Exopthalmos - Clinicals, Diagnosis, and Management

Opthalmology

Clinicals - History

Fact Explanation
Abnormal potrusion of the eyeball Abnormal protrusion of the eyeball is called exophthalmos. The causes are endocrine, inflammatory, vascular, infective, neoplastic and traumatic. When exophthalmos occurs in Graves disease it usually occurs in young females. Abnormal potrusion of the eyeball
Abnormal protrusion of the eyeball is called exophthalmos. The causes are endocrine, inflammatory, vascular, infective, neoplastic and traumatic. When exophthalmos occurs in Graves disease it usually occurs in young females.
Protrusion of the eye ball The eye ball is in a rigid bony compartment and the only place where protrusion can occur is from the front. Protrusion of the eye ball
The eye ball is in a rigid bony compartment and the only place where protrusion can occur is from the front.
Pain in the eye There's an increase in volume within the fixed bony orbit and this may press on nerves and cause pain. The cause could also be trauma or inflammation which themselves cause pain. Pain in the eye
There's an increase in volume within the fixed bony orbit and this may press on nerves and cause pain. The cause could also be trauma or inflammation which themselves cause pain.
Change in visual acuity or refraction Inflammation of the orbital tissue may result in change in visual acuity and refraction. Change in visual acuity or refraction
Inflammation of the orbital tissue may result in change in visual acuity and refraction.
Diplopia, and decreased fields of vision Extra ocular muscles gets weakened due to inflammatory process and the eye movements get defective resulting in double vision Diplopia, and decreased fields of vision
Extra ocular muscles gets weakened due to inflammatory process and the eye movements get defective resulting in double vision
Transient visual loss or blackout periods This usually suggests optic nerve compression due to increased volume within the orbit. Transient visual loss or blackout periods
This usually suggests optic nerve compression due to increased volume within the orbit.
Goitre, Anxiety, heat intolerance, weight loss These are symptoms of hyperthyroidism. There are auto antibodies in Graves disease which damage tissues in the orbital mainly the fat and the extraocular muscles. Goitre, Anxiety, heat intolerance, weight loss
These are symptoms of hyperthyroidism. There are auto antibodies in Graves disease which damage tissues in the orbital mainly the fat and the extraocular muscles.

Clinicals - Examination

Fact Explanation
Proptosis of the eye The eye ball is in a rigid bony compartment and the only place where protrusion can occur is from the front. Proptosis of the eye
The eye ball is in a rigid bony compartment and the only place where protrusion can occur is from the front.
Eyelid lesions and tenderness in palpation Traumatic or inflammatory lesions in the eyelids are noted in inspection and tenderness can be elicited in palpation Eyelid lesions and tenderness in palpation
Traumatic or inflammatory lesions in the eyelids are noted in inspection and tenderness can be elicited in palpation
Chemosis Seen in graves ophthalmopathy due to inflammation. Chemosis
Seen in graves ophthalmopathy due to inflammation.
Engorged conjunctival vessels Inflammation may cause this Engorged conjunctival vessels
Inflammation may cause this
incomplete lid closure As the eye ball is protruded to front, eyelids may be difficult to be closed incomplete lid closure
As the eye ball is protruded to front, eyelids may be difficult to be closed
Pulsations of the globe on palpation Arterio-venous malformations may cause pulsations specially seen in cavernous sinus thrmobosis Pulsations of the globe on palpation
Arterio-venous malformations may cause pulsations specially seen in cavernous sinus thrmobosis
Regional lymph nodes Infective/ inflammatory cause or malignancy cause lymph node enlargement. Regional lymph nodes
Infective/ inflammatory cause or malignancy cause lymph node enlargement.
high flow state on auscultation of the orbit Orbital bruits may be heard in conditions like cavernous sinus thrombosis, fistulas high flow state on auscultation of the orbit
Orbital bruits may be heard in conditions like cavernous sinus thrombosis, fistulas
Decreased visual acuity, change of refraction Inflammation of the orbital contents may result in change in visual acuity and refraction Decreased visual acuity, change of refraction
Inflammation of the orbital contents may result in change in visual acuity and refraction
Eye ball movement defects This indicates dysfunction of the extraocular muscles due to weakening associated with inflammation Eye ball movement defects
This indicates dysfunction of the extraocular muscles due to weakening associated with inflammation
Dilated fundoscopic examination Optic atrophy due to long standing optic nerve compression may be observed. Dilated fundoscopic examination
Optic atrophy due to long standing optic nerve compression may be observed.
Goitre, tremors, increased sweating, tachycardia These are symptoms of hyperthyroidism. The auto antibodies in Graves disease attack the fat and extra ocular muscles and resultant inflammation produces exophthalmos Goitre, tremors, increased sweating, tachycardia
These are symptoms of hyperthyroidism. The auto antibodies in Graves disease attack the fat and extra ocular muscles and resultant inflammation produces exophthalmos

Investigations - Diagnosis

Fact Explanation
Thyroid function studies Patients with exophthalmos should undergo thyroid function studies to assess the thyroid status. Usually elevated free T4, T3 is seen with reduced TSH. Thyroid function studies
Patients with exophthalmos should undergo thyroid function studies to assess the thyroid status. Usually elevated free T4, T3 is seen with reduced TSH.
Full blood count When orbital cellulitis is suspected, full blood count may show high white blood cell counts. Full blood count
When orbital cellulitis is suspected, full blood count may show high white blood cell counts.
Blood culture When orbital cellulitis is suspected, blood for cultures are taken. Blood culture
When orbital cellulitis is suspected, blood for cultures are taken.
Nasal culture When orbital cellulitis is suspected, nasal secretions are taken to identify the portal of entry of the organism and to isolate the organism Nasal culture
When orbital cellulitis is suspected, nasal secretions are taken to identify the portal of entry of the organism and to isolate the organism
Intra-ocular pressure measurement Intra-ocular pressure may be high in Graves disease therefore measurement is done. Intra-ocular pressure measurement
Intra-ocular pressure may be high in Graves disease therefore measurement is done.
CT scan of the orbit This helps in evaluation of the orbit and to detect any masses if present. CT scan of the orbit
This helps in evaluation of the orbit and to detect any masses if present.
MRI of the orbit Excellent soft tissue enhancement is an advantage to do MRI even though it;s expensive or neither widely available. MRI of the orbit
Excellent soft tissue enhancement is an advantage to do MRI even though it;s expensive or neither widely available.
Ocular ultrasonography This helps to visualize masses if present and when combined with Doppler it's particularly useful to detect increased blood flow. Ocular ultrasonography
This helps to visualize masses if present and when combined with Doppler it's particularly useful to detect increased blood flow.

Investigations - Management

Fact Explanation
Thyroid function tests Patients with Graves disease should undergo the thyroid function studies to assess the thyroid status and this test is done in the follow up to assess thyroid status. Thyroid function tests
Patients with Graves disease should undergo the thyroid function studies to assess the thyroid status and this test is done in the follow up to assess thyroid status.
Thyroid function studies Patients with Graves disease should undergo the thyroid function studies to assess the thyroid status prior to surgical management of the goitre. Thyroid function studies
Patients with Graves disease should undergo the thyroid function studies to assess the thyroid status prior to surgical management of the goitre.
Full blood count To exclude anemia prior to surgery Full blood count
To exclude anemia prior to surgery
Coagulation studies To exclude any coagulopathy prior to surgery Coagulation studies
To exclude any coagulopathy prior to surgery
Renal function tests ( Serum Creatinine, eGFR, Blood urea nitrogen) To assess the fitness for anesthesia prior to surgery Renal function tests ( Serum Creatinine, eGFR, Blood urea nitrogen)
To assess the fitness for anesthesia prior to surgery

Management - Supportive

Fact Explanation
Patient education Patient education plays an important role and the patient should be educated regarding the etiology, nature, course and prognosis, available treatment options and importance of follow up. Advices should be given to avoid smoking as it has showed to increase the risk of ocular disease. Patient education
Patient education plays an important role and the patient should be educated regarding the etiology, nature, course and prognosis, available treatment options and importance of follow up. Advices should be given to avoid smoking as it has showed to increase the risk of ocular disease.
Elevation of the head end of the bed and taping of the eye lids This is thought to reduce the peri-orbital edema associated with exophthalmos also inability to close the eye completely during sleep Elevation of the head end of the bed and taping of the eye lids
This is thought to reduce the peri-orbital edema associated with exophthalmos also inability to close the eye completely during sleep
Wearing sungalsses If patient is having inability/ pain to look at light, sunglasses during the day light is helpful Wearing sungalsses
If patient is having inability/ pain to look at light, sunglasses during the day light is helpful
Ocular lubricants This will reduce the dryness of the eyes. Ocular lubricants
This will reduce the dryness of the eyes.

Management - Specific

Fact Explanation
Treatment for underlying Graves disease Medical therapy as Carbimazole, Proplythiouracil, Radio iodine treatment are helpful. Total thyroidectomy can also be an option Treatment for underlying Graves disease
Medical therapy as Carbimazole, Proplythiouracil, Radio iodine treatment are helpful. Total thyroidectomy can also be an option
Immunosuppressants Corticosteroids are inflammatory agents, therefore reduce the inflammation and Methotrexate is also used sometimes. Immunosuppressants
Corticosteroids are inflammatory agents, therefore reduce the inflammation and Methotrexate is also used sometimes.
Selenium therapy Increased generation of free radicals is thought to be seen in Graves disease and Selenium acts as an anti-oxidant. Studies have shown that it improves quality of life and slows the progression of the disease in patients with mild Graves' ophthalmopathy. Selenium therapy
Increased generation of free radicals is thought to be seen in Graves disease and Selenium acts as an anti-oxidant. Studies have shown that it improves quality of life and slows the progression of the disease in patients with mild Graves' ophthalmopathy.
Orbital radiotherapy This can be given if there's poor response to corticosteroids and can be used in conjunction with corticosteroids as well Orbital radiotherapy
This can be given if there's poor response to corticosteroids and can be used in conjunction with corticosteroids as well
Surgical management Surgical management may vary depending on the cause. Cavernous sinus fistula can be repaired and also thyroidectomy for Graves disease can be done. Sometimes extra ocular muscle surgery is also carried out. Surgical management
Surgical management may vary depending on the cause. Cavernous sinus fistula can be repaired and also thyroidectomy for Graves disease can be done. Sometimes extra ocular muscle surgery is also carried out.
Orbital decompression surgery Orbital bone segments may be removed in order to reduce the compression Orbital decompression surgery
Orbital bone segments may be removed in order to reduce the compression
Management of any underlying malignancy which causes exophthalmos Treatment depends on the type of tumour which causes exophthalmos Management of any underlying malignancy which causes exophthalmos
Treatment depends on the type of tumour which causes exophthalmos

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. ARISAKA O., HOSAKA A., ARAI H., FUJIWARA S., TADOKORO R., YABUTA K.. Graves' disease associated with exophthalmos, cerebral ventricular dilatation and accelerated growth. Archives of Disease in Childhood [online] 1997 January, 76(1):62-64 [viewed 24 August 2014] Available from: doi:10.1136/adc.76.1.62
  2. BARTALENA L., et al. Consensus statement of the European Group on Graves' orbitopathy (EUGOGO) on management of GO. European Journal of Endocrinology [online] 2008 March, 158(3):273-285 [viewed 24 August 2014] Available from: doi:10.1530/EJE-07-0666
  3. CHATTERJEE B H, GHOSH P K. Intermittent exophthalmos- report of three cases. Indian J Ophthalmol [online] 1966,14:246-9. [viewed 24 Aug 2014] Available from: http://www.ijo.in/text.asp?1966/14/6/246/38665
  4. DESAI BOBBY. A Case of Traumatic Proptosis. Case Reports in Emergency Medicine [online] 2013 December, 2013:1-3 [viewed 24 August 2014] Available from: doi:10.1155/2013/514328
  5. DOCHERTY P T. Acute endocrine exophthalmos.. British Journal of Ophthalmology [online] 1976 June, 60(6):481-485 [viewed 24 August 2014] Available from: doi:10.1136/bjo.60.6.481
  6. DUNTAS LEONIDAS H.. The Evolving Role of Selenium in the Treatment of Graves' Disease and Ophthalmopathy. Journal of Thyroid Research [online] 2012 December, 2012:1-6 [viewed 24 August 2014] Available from: doi:10.1155/2012/736161
  7. ECKARDT ANDRé M, LEMOUND JULIANA, RANA MAJEED, GELLRICH NILS-CLAUDIUS. Orbital lymphoma: diagnostic approach and treatment outcome. Array [online] 2013 December [viewed 24 August 2014] Available from: doi:10.1186/1477-7819-11-73
  8. FARLING P. A.. Thyroid disease. [online] 2000 July, 85(1):15-28 [viewed 24 August 2014] Available from: doi:10.1093/bja/85.1.15
  9. FICHTER N., GUTHOFF R. F., SCHITTKOWSKI M. P.. Orbital Decompression in Thyroid Eye Disease. ISRN Ophthalmology [online] 2012 December, 2012:1-12 [viewed 24 August 2014] Available from: doi:10.5402/2012/739236
  10. GONZALEZ MO, DURAIRAJ VD. Understanding pediatric bacterial preseptal and orbital cellulitis. Middle East Afr J Ophthalmol [online] 2010 Apr, 17(2):134-7 [viewed 24 August 2014] Available from: doi:10.4103/0974-9233.63074
  11. GOODYEAR P W A. Periorbital swelling: the important distinction between allergy and infection. Emergency Medicine Journal [online] 2004 March, 21(2):240-242 [viewed 24 August 2014] Available from: doi:10.1136/emj.2002.004051
  12. GWINUP GRANT. Effect on Exophthalmos of Various Methods of Treatment of Graves' Disease. JAMA [online] 1982 April [viewed 24 August 2014] Available from: doi:10.1001/jama.1982.03320400047033
  13. JONES D. I. R.. THE EFFECT OF METRONIDAZOLE ON EXOPHTHALMOS IN MAN. Journal of Endocrinology [online] 1968 August, 41(4):609-610 [viewed 24 August 2014] Available from: doi:10.1677/joe.0.0410609
  14. JURECKA-LUBIENIECKA BEATA, et al. Association between Polymorphisms in the TSHR Gene and Graves' Orbitopathy. PLoS ONE [online] 2014 July [viewed 24 August 2014] Available from: doi:10.1371/journal.pone.0102653
  15. KALMANN R., MOURITS M. P.. Prevalence and management of elevated intraocular pressure in patients with Graves' orbitopathy. British Journal of Ophthalmology [online] 1998 July, 82(7):754-757 [viewed 24 August 2014] Available from: doi:10.1136/bjo.82.7.754
  16. KAPLAN JOSHUA B, BODHIT AAKASH N, FALGIANI MICHAEL L. Communicating carotid-cavernous sinus fistula following minor head trauma. Array [online] 2012 December [viewed 24 August 2014] Available from: doi:10.1186/1865-1380-5-10
  17. KUBICKY R. A., FAERBER E. N., DE CHADAREVIAN J.-P., WU S., REZVANI I., DE LUCA F.. An Adolescent With a Mediastinal Mass, Diagnosed With Graves Disease and Thymic Hyperplasia. PEDIATRICS [online] December, 125(2):e433-e437 [viewed 24 August 2014] Available from: doi:10.1542/peds.2009-2204
  18. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 24 August 2014] Available from: doi:10.4103/0970-9185.81824
  19. KWAN A. S L, WILKINSON E., ADAMS G. G W. Recurrent proptosis and thyroid eye disease. Postgraduate Medical Journal [online] 1999 November, 75(889):689-691 [viewed 24 August 2014] Available from: doi:10.1136/pgmj.75.889.689
  20. LUBIN J. R., JALLOW S. E., WILSON W. R., GROVE A. S., ALBERT D. M.. Rhinoscleroma with exophthalmos: a case report.. British Journal of Ophthalmology [online] 1981 January, 65(1):14-17 [viewed 24 August 2014] Available from: doi:10.1136/bjo.65.1.14
  21. MARCOCCI CLAUDIO, et al. Selenium and the Course of Mild Graves' Orbitopathy. N Engl J Med [online] 2011 May, 364(20):1920-1931 [viewed 07 September 2014] Available from: doi:10.1056/NEJMoa1012985
  22. MCNAB A. A. Does radiotherapy have a role in the management of thyroid orbitopathy?. [online] 2002 January, 86(1):102-107 [viewed 24 August 2014] Available from: doi:10.1136/bjo.86.1.102
  23. OESTREICHER JAMES, MEHTA SONUL. Complications of Blepharoplasty: Prevention and Management. Plastic Surgery International [online] 2012 December, 2012:1-10 [viewed 24 August 2014] Available from: doi:10.1155/2012/252368
  24. STRIANESE DIEGO, et al. Methotrexate for the Treatment of Thyroid Eye Disease. Journal of Ophthalmology [online] 2014 December, 2014:1-5 [viewed 24 August 2014] Available from: doi:10.1155/2014/128903
  25. STRIANESE DIEGO, et al. Unilateral proptosis in thyroid eye disease with subsequent contralateral involvement: retrospective follow-up study. Array [online] 2013 December [viewed 24 August 2014] Available from: doi:10.1186/1471-2415-13-21
  26. TOMASETTI P., JACBOSEN C., GANDER T., ZEMANN W.. Emergency decompression of tension retrobulbar emphysema secondary to orbital floor fracture. Journal of Surgical Case Reports [online] December, 2013(3):rjt011-rjt011 [viewed 24 August 2014] Available from: doi:10.1093/jscr/rjt011
  27. WEBER FP. Case of Exophthalmos probably caused by Non-suppurative Cavernous Sinus Thrombosis Proc R Soc Med [online] 1923, 16(Clin Sect):41-43 [viewed 05 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2103857