Exophthalmos

Exophthalmus or eye protrusion is a condition where one or both eyes are pushed forward due to increased orbital contents. When exophthalmos is mentioned, we usually think of the “bulging” of the eyes that occurs in patients with hyperthyroidism with a developed clinical picture. The most common occurrence of exophthalmos is precisely within this disorder and is called Graves-Bazedov’s disease. It develops gradually, one eye can lead, but it is most often bilateral, without pain.

Figure 1. Bilateral exophthalmos-Graves Bezedov’s disease

Bilateral protrusion can also occur in severe obesity due to the accumulation of retrobulbar fat tissue, as well as in Cushing’s syndrome.

Unilateral exophthalmos is found in:

  • Tumor etiology / tumor growth of the orbit – eye socket (primary benign or malignant or secondary – metastases)
  • Infections of the orbital contents / bacterial – cellulitis, phlegmon or abscess of the orbit (transmission of infection from the sinuses, tooth roots or septic embolus from distant parts of the body) / – fungal infections.
  • Inflammatory etiology / pseudotumor of the orbit
  • Bleeding into the orbit due to severe maxillofacial injuries
  • Vascular etiology/-occurrence of carotid-cavernous fistula most often as a result of injury-pulsatile exophthalmos, cavernous sinus thrombosis

Figure 2. Unilateral protrusion a) CA breast metastasis in the orbit on the left b) clearly limited benign tumor in the orbit on the right

Protrusion of the eye should be distinguished from an enlarged eye, in children of the youngest age it can be due to congenital glaucoma, as well as in the context of high myopia.

During the examination, a detailed history should first be taken: when the condition started, in one or both eyes, suddenly or gradually, whether it was accompanied by eye pain, whether there is pain during eye movements, the presence of double images, noise in the head, headache. Are there signs of:

  • infections in the body (elevated body temperature, sweating, weakness)
  • previous injury-circumstances
  • signs of hyperthyroidism (palpitations, sweating, insomnia, tremors)
  • Request laboratory analyzes (KKS, SE, CRP, coagulation status, T3, T4, TSH)

An ophthalmological examination should begin with:

  • visual acuity test
  • By measuring the intraocular pressure (increased volume of orbital contents puts pressure on the veins that drain the aqueous humor and there is a risk of secondary glaucoma)
  • Macroscopic examination, the presence of retraction of the upper eyelid with visible sclera above the limbus – frightened appearance, retraction of the lower eyelid, thickened orbital part of the upper eyelid, redness – emphasis on the blood vessels of the bulbar conjunctiva

Figure 3. Typical appearance of a patient with hyperthyroidism and Graves’ disease

Lid lag, the phenomenon that when looking down, the upper eyelid lags behind – Von Greffe’s sign.

Figure 4. Von Grafe’s sign

  • Examination of the anterior segment of the eye on a biomicroscope
  • Staining of the tear film with fluorescein is performed in order to detect defects in the epithelial layer of the cornea. Protrusion leads to stronger exposure of the front segment of the eye to the conditions of the external environment, the front surface of the eye becomes more pronounced dry, dry spots are irritated, subjectively patients feel scratching, burning, reflex tearing, loss of vision)
  • Eye protrusion can be measured objectively with an exophthalmometer according to Hertel and thus monitor the condition

Figure 5. Measurement of the degree of eyeball protrusion – Exophthalmometry according to Hertel

  • Examination of the fundus, looking at the condition of the optic nerve, which can suffer due to the pressure of the increased contents of the orbit
  • The most objective way to monitor the optic nerve is through OCT (Optical Coherence Tomography), which shows the thickness of the nerve fiber layer.
  • In the case of double images, it is necessary to objectify the problem with the Hess-Lancaster test
  • CT / MRI to detect tumors/hemorrhages/cysts

Therapy:

  • In the initial phase, it is enough to moisten the surface of the eye with drops and during the night with gels and vitamin ointments
  • In case of increased intraocular pressure – prescribe anti-glaucoma drops and regularly monitor eye pressure
  • Extreme cases in which there is a decrease in vision, double images, damage to the visual field – pulse corticosteroid therapy is advised under the control of an endocrinologist in hospital conditions
  • The most severe cases require surgical treatment – decompression of the orbit

The emergency is: elevated body temperature, chills, shivering, eye pain, headache, immobility of the eye, double images, redness of the eye.

Contact the ophthalmologist on time!