Exophthalmos

Exophthalmos: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Grave disease

❑ Familial

❑ Orbital asymmetry

❑ Orbital cellulitis

❑ Cavernous sinus thrombosis

❑ Orbital hemorrhage/emphysema

❑ Intracavernous carotid artery aneurysm

❑ Arteriovenous fistula

❑ Carotid-cavernous sinus fistula

❑ Orbital tumor

❑ Pituitary apoplexy

❑ Meningioma

Diagnostic Approach

The patient may present with exposure keratitis, resulting from an inability to close the eyelid fully, or with diplopia resulting from unilaterally impaired extraocular movement. By standing behind the patient, tilting the head back, and viewing down the brow ridge, as little as 2 mm of eye protrusion can be detected.

Unilateral pulsating proptosis can be caused by an AV fistula between the internal carotid and the cavernous sinus in a basilar skull fracture, by an aneurysm of the ophthalmic artery, or by a rapidly enlarging and highly vascular orbital neoplasm. These vascular lesions produce a pulsating tinnitus and a dimming of vision.

Clinical Findings

Grave disease  Eye phenomena may range from a mild stare (a look of alarm or surprise) to lid lag and proptosis; to marked protrusion, edema, limitation of extraocular movements, and optic nerve compression. Other signs of hyperthyroidism such as an enlarged thyroid with a bruit, tachycardia, and symptoms of hypermetabolism are usually evident, but the degree of proptosis does not parallel the degree of hyperthyroidism.

Familial  The patient will have had bulging eyes all his or her life and often has relatives with a similar appearance.

Orbital asymmetry  The illusion of exophthalmus may be produced by severe unilateral myopia, facial nerve paresis, or enophthalmos of the opposite eye.

Orbital cellulitis  Usually a result of direct extension of a sinusitis, this cellulitis causes prominent and rapidly evolving erythema, lid edema, proptosis, chemosis, retro-orbital pain, and fever.

Cavernous sinus thrombosis  The eyes are protruded with the lids red and engorged. There is ophthalmoplegia, hypesthesia of the upper face, and a dilated fixed pupil. Mental status changes occur in 50% and meningismus in 40%. The precipitating cause is sinusitis, periorbital cellulitis, or a furuncle.

Orbital hemorrhage/emphysema  Sudden protrusion follows strenuous physical effort. Ecchymoses do not appear initially.

Intracavernous carotid artery aneurysm  Retro-orbital pain occurs in combination with diplopia and third, fourth, or sixth cranial nerve paresis. A giant aneurysm may compress the chiasm, producing a visual field defect.

Arteriovenous fistula  Findings include a pulsating globe and a bruit that decreases with ipsilateral carotid compression.

Carotid-cavernous sinus fistula  It presents with a diffusely congested orbit with exophthalmos, prominent episcleral vessels, and elevated intraocular pressure. Ophthalmoplegia with supratemporal gaze and a palpable orbital pulsation with a bruit are additional findings.

Orbital tumor  There is painless, progressive proptosis and visual loss.

Pituitary apoplexy  Apoplexy presents acutely with severe retro-orbital pain, cranial nerve defects, and a central scotoma.

Meningioma  An orbital ridge meningioma can deform the bony structure, causing proptosis and unilateral visual loss.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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