eye disease: current state of the evidence. Front Ophthalmol 2025; 5: 1565762.

https://doi.org/10.3389/fopht.2025.1565762

13. Thyroid Eye Disease. EyeWiki [Internet]. [cited 2025 Nov 29]. Available from:

https://eyewiki.org/Thyroid_Eye_Disease

14. Rani B, Ahsan T, Aijaz W, Imran P, Fouzia S, Jabeen R. Clinical association of thyroid eye disease with disease severity and thyroid functional status — an experience of a tertiary care hospital, Karachi. Pak Armed Forces Med J 2023; 73(2): 565-568.

https://doi.org/10.51253/pafmj.v73i2.7913

15. Rauniyar RK, Thakur SD, Panda A, Sharma U. Radiological evaluation of orbit in cases of proptosis in Eastern Nepal. Nepalese J Radiol 2011; 1(1): 8-14.

https://doi.org/10.3126/njr.v1i1.6316

16. Nayar KD, Datta A, Nayar D, Bajaj S, Grewal S. Idiopathic orbital inflammatory syndrome masquerading as isolated nerve palsies: a case series. Indian J Ophthalmol Case Rep 2024; 4(4): 791-794. https://doi.org/10.4103/IJO.IJO_2298_23

17. Rachwani-Anil R, Zamorano-Martín F, Rocha-de-Lossada C, García-Lorente M, Pérez-Casaseca C, Hernando-Ayala C. Orbital inflammatory disease. Arch Soc Española Oftalmol 2022; 97(2): 89-99. https://doi.org/10.1016/j.oftale.2021.05.001

18. Patel BCK. Orbital vascular anomalies. In: Patel BCK, Singh AD, editors. Clinical Ophthalmic Oncology. Springer; 2025. [cited September 25th 2025]. Available from:

https://doi.org/10.1007/978-3-031-95179-4_9

19. Deng Y, Arafa HM, Yang T, Albadawi H, Fowl RJ, Zhang Z, et al. A soft thermal sensor for the continuous assessment of flow in vascular access. Nat Commun 2025; 16(1): 38.

https://doi.org/10.1038/s41467-024-54942-3

20. Xu J, Wei Y, Jiang S, Zhou H, Li Y, Chen X. Intelligent surgical planning for automatic reconstruction of orbital blowout fracture using a prior adversarial generative network. Med Image Anal 2025; 99: 103332.

https://doi.org/10.1016/j.media.2024.103332

21. Majithia S, Tham YC, Chee ML, Nusinovici S, Teo CL, Chee ML, et al. Cohort profile: the Singapore Epidemiology of Eye Diseases Study (SEED). Int J Epidemiol 2021; 50(1): 41-52.

https://doi.org/10.1093/ije/dyaa238

22. Ahmad SS, Anwar R, Khan MA, Usmani N, Jahan S. Evaluation of proptosis: a primer. Ophthalmol 2021: 15(1): 26-32.

https://doi.org/10.17925/OPHT.2021.15.1.26

23. Douglas RS, Dailey R, Subramanian PS, Barbesino G, Ugradar S, Batten R, et al. Proptosis and diplopia response with teprotumumab and placebo vs the recommended treatment regimen with intravenous methylprednisolone in moderate to severe thyroid eye disease: a meta-analysis and matching-adjusted indirect comparison. JAMA Ophthalmol 2022; 140(4): 328-335.

https://doi.org/10.1001/jamaophthalmol.2021.6284