EXOPHTHALMOS
The mnemonic VINDICATE is a useful and quick way to recall the causes of exophthalmos (for enophthalmos see the section on ptosis, page 441).
- V—Vascular disorders include a carotid–cavernous fistula and cavernous sinus thrombosis.
- I—Inflammatory diseases recall orbital cellulitis, osteomyelitis, and sinusitis.
- N—Neoplasms suggest hemangiomas, lymphangiomas, sarcomas, metastatic carcinoma, and nervous system tumors such as sphenoid ridge meningiomas.
- D—Deficiency diseases suggest the retroorbital hemorrhages of scurvy.
- Degenerative diseases suggest the apparent exophthalmos of facial palsy associated with progressive muscular atrophy and dystrophy in many forms.
- I—Intoxication suggests the exophthalmos that develops or progresses on treatment in hyperthyroidism. Idiopathic diseases such as Paget disease and fibrous dysplasia of the skull must also be considered.
- C—Congenital brings to mind hydrocephalus, Hand–Schüller–Christian disease, meningoceles, and cleidocranial dystosis, all of which cause exophthalmos. In this category, one should also include the genetic exophthalmos of blacks.
- A—Autoimmune disorders suggest Wegener granulomatosis.
- T—Trauma suggests orbital fractures and hematomas, which will cause proptosis in many cases.
- E—Endocrine disorders suggest that the most significant cause of exophthalmos is Graves disease.
If exophthalmos can be classified as a result of a mass, then the causes can be recalled by the methods applied to any mass. The mass may be air (orbital emphysema), fluid (orbital abscess), blood (e.g., hematomas from trauma, scurvy, hemophilia), a foreign substance (e.g., echinococcal cyst), or hypertrophy of one of the tissues around the orbit. The latter can be developed by a histologic analysis. Thus,
fat may hypertrophy or multiply in Hand–Schüller–Christian disease and in exophthalmic goiter.
Blood vessels may become hypertrophied in cavernous sinus thrombosis, carotid–cavernous fistulas, and aneurysms and will undergo hyperplasia in hemangiomas.
Lymph tissue and
connective tissue may form sarcomas or granulomas.
Bone may swell with a periosteitis and may undergo hyperplasia in Paget disease, osteomas, metastatic carcinoma, and meningiomas.
Nerve tissue may undergo hyperplasia in neurofibromatosis.
EXOPHTHALMOS
Approach to the Diagnosis
Because bilateral exophthalmos is usually due to hyperthyroidism, a thyroid profile must be done. The most useful in this profile are the total T4 level by immunoassay, the free thyroxine index, and the RAI uptake and scan. A total T3 by immunoassay should be done to exclude T3 thyrotoxicosis. Because bilateral exophthalmos can occur without hyperthyroidism, testing for thyrotropin receptor antibody and peroxidase antibodies must be done if thyroid function tests are negative. With exophthalmos, chemosis, and ecchymosis, the patient should be hospitalized for a workup of cavernous sinus thrombosis and a neurologist consulted. When there is unilateral exophthalmos, ultrasonography and angiography will rule out carotid–cavernous fistula and a cystic lesion. A CT scan of the brain and orbits will rule out tumors and abscess. It is wise to consult a neurologist, ophthalmologist, or endocrinologist to assist in this workup.
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Bulging eyes
» Next page: EYE PAIN (Differential Diagnosis in Primary Care)
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