What is the approach to managing proptosis in the Intensive Care Unit (ICU)?

Approach to Proptosis in the ICU

In the ICU setting, immediately assess for vision-threatening complications—specifically corneal exposure, compressive optic neuropathy, and elevated intraocular pressure—while simultaneously establishing the underlying etiology through targeted imaging and ophthalmology consultation. 1

Immediate Assessment and Stabilization

Critical Vision-Threatening Conditions to Rule Out

• Compressive optic neuropathy: Assess visual acuity, pupillary responses, color vision, and look for relative afferent pupillary defect 1
• Corneal exposure keratopathy: Examine for epithelial defects using fluorescein staining, particularly in unconscious or sedated patients 1
• Elevated intraocular pressure: Measure IOP in all patients with proptosis, as orbital congestion can cause secondary glaucoma 1
• Globe rupture or severe trauma: In trauma cases, assess for direct globe injury before manipulating the orbit 1

Immediate Protective Measures for Corneal Exposure

In unconscious or sedated ICU patients, corneal exposure prophylaxis is mandatory and must be implemented immediately. 1

• Apply moisture chambers using polyethylene film to maintain corneal epithelial integrity 1
• Use paper tape to affix the moisture chamber on healthy eyelid skin; exercise caution if eyelid skin is compromised 1
• Initiate two-hourly application of preservative-free lubricants (hyaluronate or carmellose drops) 1
• All ICUs should have standardized corneal exposure prophylaxis protocols in place 1

Diagnostic Workup

Imaging Selection

MRI of the orbits with and without contrast is the optimal initial imaging modality for proptosis in the ICU. 1

• MRI orbits with contrast: Superior soft tissue characterization for masses, inflammatory conditions, vascular malformations, and optic nerve pathology 1
• CT orbits with contrast: Complementary to MRI; essential when assessing bony anatomy, orbital fractures, or when MRI is contraindicated 1
• Add MRI head with contrast: When intracranial extension or carotid-cavernous fistula is suspected 1

Key Clinical Distinctions

• Bilateral proptosis: Suggests thyroid eye disease, systemic inflammatory conditions (IgG4-related disease, idiopathic orbital inflammatory syndrome) 1
• Unilateral proptosis: Concerning for orbital mass, vascular malformation, carotid-cavernous fistula, or focal inflammatory process 1
• Associated chemosis and orbital congestion: Consider anterior-draining carotid-cavernous fistula 1

Etiology-Specific Management

Thyroid Eye Disease (Most Common Cause)

For severe proptosis or compressive optic neuropathy in thyroid eye disease, orbital decompression, high-dose pulse IV steroids, or orbital radiation should be considered urgently. 1, 2

Medical Management

• Teprotumumab: Reduces proptosis and clinical activity score in active TED; improves diplopia and reduces need for strabismus surgery 1, 2, 3
  • Contraindications: Pregnancy (absolute), inflammatory bowel disease (relative), pre-existing hearing loss (use with caution) 1, 3
  • Adverse effects: Hyperglycemia, muscle spasms, nausea, alopecia, diarrhea, tinnitus, hearing impairment 1, 3
• High-dose IV methylprednisolone: For severe proptosis or optic neuropathy when teprotumumab unavailable or contraindicated 2
• Ocular lubricants: Essential for all patients with exposure symptoms 1, 2
• Punctal plugs: Useful adjunct for severe dry eye 1, 2
• Smoking cessation: Mandatory counseling, as smoking worsens TED 1, 2

Surgical Considerations

• Orbital decompression: Indicated for compressive optic neuropathy or severe proptosis unresponsive to medical therapy 1, 2
• Coordinate with orbital specialist before any strabismus surgery, as decompression alters alignment and muscle recession worsens proptosis 1

Orbital Inflammatory Conditions

• Idiopathic orbital inflammatory syndrome (IOIS) and IgG4-related disease: May present with unilateral or bilateral proptosis 1
• Imaging with either CT or MRI provides overlapping information; no consensus on optimal modality 1
• Treatment typically involves systemic corticosteroids or immunosuppression (managed by ophthalmology/rheumatology)

Vascular Malformations and Carotid-Cavernous Fistula

• Carotid-cavernous fistula: Presents with proptosis, orbital congestion, chemosis (anterior-draining) or diplopia and pain (posterior-draining) 1
• Requires urgent neuro-interventional consultation for potential endovascular treatment
• MRI/MRA or CT angiography to confirm diagnosis 1

Traumatic Proptosis

• Assess for orbital fractures, muscle entrapment, hemorrhage, and direct muscle injury 1
• Life-threatening and vision-threatening conditions take priority over strabismus management 1
• CT orbits is essential for evaluating bony anatomy and soft tissue injury 1

Ophthalmology Consultation

Immediate ophthalmology consultation is mandatory for all ICU patients with proptosis. 1

• Daily ophthalmological review is necessary during acute illness 1
• Ophthalmologist should perform ocular hygiene to remove inflammatory debris and break down conjunctival adhesions using saline irrigation, squint hook, and forceps 1
• Apply topical anesthetic (proparacaine or tetracaine) prior to examination procedures 1
• Avoid blind sweeping of fornices with cotton buds or glass rods, which may cause damage 1

Antibiotic Prophylaxis

• Broad-spectrum topical antibiotics: Recommended when corneal fluorescein staining or frank ulceration is present (after excluding microbial keratitis) 1
• In the UK, quinolone preparations (moxifloxacin or levofloxacin) four times daily are recommended 1
• For suspected corneal infection: Obtain cultures for bacteria and fungus, then initiate hourly broad-spectrum topical antibiotics per local protocols 1

Common Pitfalls

• Failing to protect the cornea in sedated patients: This leads to irreversible corneal scarring and vision loss 1
• Delaying ophthalmology consultation: Compressive optic neuropathy requires urgent intervention within hours to prevent permanent blindness 1
• Missing carotid-cavernous fistula: Look for pulsatile proptosis, orbital bruit, or conjunctival chemosis 1
• Using topical corticosteroids without ophthalmology supervision: These can mask corneal infection and should only be used under specialist guidance 1