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A Young Man with Unilateral Proptosis
Presented by: Dr. Md. Kamal Hossen
Asstt. Registrar Dept. of Neurosurgery, MMCH
“A Young Man with Unilateral Proptosis”
ChairpersonProf ( Dr.) M A Gafur Miah
Professor & HeadDepartment of Surgery
Mymensingh Medical College
CoordinatorDr Saumitra Sarkar
Assistant Professor & HeadDeptt. of Neurosurgery
Mymensingh Medical College
Particulars of the patient
Particulars of the Patient:
Name : Md. Shafayet Age : 27 years Sex : Male Religion : Islam Address :Purbadhola, Netrokona Marital status : Unmarried Occupation : Unemployed Date of admission : 21st November 2011 Date of examination : 21st November 2011
Presenting complaints :(Pre-Operative)
Irritation and watering of the left eye for 10 month.
Forward displacement of left eye ball for 3 months
Gradual dimness of vision in left eye for 3 months
According to the statement of the patient he was
reasonably well about 10 months back. Then he
complained about irritation and watering of the left eye
which was prominent in day time. In last 3 months he
developed forward displacement of left eye ball,
History of present illness :-
which was gradually increasing and not
associated with pain and pulsation. He also
complained gradual dimness of vision in left
eye and occasional double vision for 3 months.
History of present illness :-
Patient had no history of Headache, vomiting,
vertigo, fever, night sweats, weight loss, cough
or haemoptysis, haematuria or per rectal
bleeding, bone pain. There was no history of
trauma.
History of present illness (Cont.)
H/O of Past illness – The patient has a history
of jaundice 2 years back.
Personal history – The patient is a smoker. He
took 5 sticks per day .
Immunizations History – Completed immunization.
Family history – No such diseases found in the
other family members.
At first he was treated by Ophthalmologist at BNSB,
Mymensingh for watering and irritation and he used eye
drop and took some medicine for his illness but he
couldn’t mention any name. Then he got treatment at Dr.
Muktadir Eye Hospital, Gauripur and After doing the CT
scan, the patient was referred to a Neurosurgeon of
Dhaka. But, according to the advise of a physician he
got admitted in the Neurosurgery dept. of MMCH.
Treatment History
General Examination (Preoperative)
Appearance – ill looking Body build – Average Anemia – Absent Cyanosis – Absent Jaundice – Absent Oedema – Absent Dehydration – Absent Lymph nodes – not
palpable
Thyroid gland – not enlarged
Neck vein – not engorged Clubbing – Absent Koilonychia – Absent Leukonychia – Absent Pulse – 76/min B.P – 130/80 mm of Hg Temp – Normal Respiration – 16/min
Local Examination (Preoperative)
Local Examination of the Left Eye
- Inferonasal globe displacement and fullness of the
superotemporal lid and orbit.
- Proptosis – 4 mm
- A S-shaped contour to the upper lid.
- Tenderness absent.
- Motility of the left globe restricted in superior and lateral
direction.
- Intraocular pressure (IOP)- Not measured
- Preauricular lymphadenopathy - Absent
Systemic examination (Preoperative)
Nervous system examination –
Higher Psychic function – Normal Speech – Normal Gait – Normal
Systemic examination (Preoperative)
Nervous system examination – Examination of cranial nerve Olfactory nerve – sense of smell is intact Optic nerve – Visual acuity : 6/6 (Rt) Finger
counting at 2 feet (Lt)
Field of vision : reduced
Color vision : normal Ophthalmoscopic examination :
Disc swelling on left eye Light reflex : normal
Systemic examination (Preoperative)
Nervous system examination – Oculomotor nerve : normal Trochlear nerve : normal Abducent nerve : normal Trigeminal nerve : normal Facial nerve : normal
Systemic examination (Preoperative)
Nervous system examination – Vestibule-cochlear nerve : normal Glossopharyngeal nerve : normal Vagus nerve : normal Accessory nerve ( spinal part) : normal Hypoglossal nerve : normal
Systemic examination –
Motor function Upper limbs – Lt. Rt.
Bulk of muscle – Normal Normal Tone of muscle – Normal Normal Muscle Power – Grade ‘5` G - 5
Lower limbs – Lt. Rt. Bulk of muscle – Normal Normal Tone of muscle – Normal Normal Muscle Power – Grade ‘5` G - 5
Systemic examination –
Co ordination of movement : Finger nose test – intact Heel shin test – intact Involuntary movement : absent
Systemic examination –
Jerks
All jerks are Normal
Planter response: Flexor (B/L)
Clonus- Absent (B/L)
Systemic examination –
Sensory function test : Pain, touch, temperature – intact Joint position sense – intact Vibration sense – intact
Autonomic function
Normal
Systemic examination –
Signs of meningeal irritation : Neck rigidity : absent Kerning’s sign : negative Brudzinski’s sign : negative
Systemic examination –
Cardiovascular system
Nothing abnormalities are detected Respiratory system
Nothing abnormalities are detected Alimentary system
Nothing abnormalities are detected
Salient feature
A young man, 27 years of age right handed
hailing from Purbadhola, Netrogona
presented with irritation and watering of the
left eye for 10 months, forward displacement
of left eye ball for 3 months and gradual
dimness of vision in left eye for 3 months.
Salient feature (Cont.)
He complained about irritation and watering of the
left eye which was prominent in day time. In last 3
months he noticed forward displacement of left eye
ball which was gradually increasing and not
associated with pain and pulsation. He also
complained gradual dimness of vision in left eye
and occasional double vision .
Salient feature (Cont.)
The patient had no history of Headache,
vomiting, vertigo, fever, night sweats, weight
loss, cough or haemoptysis, haematuria or
per rectal bleeding, bone pain. There was no
history of trauma.
Salient feature (Cont.)
On examination, the patient was ill looking and his pulse
was 76/min & BP was 130/80 mm Hg . On local examination
of the left eye he was found Inferonasal globe displacement
and fullness of the superotemporal lid and orbit with 4mm
proptosis of left eye and A S-shaped contour to the left
upper lid. Tenderness was absent. The motility of the left
globe restricted in superior and lateral direction with
absent preauricular lymphadenopathy.
Salient feature (Cont.)
He was found with visual acquity 6/6 (Rt),
finger counting from 2 feet (Lt) & with
restricted field of vision. He was found disc
swelling in left eye.
Provisional Diagnosis
Left sided Retrobulbar Benign Tumour
Diferential Diagnosis
PseudotumourMalignant Retrobulbar tumourCarotido- Cavernous Fistula
Orbital vein thrombosisHaemangiomaNeurofibroma
Optic Nerve Glioma
Investigation
Investigations (Preoperative)
CBC :
TC – 10,300/cmm DC – N 68%
L 26%
M 02%
E 04%
Hb% - 12 gm/dl
ESR – 18 mm in 1st hour
Serum creatinine - 1.2 mg/dl
RBS- 5.4 mM/L
Urine R/M/E- Normal
ECG – Within normal limit
CXR P/A - Within normal limit
Investigations (Cont…)
CT Scan of Brain
Clinical Diagnosis
Retrobulbar solid tumour on left orbit
Clinical Diagnosis
Transcranial Orbitotomy and Removal of
the Tumour was done under G/A on 11th
December, 2011
Treatment
Operative Procedure
Confirm Diagnosis by Histopathology
Pleomorphic Adenoma
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