Exophthalmos
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. Also known as proptosis, 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
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 the pain is and how long he has had it. Then ask about recent sinus infection or vision problems.
Physical assessment
Begin the assessment by taking the patient’s vital signs, noting fever, which may accompany 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
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. Loss of vision or blurred vision may occur in the affected eye.
Hemangioma
Most common in young adults, hemangioma is an orbital tumor that produces progressive exophthalmos, which may be mild or severe, unilateral or bilateral. Other signs and symptoms include ptosis, limited extraocular movements, and blurred vision.
Lacrimal gland tumor
In patients with a lacrimal gland tumor, exophthalmos usually develops slowly in one eye, causing its downward displacement toward the nose. The patient may also have ptosis, eye deviation, and pain.
Optic nerve meningioma
An optic nerve meningioma 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, orbital cellulitis is an ocular emergency that causes sudden onset of unilateral exophthalmos, which may be mild or severe. It may also produce fever, eye pain, headache, malaise, conjunctival injection, tearing, eyelid edema and erythema, purulent discharge, and impaired extraocular movements.
Orbital choristoma
A common sign of orbital choristoma (a benign tumor), progressive exophthalmos may be associated with diplopia and blurred vision. A mass may be visible in the orbital area.
Orbital emphysema
With orbital emphysema, air leaking from the sinus into the orbit usually causes unilateral exophthalmos. Palpation of the globe elicits crepitation. The patient may report orbital pressure.
Parasite infestation
Usually, parasite infestation 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 with scleritis. Other signs and symptoms include severe eye pain, diplopia, papilledema, limited extraocular movement, and impaired visual acuity.
Thyrotoxicosis
Although a classic sign of thyrotoxicosis, 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 any 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
Rhabdomyosarcoma 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.
Patient counseling
Teach the patient to protect his eyes from trauma and to avoid exposure to wind and dust. Demonstrate how to apply lubricants to prevent corneal drying. Encourage the patient to verbalize his feelings about changes in body image.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Goiter
Read excerpts from these other book chapters related to Goiter:
Medical Books Excerpts
- Thyroid Nodule
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Goiter
- "The 5-Minute Pediatric Consult" (2008)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Goiter
» Next page: Thyroid enlargement (Nursing: Interpreting Signs and Symptoms)
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