Short Case: Proptosis — Examination Sequence in 5 Minutes

A proptosis short case is best handled as a sequence: establish that the globe is forward or displaced, describe the pattern, document visual function and only then organise the differential. In five minutes, an examiner can see whether you have a safe, repeatable order. They do not need a premature label such as thyroid eye disease, cellulitis or tumour.

This is a postgraduate examination-revision framework for doctors. It is not a protocol for assessing or managing a patient. In clinical work, use supervision, local pathways and current specialist guidance.

The rule for the station: describe before you diagnose. Record what you can demonstrate; say what you would complete if the station time or equipment is limited.

The five-minute proptosis examination at a glance

The order is deliberate. A review of orbital disease recommends a systematic history and physical examination, including visual acuity, pupils, colour testing, ocular motility, globe position, Hertel measurement, orbital palpation and posterior-segment assessment. The same domains recur in the ATA/ETA consensus description of a formal thyroid eye disease examination: vision, soft tissue, strabismus/motility, and appearance/exposure. In a short case, you are using the order to show clinical reasoning, not to claim a diagnosis from one sign.¹²

First 30 seconds: see the patient before touching the orbit

Introduce yourself, confirm the patient’s identity as required by the station and ask permission to examine. Position yourself so that you can compare both eyes at the same level. Take a moment from the front and, if appropriate, from above. The aim is not theatrical inspection; it is to avoid missing the first description.

Start with five observations:

1. Is the appearance unilateral or bilateral?
2. Is the globe actually forward, or is there an asymmetry that could mimic proptosis?
3. Does the globe appear to move directly forward or away from a particular orbital quadrant?
4. Are there lid, conjunctival or corneal exposure signs?
5. Is there facial asymmetry, periocular swelling, a scar, skin change or a visible mass?

Proptosis/exophthalmos refers to anterior protrusion of one or both globes due to increased orbital content. A practical examiner may also expect you to remember pseudoproptosis: an apparent asymmetry can arise from a large globe, high myopia, contralateral enophthalmos, lid asymmetry or facial/orbital asymmetry. Do not declare pseudoproptosis from across the room. Say that you would consider it if the appearance and measurements do not agree.³

Say the finding in a fixed order

Use one sentence every time:

“There is [unilateral/bilateral] [axial/non-axial] proptosis, with [superior/inferior/medial/lateral] displacement, associated with [lid, conjunctival, surface or motility finding].”

This keeps the sign separate from the cause. It also prevents an easy error: calling every prominent eye “thyroid.” Thyroid eye disease is an important cause of proptosis, but a timed station rewards the demonstrable examination first.

Characterise the displacement: axial is a clue, not a conclusion

View the face from above when feasible. Axial proptosis means that the globe comes forward in line with the orbital axis. Eccentric or non-axial proptosis means that the globe is displaced in a direction as well as forward. An intraconal process may produce an axial appearance; an extraconal mass often displaces the globe away from its site of origin. These are localisation clues, not rules that identify a specific lesion.¹

State the direction precisely. “Down and out” is more useful than “displaced”; “inferomedial displacement” is more useful than “not axial.” If you can see a palpable or visible superior orbital fullness and the globe is down and out, describe both observations before suggesting the compartmental relationship.

Dynamic signs belong in the description if they are demonstrated or supplied by the examiner:

The review literature makes the same point: direction of displacement, a bruit or pulsation, and orbital-rim/anterior-orbit palpation help build a relevant differential. In a station, a calm description earns more than a long causes list.¹

Measure properly: the Hertel rule is “base plus both readings”

If a Hertel exophthalmometer is available, explain what you are measuring: the distance from the corneal apex to the orbital rim reference point. Record the base and both readings in millimetres. For example: “Hertel base 110 mm; right 22 mm, left 18 mm.” The numbers are not meaningful without the base and the instrument context, particularly if another examiner or visit will compare them.

Do not recite a universal normal value as though it applied to every population, instrument and orbit. The review literature notes that asymmetry is clinically useful, while normal globe position varies between populations. For examination purposes, compare sides, record the method and connect a difference to the rest of the findings. A commonly cited threshold of 2 mm asymmetry appears in review literature, but it is not a substitute for measurement quality or the clinical picture.¹³

Then assess resistance to retropulsion gently, comparing sides. A useful spoken line is: “I would compare resistance to retropulsion, taking care not to cause discomfort or pressure on the globe.” Palpate the accessible orbital rim and anterior orbit only if the patient and station permit. State tenderness, a palpable mass, its site and mobility. Do not palpate simply to look busy.

Check visual function before you build the differential

The high-yield part of a proptosis station is proving that you have looked for visual pathway compromise and exposure. Work in a consistent sequence:

1. Visual acuity: record each eye separately with correction/pinhole as the station permits.
2. Pupils: compare size and reactions; look for an RAPD when appropriate.
3. Colour vision: use plates or red desaturation if available and relevant.
4. Fields: perform confrontation testing if time and the scenario justify it.
5. Motility and diplopia: assess versions in the nine positions, then ask about diplopia rather than inferring it from a limited movement.
6. Fundus: look for disc swelling, pallor, choroidal folds or vascular congestion when the station allows.

Reduced acuity, altered colour perception, a relative afferent pupillary defect, visual-field change and disc swelling or pallor are examination findings that matter when compressive optic neuropathy is considered. The ATA/ETA consensus specifically lists acuity, colour vision, pupil testing and fundus examination in formal assessment, alongside ocular motility and proptosis documentation.² Do not say “there is no optic neuropathy” from one normal test. Say what you found and what you would complete.

This is also where candidates lose time. Do not test every extraocular movement twice because you have not chosen an order. Start in primary position, assess ductions systematically, note pain or restriction if present, and ask about diplopia. A full cranial-nerve screen may be appropriate in a real orbital evaluation; in a short station, state that you would complete it if time is limited.¹

Finish the eye, lids and surface

After visual function and motility, inspect and examine the structures that explain the observed appearance:

• lid position: retraction, lag, ptosis, closure and lagophthalmos;
• conjunctiva: injection, chemosis and prominent episcleral vessels;
• cornea: exposure or staining if the station provides a slit lamp;
• IOP: record it in primary gaze and, when relevant to the supplied scenario, explain that you would compare it in upgaze;
• anterior segment and fundus: complete the directed examination rather than listing findings you have not looked for.

Lid retraction, soft-tissue change, exposure, motility restriction and proptosis are documented domains in thyroid eye disease assessment, but none is diagnostic on its own.² In a viva, that distinction matters. “The lid signs make thyroid eye disease a differential” is defensible. “This is thyroid eye disease” is overconfident until history, systemic findings and relevant investigations support it.

For broader oculoplastics revision, use the oculoplastics study guide. It is a topic map, not a substitute for a live examination or local clinical protocol.

Turn observations into a short-case presentation

Your presentation should be short enough to say without losing the examiner. Use this four-part formula.

“This patient has [unilateral/bilateral] [axial/non-axial] proptosis with [direction] globe displacement. Visual function is [acuity/pupil/colour/field findings], and ocular motility shows [finding]. The lids, surface and fundus show [relevant findings]. My differential is organised by tempo and orbital compartment; I would correlate with a focused history, systemic examination and appropriate imaging.”

Then give only two or three defensible groups, shaped by the case:

Avoid memorising this table as a diagnostic algorithm. The published review emphasises that onset, pain, systemic history, examination features and imaging all contribute to the differential. Its value in an exam is that it keeps your answer structured.¹

Rehearse the sequence, not a monologue

Practise with a partner who has a stopwatch. On the first run, speak every step. On the second, remove all words that do not communicate an observation or planned examination. On the third, ask your partner to interrupt with a finding—“the patient has diplopia in upgaze” or “Hertel is asymmetric”—and reorganise the presentation without starting again.

Use this compact rehearsal card:

For repeated practical rehearsal, the OSCE, Practical & Viva Voce Ready bundle is OphthaMCQ’s practical-exam resource page. If a structured write-up format would help your practice, inspect Ophthalmology Case Presentation Format before deciding whether it fits your preparation. OphthaMCQ is independent and is not affiliated with RCOphth, ICO, AIOS, NBE or AAO.

Errors that make a competent candidate sound unsafe

Naming the diagnosis before the examination

Start with what you observe. A label can be tested later; an incomplete examination cannot be recovered by listing more diseases.

Giving a Hertel value without the base

“Twenty-two millimetres” is an incomplete record. State the base, both eye readings and side comparison. If no Hertel is present, say that you would quantify proptosis with it rather than inventing a measurement.

Equating proptosis with axial proptosis

Proptosis describes forward prominence. Axial versus eccentric displacement is an additional localisation observation. Make both statements when they are demonstrable.

Forgetting the visual-function screen

The globe position may be obvious; acuity, pupils, colour vision, fields and disc appearance show whether you have thought about optic-nerve function. In a short case, it is acceptable to state what you would complete if the station limits equipment or time.

Turning examination findings into management orders

This article is for exam education. In a real patient, urgency, investigation and treatment depend on the full clinical context, local systems and senior input. Keep your viva answer at the level of findings, priorities and appropriate escalation of assessment—not a prescription.

Final five-minute checklist

Before you finish, ask yourself: Did I compare both eyes? Did I describe laterality, direction and axial/eccentric pattern? Did I record or state how I would record Hertel base and both readings? Did I cover acuity, pupils, colour/fields when appropriate, movements/diplopia, lids/surface and fundus? Did I give a compartment-and-tempo differential rather than a diagnosis dump?

That sequence is what makes a proptosis short case reproducible. Learn the order until your words become a report of what you have actually examined.

Sources

1. Topilow NJ et al. Etiologies of Proptosis: A Review — systematic orbital history/examination, Hertel measurement, globe displacement, optic-nerve-function assessment and differential structure; checked 18 August 2026.
2. Douglas RS et al. ATA/ETA Consensus Statement on Management of Thyroid Eye Disease — standardised examination domains and documented visual, motility, proptosis, lid and exposure findings; checked 18 August 2026.
3. Butt S, Patel BC. Exophthalmos — definition, broad eye examination and exophthalmometry principle; accessed 18 August 2026 (updated 26 June 2023).