Proptosis and periorbital swelling
- Clinical approach
A bulging eye in an adult is usually thyroid disease; in a child with fever, orbital infection. Poor vision or painful, limited movements make it urgent.
See it in 3D: Optic nerve · Eyelids
What it is
Proptosis is forward displacement of the eye. In adults the commonest cause, in one or both eyes, is thyroid eye disease. In children it is orbital cellulitis, usually spreading from the ethmoid sinus. Other causes are orbital tumours (lymphoma, metastases, rhabdomyosarcoma in children), vascular lesions such as a carotid-cavernous fistula, and orbital haemorrhage after trauma. Periorbital swelling without proptosis is usually preseptal cellulitis, in front of the orbital septum.
Red flags
- Reduced vision, faded colours or an afferent pupillary defect: optic nerve compression.
- Painful or restricted eye movements, fever, proptosis: orbital (not preseptal) cellulitis.
- Rapid proptosis in a child: rhabdomyosarcoma.
- Pulsating eye, bruit, red swollen conjunctiva after head trauma: carotid-cavernous fistula.
- Tense orbit and falling vision after trauma: orbital compartment syndrome.
Step-by-step approach
- Look from above the head and from the side: one or both eyes, axial or displaced.
- Measure acuity, colour vision and pupils.
- Test eye movements and ask about pain on movement.
- Look for lid retraction and lid lag (thyroid), fever, sinus symptoms, a bruit and a mass.
- Decide preseptal or orbital: vision, pupils and movements are normal in preseptal cellulitis.
Causes of proptosis
| Cause | Typical patient | Clue | First test |
|---|---|---|---|
| Thyroid eye disease | Adult, often a woman, smoker | Lid retraction, lid lag, both eyes | Thyroid tests, orbit imaging |
| Orbital cellulitis | Child with sinusitis | Fever, painful restricted movements | Contrast CT of orbits and sinuses |
| Preseptal cellulitis | Child or adult | Swollen lid, normal eye movements and vision | Clinical |
| Orbital tumour | Any age | Slow, painless, displaced globe | MRI or CT |
| Carotid-cavernous fistula | After head trauma | Pulsation, bruit, corkscrew vessels | CT or MR angiography |
| Orbital haemorrhage | After trauma or surgery | Tense orbit, falling vision | Clinical: decompress first |
Keys to the differential
- Thyroid eye disease can occur with hyperthyroid, normal or low thyroid function, and smoking makes it worse.
- Orbital cellulitis can lead to blindness, cavernous sinus thrombosis and brain abscess.
- Very short-sighted eyes are long and can look proptotic (pseudoproptosis).
Next step / Initial management
- Orbital cellulitis: admit, intravenous antibiotics, contrast CT of the orbits and sinuses, ophthalmology and ENT; surgery for an abscess or failing vision.
- Preseptal cellulitis: oral antibiotics and review within 24 to 48 hours; admit young or unwell children.
- Thyroid eye disease: thyroid tests, stop smoking, lubricants, ophthalmology; reduced vision or colour vision means optic neuropathy, an emergency for intravenous corticosteroids or decompression.
- Acute traumatic proptosis with a tense orbit and falling vision: lateral canthotomy and cantholysis without waiting for imaging.
- Unexplained or progressive proptosis: orbital imaging and referral; urgent in a child.
Test yourself
Think of the answer, then tap the question to see it.
What is the commonest cause of proptosis in adults?
Thyroid eye disease, which can affect one or both eyes.
Which findings separate orbital from preseptal cellulitis?
Proptosis, painful or restricted eye movements, reduced vision and an afferent pupillary defect occur only in orbital cellulitis.
What does reduced colour vision mean in thyroid eye disease?
Compressive optic neuropathy: an emergency treated with intravenous corticosteroids or orbital decompression.
Connections
See it in 3D2
The structures of Durgical's 3D anatomy where it is found.
In Pharmacology3
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Exophthalmos (StatPearls Publishing (NCBI Bookshelf), 2023); Orbital Cellulitis (StatPearls Publishing (NCBI Bookshelf), 2026); Thyroid Eye Disease (StatPearls Publishing (NCBI Bookshelf), 2025).
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Representative model, for educational purposes only.