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ULY CLINIC

9 Septemba 2025, 05:29:46

Exophthalmos

Exophthalmos, or proptosis, is the abnormal protrusion of one or both eyeballs caused by hemorrhage, edema, inflammation behind the eye, extraocular muscle relaxation, or space-occupying intraorbital lesions and tumors. Onset may be sudden or gradual, with mild to dramatic protrusion, occasionally accompanied by pulsation of the affected eye. The most common cause in adults is dysthyroid eye disease (Graves’ orbitopathy). Differentiation from lid retraction or ptosis is critical: an exophthalmometer can accurately measure ocular protrusion.

Pathophysiology

Exophthalmos results from increased orbital volume due to inflammation, edema, hemorrhage, tumor growth, or fat deposition. Common mechanisms include:

Autoimmune-mediated tissue expansion (e.g., Graves’ disease)
Orbital infection or cellulitis
Orbital tumors (benign or malignant)
Trauma or sinus pathology leading to orbital emphysema
Vascular congestion (e.g., cavernous sinus thrombosis)

These changes can impair extraocular muscle function, cause diplopia, and compromise corneal integrity. Chronic or severe protrusion may lead to exposure keratopathy and optic nerve compression.

Clinical Assessment

History Taking

Onset, duration, and progression of protrusion
Associated eye pain, diplopia, foreign body sensation, or dryness
Visual changes, blurred vision, or photophobia
History of thyroid disease, systemic autoimmune disorders, sinus infections, trauma, or tumors
Drug history, including steroids or immunosuppressants
Pediatric considerations: age-related tumors (optic nerve glioma, rhabdomyosarcoma), syndromic features (Hand-Schüller-Christian syndrome)

Physical Examination

Assess symmetry, degree of protrusion using exophthalmometer
Check eyelid position for retraction or ptosis
Examine cornea for cloudiness, ulceration, or exposure keratopathy
Assess extraocular movements and visual acuity
Palpate for orbital masses, tenderness, or crepitus
Thyroid examination for goiter or nodules
Pediatric/geriatric special considerations (age-specific etiologies, fragile orbital structures)

Table 1: Causes of Exophthalmos – Distinguishing Features and Key Clinical Information

Cause	Clinical Features / Distinguishing Signs	Distribution / Pattern	Other Key Information / Considerations
Graves’ Disease (Thyroid Eye Disease)	Bilateral or asymmetric proptosis, eyelid retraction, lid lag, tearing, photophobia, diplopia	Usually bilateral; asymmetry possible	Autoimmune; commonly adults 30–60 years; may have systemic hyperthyroidism signs
Cavernous Sinus Thrombosis	Sudden, pulsatile unilateral exophthalmos, eyelid edema, impaired eye movements, decreased pupillary reflexes, fever, headache	Unilateral	Life-threatening; often secondary to facial or sinus infection; requires immediate anticoagulation and antibiotics
Orbital Cellulitis	Painful, erythematous eyelid, fever, conjunctival injection, impaired extraocular movement	Usually unilateral	Often secondary to sinusitis; ophthalmic emergency; risk of vision loss
Dacryoadenitis	Slowly progressive unilateral exophthalmos, ptosis, eyelid edema, limited extraocular movement, diplopia	Unilateral	Usually viral or bacterial; treat underlying infection; supportive care
Orbital Tumors (Hemangioma, Leiomyosarcoma, Lacrimal Gland Tumor, Choristoma)	Gradual onset, unilateral or bilateral, may have diplopia, ptosis, vision changes, pain	Unilateral or bilateral depending on tumor	Imaging required; biopsy for diagnosis; age-specific prevalence (hemangioma: young adults; leiomyosarcoma: >45 years)
Orbital Emphysema	Air in orbit causing unilateral protrusion; crepitus on palpation	Unilateral	Usually post-trauma or sinus fracture; may require decompression if vision threatened
Parasite Infestation	Progressive, painless exophthalmos; limited eye movement; diplopia	Unilateral, may spread	Consider endemic parasitic infections; treat systemic cause
Scleritis (Posterior)	Gradual unilateral exophthalmos with severe eye pain, diplopia, papilledema	Unilateral	Often autoimmune; systemic evaluation needed
Pediatric Tumors (Optic Nerve Glioma, Rhabdomyosarcoma)	Rapid onset, unilateral, possible proptosis with pain or visual loss	Unilateral	Age-specific; urgent imaging and oncology referral required
Thyrotoxicosis (without Graves’ orbitopathy)	Sometimes bilateral exophthalmos, lid lag, ptosis, tearing	Bilateral or mild asymmetry	Exophthalmos not always present; systemic hyperthyroid signs may dominate

Emergency Interventions & Supportive Care

Cause / Condition	Emergency Interventions	Supportive Care / Monitoring
Graves’ Orbitopathy with Severe Proptosis	Assess vision and corneal exposure; ophthalmology referral; corticosteroids if active inflammation	Lubricating drops; tape eyelids at night; monitor for optic neuropathy
Orbital Cellulitis	Hospitalization; IV antibiotics; monitor for sepsis	Daily ophthalmic exam; imaging if abscess suspected; manage fever and hydration
Cavernous Sinus Thrombosis	ICU admission; IV antibiotics; anticoagulation	Monitor neurological status; manage complications (seizures, visual loss)
Rapidly Expanding Orbital Tumor	Urgent imaging; surgical evaluation if compressive	Eye protection; manage pain and diplopia; oncology referral
Orbital Emphysema	Monitor vision; needle decompression if severe	Avoid Valsalva; manage underlying sinus or trauma cause
Parasite Infestation	Treat systemic infection	Monitor eye movements and vision; supportive care for inflammation
Pediatric Tumors	Urgent referral to pediatric oncology/ophthalmology	Protect eye; monitor vision; address systemic symptoms

Special Considerations

Protect the cornea from exposure and trauma; avoid covering with gauze that may abrade the epithelium.
Emotional support and privacy are important due to cosmetic and psychosocial concerns.
Pediatric and geriatric populations may present atypically and require age-specific evaluation.
Imaging (CT or MRI) is often required to determine etiology and extent.
Laboratory studies may include thyroid panel, CBC, and markers of infection or inflammation.

Patient Counseling

Protect eyes from trauma, dust, wind, and sunlight.
Use lubricating drops as prescribed and educate on proper application.
Report any rapid progression, visual changes, or eye pain immediately.
Adherence to systemic therapy for underlying conditions (thyroid, infection, autoimmune) is essential.

Conclusion

Exophthalmos is the abnormal protrusion of the eyeball due to orbital inflammation, tumors, infection, or autoimmune disorders. Early identification of etiology, prompt emergency intervention for vision-threatening causes, and supportive ocular care are critical for optimal patient outcomes.

References

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