![Research Article
Clinical Profile of Unilateral Proptosis in a Tertiary Care Centre
Susan Dsouza, Pooja Kandula, Gurudutt Kamath, and Manjunath Kamath
Department of Ophthalmology, Kasturba Medical College, Manipal University, Mangalore, India
Correspondence should be addressed to Susan Dsouza; docsu2007@hotmail.com
Received 27 April 2017; Accepted 14 August 2017; Published 3 October 2017
Academic Editor: Lisa Toto
Copyright © 2017 Susan Dsouza et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Proptosis, the forward protrusion of the eyeball, is a common manifestation of a wide variety of diseases inside the orbit and its
spaces. Its diagnosis is usually a combined effort of the ophthalmologist, otolaryngologist, neurosurgeon, and radiologist. A
clinical study of twenty-five cases with unilateral proptosis were studied in different age groups over a period of about 3 years
under different headings like distribution, clinical features, radiological features, histopathological aspects, management, and
outcomes of diseases. Proptosis measurement was done by simple/plastic ruler exophthalmometry, and diagnosis was made after
a detailed clinical examination and ancillary tests. Treatment modality was decided based on radiological and histopathological
examination reports, which included medical surgery, radiotherapy, and chemotherapy or a combination of all. In our study,
most of the patients were in the age group of more than 60 years. The M : F ratio is 3 : 1. One case had a large proptosis of
18 mm above normal and 2 cases were as small as 3 mm. Diagnosis was mainly done by clinical features and confirmed by
radiological and histopathological features. Most of them were treated medically (13 cases, i.e., 52%) and the rest by surgery
with a combination of radiotherapy/chemotherapy (12 cases, i.e., 48%).
1. Introduction
Proptosis is described as an abnormal protrusion of the eye-
ball [1], and in relation to the skull, proptosis is measured
from the corneal apex to the outer orbital margin of the orbit,
with the eye looking straight [2].
The causes of unilateral proptosis are innumerable.
The eye is a major crossroad for all the structures around
it which help in its support and functioning, which when
affected extends into the orbit causing proptosis. It can
be the most dramatic of the orbital symptoms, especially if
it has an acute onset.
A clear knowledge of the aetiologies will help the
ophthalmologist to suspect, diagnose early, and provide
treatment.
An attempt has been made to study the aetiology, clinical
features, histopathology, and management of proptosis and
its outcome.
2. Material and Methods
This is a retrospective record based on a clinical analysis
of 25 cases of patients who presented to the eye outpatient
department with unilateral proptosis during a period of 3
years. A detailed ophthalmological examination was done
and a simple/plastic ruler was used to measure proptosis.
Readings greater than 18 mm were considered as having
proptosis [3]. A difference between both the eyes more than
2 mm was also considered significant.
Demographic details, clinical presentation, investigation
details, and treatment details were noted. X-rays, B-scan,
CT scan, and MRI orbit were performed to confirm the
diagnosis.
3. Results
In our study of 25 patients presenting with unilateral propto-
sis, the age of the patients were between 6 and 75 years, and
most of them were in the age group of more than 60 years
old (24%) as shown in Table 1.
18 were males (72%) and 7 were females (28%).
The minimum proptosis was 3 mm and the maximum
was 18 mm above the normal. Most of the patients had a
right-sided proptosis, that is, 13 cases (52%). It was axial in
15 cases and eccentric in 10 cases as in Table 2.
Hindawi
Journal of Ophthalmology
Volume 2017,Article ID 8546458, 4 pages
https://doi.org/10.1155/2017/8546458](https://image.slidesharecdn.com/dsouza2017-2-200723005003/85/Dsouza2017-2-1-320.jpg)
![clinically and with the help of CT/MRI scans. Scans helped in
localising the lesions and gave an idea into the aetiology of
the condition and in making a decision in the management
of the patient. In tumours, histopathology reports after
biopsy wherever possible confirmed the diagnosis.
Inflammations (13) were medically managed with sys-
temic antibiotics and steroids. 12 patients were surgically
managed by orbitotomies or orbital exploration, depending
on the site, out of which 4 cases were done by the neurosur-
geon. Following surgery, 5 underwent radiotherapy and
chemotherapy, as shown in Table 5.
No complications were seen in follow-ups.
16 (60%) improved with no disease, 3 (12.5%) were with
disease as status quo, 1 (4%) steadily deteriorated, and there
was 1 (4%) mortality in the study period.
4. Discussion
Orbital pathology usually presents as proptosis. Symptoms
reflect the orbital volume increase. Direction indicates the
site of lesion [4]. In comparison to other studies where
neoplasms are seen to be more common, in our study,
inflammations in the orbit were more common and con-
tributed to most of the cases.
There are very few studies available about unilateral
proptosis which include all lesions giving rise to unilateral
proptosis.
The causes of adult unilateral proptosis may be a retro-
bulbar haematoma following trauma, inflammatory condi-
tions like orbital cellulitis, an orbital abscess, usually
following frontal or ethmoid sinusitis, a pseudotumour of
the orbit due to a granuloma of unknown cause, an epider-
moid or dermoid cyst, a mixed lacrimal tumour (lacrimal
adenoma), or a haemangioma. Malignant tumours include
malignant melanoma, carcinoma of the maxillary or ethmoi-
dal sinuses invading the orbit, and meningioma of the sphe-
noid. Thyroid eye disease which is usually bilateral also can
present as a unilateral proptosis in its initial stages [3, 5]. Pri-
mary tumours of the orbit are usually mixed tumours of the
lacrimal gland and dermoid cysts [2]. Anterior temporal lobe
lesions into the orbit can lead to proptosis and blindness [6].
The causes of unilateral proptosis in a child include
retinoblastoma in the first 5 years of life and infective
orbital cellulitis [7].
The direction of exophthalmos may indicate the likely
aetiology and site of lesion [1]. Axial proptosis is seen in
Figure 6: Pleomorphic adenoma—eccentric.
Figure 7: Osteoblastoma—eccentric.
Figure 8: Lymphangioma—eccentric.
Table 4: Cause of proptosis.
Inflammatory
(a) Orbital cellulitis 5 20%
(b) Orbital apex syndrome 1 4%
(c) Frontal mucocele 1 4%
(d) Mucormycosis 1 4%
Pleomorphic adenoma of lacrimal gland 1 4%
Pseudotumours 2 8%
Trauma (retrobulbar haemorrhage) 1 4%
Hodgkin’s lymphoma 1 4%
Squamous cell carcinoma 3 12%
Lacrimal gland adenocarcinoma 1 4%
Osteoblastoma 1 4%
Meningioma 1 4%
Haemangioma 1 4%
Acoustic schwannoma 1 4%
Retinoblastoma 1 4%
Lymphangioma 1 4%
Dermoid 1 4%
Luxated globe 1 4%
Table 5: Treatment modalities.
Treatment modalities Cases
Medical 13
Surgery 12
Radiation + chemotherapy 05
Referred cases 04
3Journal of Ophthalmology](https://image.slidesharecdn.com/dsouza2017-2-200723005003/85/Dsouza2017-2-3-320.jpg)
![tumours arising within the muscle cone like optic nerve gli-
oma. The eyeball is displaced down and/or lateral in diseases
of frontal or ethmoid sinuses. Lacrimal gland or temporal
fossa tumours have a medial displacement [8].
To evaluate and treat the patient with unilateral prop-
tosis, an ophthalmologist must work closely with the ENT
surgeon, neurosurgeon, and radiologist to ensure a successful
outcome in each case.
During the past few decades, advances in diagnostic
instrumentation and surgical technique have helped to ele-
vate the orbit to an anatomical area of great clinical inter-
est. CT, MRI, and orbital echography have dramatically
improved diagnostic accuracy and allowed a more careful
therapeutic planning [9, 10]. Orbital surgery has become
safer and more precise, and treatment results are signifi-
cantly enhanced. The operating microscope, specialized
orbital instruments, fibre optic illumination, endoscopy,
and hypotensive anaesthesia have allowed orbital surgeons
to perform complex deep dissections more easily and with
fewer complications.
As regards the management, inflammatory cases and
benign orbital neoplasms were most amenable to satisfactory
treatment, medical or surgical, while malignant primary
tumours if detected early could be eradicated with fair
chances of success. Surgically, results were more encouraging
in cases of retinoblastoma and lacrimal gland tumours than
in other highly malignant and infiltrative growths where deep
X-ray therapy was the only possible recourse for palliative
and temporary improvement.
Proptosis in many cases if undiagnosed and unexplained
when deep in the orbit and left to fate is not advisable, so
orbital exploration is necessary to clear the worry of the
patient as well as the ophthalmologist [11]. Anterior orbitot-
omy with ethmoidectomy was the most satisfactory
approach for anteriorly situated neoplasms, while transfron-
tal approach by neurosurgeons gave better accessibility for
tumours situated medial to the optic nerve or extending
intracranially. Palliative decompression of the orbit through
this route was found most effective.
5. Conclusion
Unilateral proptosis is a multidisciplinary problem and
requires collaboration of different specialties [4] of an oph-
thalmologist along with an otorhinolaryngologist, neurosur-
geon, oncologist, and radiotherapist. A thorough ENT
examination is mandatory in proptosis [2]. A small number
of cases can never go noticed, but in proptosis, however small
the bulge, malignancy has to be ruled out. The commonest
cause is malignancy in other studies; our study showed more
of an inflammatory origin. CT scan was valuable in evaluat-
ing a case of proptosis, but histopathological examination
provides a definitive diagnosis of the exact aetiology.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
References
[1] B. B. Kanski, Clinical Ophthalmology, A Systemic Approach,
Elsevier Saunders Ltd, 8th edition, 2016.
[2] P. Keche, A. Z. Nitnaware, M. Mair, P. Sakhare, and S. Satpute,
“A study of tumours giving rise to unilateral proptosis,” Indian
Journal of Otolaryngology and Head & Neck Surgery, vol. 65,
Supplement 1, pp. 6–13, 2012.
[3] A. Turnbull, S. Trikha, C. Whaley, D. Gibson, and E. Kashef,
“Acquired unilateral proptosis – an overview of aetiology and
radiological considerations,” RAD Magazine, vol. 42, no. 488,
pp. 15–17, 2016.
[4] N. K. Khan, M. Moin, M. A. Khan, and A. Hameed, “Unilateral
proptosis: a local experience,” Biomédica, vol. 20, 2004.
[5] H. S. Zakharia, K. E. Asdourian, and C. S. Matta, “Unilateral
exophthalmos. Aetiological study of 85 cases,” The British
Journal of Ophthalmology, vol. 56, pp. 678–686, 1972.
[6] C. Sys and P. Kestelyn, “Unilateral proptosis and blindness
caused by meningioma in a patient treated with cyproterone
acetate,” GMS Ophthalmology Cases, vol. 5, 2015.
[7] K. Sindhu, J. Downie, R. Ghabrial, and F. Martin, “Aetiology
of childhood proptosis,” Journal of Paediatrics and Child
Health, vol. 34, 1998.
[8] K. P. Rao, K. V. Rao, M. R. Rao, and B. S. Rao, “Clinical
study of proptosis,” Indian Journal of Ophthalmology, vol. 30,
pp. 489-490, 1982.
[9] R. L. Dallow, “Reliability of orbital diagnostic tests: ultrasonog-
raphy, computerised tomography, radiology,” Ophthalmology,
vol. 85, pp. 1218–1228, 1978.
[10] L. Kreel, “Unilateral proptosis,” Postgraduate Medical Journal,
vol. 66, no. 778, pp. 662-663, 1990.
[11] A. Mortada, “Unilateral proptosis of unexplained origin:
report of nine cases,” The British Journal of Ophthalmology,
vol. 46, no. 6, pp. 369–373, 1962.
4 Journal of Ophthalmology](https://image.slidesharecdn.com/dsouza2017-2-200723005003/85/Dsouza2017-2-4-320.jpg)
Dsouza2017 2
- 1. Research Article Clinical Profile of Unilateral Proptosis in a Tertiary Care Centre Susan Dsouza, Pooja Kandula, Gurudutt Kamath, and Manjunath Kamath Department of Ophthalmology, Kasturba Medical College, Manipal University, Mangalore, India Correspondence should be addressed to Susan Dsouza; docsu2007@hotmail.com Received 27 April 2017; Accepted 14 August 2017; Published 3 October 2017 Academic Editor: Lisa Toto Copyright © 2017 Susan Dsouza et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Proptosis, the forward protrusion of the eyeball, is a common manifestation of a wide variety of diseases inside the orbit and its spaces. Its diagnosis is usually a combined effort of the ophthalmologist, otolaryngologist, neurosurgeon, and radiologist. A clinical study of twenty-five cases with unilateral proptosis were studied in different age groups over a period of about 3 years under different headings like distribution, clinical features, radiological features, histopathological aspects, management, and outcomes of diseases. Proptosis measurement was done by simple/plastic ruler exophthalmometry, and diagnosis was made after a detailed clinical examination and ancillary tests. Treatment modality was decided based on radiological and histopathological examination reports, which included medical surgery, radiotherapy, and chemotherapy or a combination of all. In our study, most of the patients were in the age group of more than 60 years. The M : F ratio is 3 : 1. One case had a large proptosis of 18 mm above normal and 2 cases were as small as 3 mm. Diagnosis was mainly done by clinical features and confirmed by radiological and histopathological features. Most of them were treated medically (13 cases, i.e., 52%) and the rest by surgery with a combination of radiotherapy/chemotherapy (12 cases, i.e., 48%). 1. Introduction Proptosis is described as an abnormal protrusion of the eye- ball [1], and in relation to the skull, proptosis is measured from the corneal apex to the outer orbital margin of the orbit, with the eye looking straight [2]. The causes of unilateral proptosis are innumerable. The eye is a major crossroad for all the structures around it which help in its support and functioning, which when affected extends into the orbit causing proptosis. It can be the most dramatic of the orbital symptoms, especially if it has an acute onset. A clear knowledge of the aetiologies will help the ophthalmologist to suspect, diagnose early, and provide treatment. An attempt has been made to study the aetiology, clinical features, histopathology, and management of proptosis and its outcome. 2. Material and Methods This is a retrospective record based on a clinical analysis of 25 cases of patients who presented to the eye outpatient department with unilateral proptosis during a period of 3 years. A detailed ophthalmological examination was done and a simple/plastic ruler was used to measure proptosis. Readings greater than 18 mm were considered as having proptosis [3]. A difference between both the eyes more than 2 mm was also considered significant. Demographic details, clinical presentation, investigation details, and treatment details were noted. X-rays, B-scan, CT scan, and MRI orbit were performed to confirm the diagnosis. 3. Results In our study of 25 patients presenting with unilateral propto- sis, the age of the patients were between 6 and 75 years, and most of them were in the age group of more than 60 years old (24%) as shown in Table 1. 18 were males (72%) and 7 were females (28%). The minimum proptosis was 3 mm and the maximum was 18 mm above the normal. Most of the patients had a right-sided proptosis, that is, 13 cases (52%). It was axial in 15 cases and eccentric in 10 cases as in Table 2. Hindawi Journal of Ophthalmology Volume 2017,Article ID 8546458, 4 pages https://doi.org/10.1155/2017/8546458
- 2. Headache and protrusion of eye were the commonest presented complains in these patients along with other com- plains like pain, defective vision, epiphora, and diplopia shown in Table 3. The most common etiology seen in our study was inflam- mation with 8 cases of acute onset (32%), then there were 5 cases of orbital cellulitis (20%), 1 case of mucormycosis (4%), 1 case of orbital apex syndrome (4%), and 1 case of frontal mucocele (4%). Other causes include pseudotumours (2 cases, i.e., 8%) Figure 1, posttraumatic retrobulbar haem- orrhage (1 case, i.e., 4%) Figure 2, dermoid (1 case, i.e., 4%) Figure 3, and luxated globe (1 case, i.e., 4%). Malignant tumours were retinoblastoma (1 case, i.e., 4%) Figure 4, Hodgkin’s lymphoma (1 case, i.e., 4%), squamous cell carcinoma (3 cases, i.e., 12%) Figure 5, and adenocarcinoma of the lacrimal gland (1 case, i.e., 4%); benign tumours were pleomorphic adenoma of the lacrimal gland (1 case, i.e., 4%) Figure 6, osteoblastoma (1 case, i.e., 4%) Figure 7, lymphan- gioma (1 case, i.e., 4%) Figure 8, acoustic schwannoma (1 case, i.e., 4%), meningioma (1 case, i.e., 4%), and haeman- gioma (1 case, i.e., 4%) shown in Table 4. References to ENT, neurosurgery, and oncology were given for any associated conditions. Diagnosis was confirmed Table 1: Age distribution. Age in years Number of cases % 0–9 2 8 10–19 0 0 20–29 4 16 30–39 5 20 40–49 5 20 50–59 3 12 >60 6 24 Table 2: Type of proptosis. Axial 15 Eccentric 10 Table 3: Presenting symptoms. Symptoms No of patients N-25 Proptosis 25 Diminished vision 20 Diplopia 2 Diminished motility 6 Epiphora 2 Headache 24 Chemosis 20 Orbital mass 10 Eye pain 24 Ptosis 5 Figure 1: Pseudotumor—axial. Figure 2: Retrobulbar haemorrhage—axial. Figure 3: Angular dermoid—eccentric. Figure 4: Retinoblastoma—axial. Figure 5: Squamous cell carcinoma—eccentric. 2 Journal of Ophthalmology
- 3. clinically and with the help of CT/MRI scans. Scans helped in localising the lesions and gave an idea into the aetiology of the condition and in making a decision in the management of the patient. In tumours, histopathology reports after biopsy wherever possible confirmed the diagnosis. Inflammations (13) were medically managed with sys- temic antibiotics and steroids. 12 patients were surgically managed by orbitotomies or orbital exploration, depending on the site, out of which 4 cases were done by the neurosur- geon. Following surgery, 5 underwent radiotherapy and chemotherapy, as shown in Table 5. No complications were seen in follow-ups. 16 (60%) improved with no disease, 3 (12.5%) were with disease as status quo, 1 (4%) steadily deteriorated, and there was 1 (4%) mortality in the study period. 4. Discussion Orbital pathology usually presents as proptosis. Symptoms reflect the orbital volume increase. Direction indicates the site of lesion [4]. In comparison to other studies where neoplasms are seen to be more common, in our study, inflammations in the orbit were more common and con- tributed to most of the cases. There are very few studies available about unilateral proptosis which include all lesions giving rise to unilateral proptosis. The causes of adult unilateral proptosis may be a retro- bulbar haematoma following trauma, inflammatory condi- tions like orbital cellulitis, an orbital abscess, usually following frontal or ethmoid sinusitis, a pseudotumour of the orbit due to a granuloma of unknown cause, an epider- moid or dermoid cyst, a mixed lacrimal tumour (lacrimal adenoma), or a haemangioma. Malignant tumours include malignant melanoma, carcinoma of the maxillary or ethmoi- dal sinuses invading the orbit, and meningioma of the sphe- noid. Thyroid eye disease which is usually bilateral also can present as a unilateral proptosis in its initial stages [3, 5]. Pri- mary tumours of the orbit are usually mixed tumours of the lacrimal gland and dermoid cysts [2]. Anterior temporal lobe lesions into the orbit can lead to proptosis and blindness [6]. The causes of unilateral proptosis in a child include retinoblastoma in the first 5 years of life and infective orbital cellulitis [7]. The direction of exophthalmos may indicate the likely aetiology and site of lesion [1]. Axial proptosis is seen in Figure 6: Pleomorphic adenoma—eccentric. Figure 7: Osteoblastoma—eccentric. Figure 8: Lymphangioma—eccentric. Table 4: Cause of proptosis. Inflammatory (a) Orbital cellulitis 5 20% (b) Orbital apex syndrome 1 4% (c) Frontal mucocele 1 4% (d) Mucormycosis 1 4% Pleomorphic adenoma of lacrimal gland 1 4% Pseudotumours 2 8% Trauma (retrobulbar haemorrhage) 1 4% Hodgkin’s lymphoma 1 4% Squamous cell carcinoma 3 12% Lacrimal gland adenocarcinoma 1 4% Osteoblastoma 1 4% Meningioma 1 4% Haemangioma 1 4% Acoustic schwannoma 1 4% Retinoblastoma 1 4% Lymphangioma 1 4% Dermoid 1 4% Luxated globe 1 4% Table 5: Treatment modalities. Treatment modalities Cases Medical 13 Surgery 12 Radiation + chemotherapy 05 Referred cases 04 3Journal of Ophthalmology
- 4. tumours arising within the muscle cone like optic nerve gli- oma. The eyeball is displaced down and/or lateral in diseases of frontal or ethmoid sinuses. Lacrimal gland or temporal fossa tumours have a medial displacement [8]. To evaluate and treat the patient with unilateral prop- tosis, an ophthalmologist must work closely with the ENT surgeon, neurosurgeon, and radiologist to ensure a successful outcome in each case. During the past few decades, advances in diagnostic instrumentation and surgical technique have helped to ele- vate the orbit to an anatomical area of great clinical inter- est. CT, MRI, and orbital echography have dramatically improved diagnostic accuracy and allowed a more careful therapeutic planning [9, 10]. Orbital surgery has become safer and more precise, and treatment results are signifi- cantly enhanced. The operating microscope, specialized orbital instruments, fibre optic illumination, endoscopy, and hypotensive anaesthesia have allowed orbital surgeons to perform complex deep dissections more easily and with fewer complications. As regards the management, inflammatory cases and benign orbital neoplasms were most amenable to satisfactory treatment, medical or surgical, while malignant primary tumours if detected early could be eradicated with fair chances of success. Surgically, results were more encouraging in cases of retinoblastoma and lacrimal gland tumours than in other highly malignant and infiltrative growths where deep X-ray therapy was the only possible recourse for palliative and temporary improvement. Proptosis in many cases if undiagnosed and unexplained when deep in the orbit and left to fate is not advisable, so orbital exploration is necessary to clear the worry of the patient as well as the ophthalmologist [11]. Anterior orbitot- omy with ethmoidectomy was the most satisfactory approach for anteriorly situated neoplasms, while transfron- tal approach by neurosurgeons gave better accessibility for tumours situated medial to the optic nerve or extending intracranially. Palliative decompression of the orbit through this route was found most effective. 5. Conclusion Unilateral proptosis is a multidisciplinary problem and requires collaboration of different specialties [4] of an oph- thalmologist along with an otorhinolaryngologist, neurosur- geon, oncologist, and radiotherapist. A thorough ENT examination is mandatory in proptosis [2]. A small number of cases can never go noticed, but in proptosis, however small the bulge, malignancy has to be ruled out. The commonest cause is malignancy in other studies; our study showed more of an inflammatory origin. CT scan was valuable in evaluat- ing a case of proptosis, but histopathological examination provides a definitive diagnosis of the exact aetiology. Conflicts of Interest The authors declare that they have no conflicts of interest. References [1] B. B. Kanski, Clinical Ophthalmology, A Systemic Approach, Elsevier Saunders Ltd, 8th edition, 2016. [2] P. Keche, A. Z. Nitnaware, M. Mair, P. Sakhare, and S. Satpute, “A study of tumours giving rise to unilateral proptosis,” Indian Journal of Otolaryngology and Head & Neck Surgery, vol. 65, Supplement 1, pp. 6–13, 2012. [3] A. Turnbull, S. Trikha, C. Whaley, D. Gibson, and E. Kashef, “Acquired unilateral proptosis – an overview of aetiology and radiological considerations,” RAD Magazine, vol. 42, no. 488, pp. 15–17, 2016. [4] N. K. Khan, M. Moin, M. A. Khan, and A. Hameed, “Unilateral proptosis: a local experience,” Biomédica, vol. 20, 2004. [5] H. S. Zakharia, K. E. Asdourian, and C. S. Matta, “Unilateral exophthalmos. Aetiological study of 85 cases,” The British Journal of Ophthalmology, vol. 56, pp. 678–686, 1972. [6] C. Sys and P. Kestelyn, “Unilateral proptosis and blindness caused by meningioma in a patient treated with cyproterone acetate,” GMS Ophthalmology Cases, vol. 5, 2015. [7] K. Sindhu, J. Downie, R. Ghabrial, and F. Martin, “Aetiology of childhood proptosis,” Journal of Paediatrics and Child Health, vol. 34, 1998. [8] K. P. Rao, K. V. Rao, M. R. Rao, and B. S. Rao, “Clinical study of proptosis,” Indian Journal of Ophthalmology, vol. 30, pp. 489-490, 1982. [9] R. L. Dallow, “Reliability of orbital diagnostic tests: ultrasonog- raphy, computerised tomography, radiology,” Ophthalmology, vol. 85, pp. 1218–1228, 1978. [10] L. Kreel, “Unilateral proptosis,” Postgraduate Medical Journal, vol. 66, no. 778, pp. 662-663, 1990. [11] A. Mortada, “Unilateral proptosis of unexplained origin: report of nine cases,” The British Journal of Ophthalmology, vol. 46, no. 6, pp. 369–373, 1962. 4 Journal of Ophthalmology
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