Exophthalmos [Proptosis]
Exophthalmos—the abnormal protrusion of one or both eyeballs—may result from hemorrhage, edema, or inflammation behind the eye; extraocular muscle relaxation; or space-occupying intraorbital lesions and metastatic tumors. This sign may occur suddenly or gradually, causing mild to dramatic protrusion. Occasionally, the affected eye also pulsates. The most common cause of exophthalmos in adults is dysthyroid eye disease.
Exophthalmos is usually easily observed. However, lid retraction may mimic exophthalmos even when protrusion is absent. Similarly, ptosis in one eye may make the other eye appear exophthalmic by comparison. An exophthalmometer can differentiate these signs by measuring ocular protrusion.
History and physical examination
Begin by asking when the patient first noticed exophthalmos. Is it associated with pain in or around the eye? If so, ask him how severe it is and how long he has had it. Then ask about recent sinus infection or vision problems. Take the patient’s vital signs, noting fever, which may accompany an eye infection. Next, evaluate the severity of exophthalmos with an exophthalmometer. (See Detecting unilateral exophthalmos.) If the eyes bulge severely, look for cloudiness on the cornea, which may indicate ulcer formation. Describe any eye discharge and observe for ptosis. Then check visual acuity, with and without correction, and evaluate extraocular movements. Palpate the patient’s thyroid for enlargement or goiter.
Medical causes
Cavernous sinus thrombosis
This disorder usually causes sudden onset of pulsating unilateral exophthalmos. Accompanying it may be eyelid edema, decreased or absent pupillary reflexes, limited extraocular movement, and impaired visual acuity. Other features include high fever with chills, papilledema, headache, nausea, vomiting, somnolence and, rarely, seizures.
Dacryoadenitis
Unilateral, slowly progressive exophthalmos is the most common sign of dacryoadenitis. Assessment may also reveal limited extraocular movement (especially on elevation and abduction), ptosis, eyelid edema and erythema, conjunctival injection, eye pain, and diplopia.
Foreign body in the eye
When a foreign body enters the eye, exophthalmos may accompany other signs and symptoms of ocular trauma, such as eye pain, redness, and tearing.
Hemangioma
Most common in young adults, this orbital tumor produces progressive exophthalmos, which may be mild or severe and unilateral or bilateral. Other signs and symptoms include ptosis, limited extraocular movement, and blurred vision.
Hodgkin’s disease
In this disorder, unilateral exophthalmos may develop gradually along with eyelid edema, diplopia, and a palpable eyelid mass. More characteristic findings include painless swelling of one or more lymph nodes, intermittent fever, weight loss, fatigue, malaise, night sweats, hepatosplenomegaly, and pruritus.
Lacrimal gland tumor
Exophthalmos usually develops slowly in one eye, causing its downward displacement toward the nose. The patient may also have ptosis and eye deviation and pain.
Leiomyosarcoma
Most common in people ages 45 and older, this tumor is characterized by slowly developing unilateral exophthalmos. Other effects include diplopia, impaired vision, and intermittent eye pain.
Leukemia
When leukemia causes intraorbital hemorrhage, mild to moderate bilateral exophthalmos and lacrimal gland enlargement also result. Associated signs and symptoms include bleeding tendency, fever, arthralgia, pallor, weakness, hepatosplenomegaly and, possibly, lymphadenopathy.
Lymphangioma
Hemorrhage of this congenital tumor causes unilateral or bilateral exophthalmos, among other signs.
Neuroblastoma
This highly malignant tumor, the most common extracranial solid tumor of childhood, may produce exophthalmos.
Ocular tuberculosis
Occasionally, this rare disease causes progressive exophthalmos accompanied by ptosis, painless eyelid edema and erythema, and enlarged lacrimal glands. Examination may reveal yellow or white fat deposits on the cornea and small white nodules in the iris.
Optic nerve meningioma
This tumor usually produces unilateral exophthalmos and a swollen temple. Impaired visual acuity, visual field deficits, and headache may occur.
Orbital cellulitis
Commonly the result of sinusitis, this ocular emergency causes sudden onset of unilateral exophthalmos, which may be mild or severe. Orbital cellulitis may also produce eye pain, conjunctival injection, tearing, eyelid edema and erythema, a purulent discharge, and limited extraocular movement as well as fever, headache, and malaise.
Orbital choristoma
A common sign of this benign tumor, progressive exophthalmos may be associated with diplopia and blurred vision.
Orbital emphysema
Air leaking from the sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation.
Orbital pseudotumor
Progressive unilateral exophthalmos characterizes this uncommon disorder. Limited extraocular movement, eyelid edema, eye pain, and diplopia may also occur.
Parasite infestation
Usually, this disorder causes painless progressive exophthalmos in one eye that may spread to the other eye. Associated findings include limited extraocular movement, diplopia, eye pain, and impaired visual acuity.
Scleritis (posterior)
Gradual onset of mild to severe unilateral exophthalmos is common in scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.
Thyrotoxicosis
Although a classic sign of this disorder, exophthalmos is absent in many patients. It’s usually bilateral, progressive, and severe. Associated ocular features include ptosis, increased tearing, lid lag and edema, photophobia, conjunctival injection, diplopia, and decreased visual acuity. Other findings include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, sweating, diarrhea, tremors, palpitations, and tachycardia.
Special considerations
Exophthalmos usually makes the patient self-conscious, so provide privacy and emotional support. Protect the affected eye from trauma, especially drying of the cornea. However, never place a gauze eye pad or other object over the affected eye; removal could damage the corneal epithelium. If a slit-lamp examination is indicated, explain the procedure to the patient. If necessary, refer him to an ophthalmologist for a complete examination. The cause of exophthalmos determines the therapy. Prepare the patient for blood tests, such as a thyroid panel and a white blood cell count.
Pediatric pointers
In children around age 5, a rare tumor—optic nerve glioma—may cause exophthalmos. Rhabdomyosarcoma, a more common tumor, usually affects children between ages 4 and 12 and produces rapid onset of exophthalmos. In Hand-Schüller-Christian syndrome, exophthalmos typically accompanies signs of diabetes insipidus and bone destruction.
Pictures
![Exophthalmos [Proptosis] - 2572.png](/bookimages/8/2572.png)
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Bulging eyes
» Next page: Eye pain [Ophthalmalgia] (Professional Guide to Signs & Symptoms (Fifth Edition))
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