Pathologic protrusion of the eyeball is referred to as exophthalmos and can be attributed to many different causes. In all cases, exophthalmos is not a disease in its own right, but rather an accompanying symptom of an underlying disease.
What is exophthalmos?
Exophthalmos refers to a pathologic protrusion of one or both eyeballs (bulbus oculi) from the orbit (eye socket) that can be attributed to a variety of causes. Accordingly, exophthalmos is not an independent clinical picture, but a secondary symptom of an underlying disease, which is divided into six stages or degrees depending on its severity. As a result of the protrusion of the eyeball, the mobility of the eyeball is restricted and closing of the eyelids becomes difficult or impossible (grade I). As the disease progresses, chemosis (conjunctival edema) and photophobia develop (grade II), while the protrusion of the eyeball becomes prominent (grade III). In addition, exophthalmos may manifest as double vision or blurred vision due to impairment of the orbital nerves and eye muscles (grade IV), xerophthalmia (corneal desiccation) and/or lagophthalmos (desiccation of the eyeball), and inflammation and ulceration of the cornea (grade V). If the optic nerve (optic nerve) is markedly involved, exophthalmos can lead to visual deficits and even loss of vision.
Causes
Exophthalmos can be attributed to a variety of causes as a secondary symptom of the individual underlying disease. For example, endocrine exophthalmos is caused by autoimmune diseases such as Graves’ disease or Hashimoto’s thyroiditis, in which autoimmune-induced processes can lead to inflammation of the orbital adipose tissue and swelling of the retrobulbar (posterior to the eyeball) structures so that the eyeball is displaced anteriorly. As a result of trauma, the orbital arteries and veins may short-circuit, causing pulsation and protrusion of the eyeball (unilateral exophthalmos pulsans). Blunt trauma can induce exophthalmos via retrobulbar hematoma. In addition, orbital phlegmon (bacterial inflammation of the orbit), which is associated with diffuse inflammation of the orbit and swelling of the orbital structures, and orbital tumors (including hemangioma, neuro-, retinoblastoma) may displace the eyeball anteriorly by their growth, causing exophthalmos. A genetic or acquired varicosis (varicose vein) in the orbital region can cause a so-called exophthalmus intermittens via blood stasis. In addition, myopia (pronounced myopia), dyscrania (cranial malformations), and aneurysms and thromboses of the cerebral veins can cause exophthalmos.
Symptoms, complaints, and signs
First and foremost, exophthalmos results in severely protruding eyeballs. These have a very negative effect on the aesthetics of the affected person, so that many patients with exophthalmos also suffer from depression or other psychological complaints and moods. The quality of life of the affected person is significantly reduced by the disease. Often, the disease also leads to pain in the eyes and various visual complaints. This results in veil vision or double vision. In general, the disease also has a negative effect on the vision of the affected person, so that patients are dependent on glasses in their daily lives. The eyes of the affected person appear very dry due to the exophthalmos, whereby especially the cornea dries out. The cornea can also become inflamed. If this inflammation is not treated, the affected person may go completely blind. Whether the disease can be treated easily or not, however, depends very much on the underlying disease. As a rule, the causative disease is also associated with various symptoms and complaints, although no general statement can be made about this. However, the patient’s life expectancy is not negatively affected by the disease.
Diagnosis and course
During a clinical examination of the eyes, the extent of exophthalmos and a possible lateral difference, which provides initial clues regarding the cause, can be determined. An exophthalmometer can be used to determine the progression of the protrusion.Imaging procedures such as computer and resonance tomography as well as sonography and X-ray examination can be used to visualize the orbital structures as well as any inflammations or tumors. A blood analysis with determination of thyroid values (including thyroxine, TRH, autoantibodies) or inflammation markers (including leukocytes, C-reactive protein) enables statements to be made about thyroid disease or existing inflammation (orbital phlegmon). In addition, arteriovenous short circuits can be diagnosed during auscultation (diagnostic detection of the pulse-synchronous sound). Course Prognosis and course in exophthalmos depend largely on the underlying disease and its therapeutic success.
When should you see a doctor?
Exophthalmos must always be examined and treated by a physician. With this disease, self-healing does not occur, so a doctor must be consulted in any case. The doctor should be consulted if the affected person suffers from eye pain. Protruding eyeballs may also indicate exophthalmos and should be examined. Various visual disturbances, such as double vision or veil vision, may also be indicative of this condition. If these visual complaints occur suddenly and cannot be alleviated by visual aids, an examination by a physician must be performed. Dry eyes can also be an indication of the disease. Furthermore, inflammation of the cornea is also a symptom of exophthalmos and must also be examined. As a rule, the ophthalmologist is consulted in case of this disease. If it is an emergency, the nearest hospital can be visited. Further treatment of the disease is also carried out in a hospital. In most cases, the course of the disease is positive and there are no further complaints. The life expectancy of the patient is also not negatively affected by the disease in most cases.
Treatment and therapy
Therapeutic measures in cases of exophthalmos are based on the individual triggering underlying disease and aim to prevent complications such as malignant exophthalmos, corneal ulceration, conjunctivitis, or glaucoma. If the exophthalmos is preceded by an orbital phlegmon or an abscess (accumulation of pus in the tissue), these can be treated with antibiotics. If necessary, these should be opened for relief and drained during a surgical procedure. Retrobulbar fatty tissue and tumors that displace the eyeball anteriorly due to their growth can also be surgically removed. In some cases, a tarsorrhaphy may also be necessary. In this case, the eyelid fissure is surgically reduced by temporal suturing of the lower and upper eyelid to ensure closure of the eyelids and accordingly to avoid damage to the cornea or the eyeball (e.g. dehydration). To avoid dehydration and structural damage of the cornea, a consistent eye care and artificial moistening of the eyes with synthetic tears is recommended. If exophthalmos results from underlying diseases such as Graves’ disease or thyroid disease, these must be adequately and specifically treated to induce permanent regression of the protrusion.
Outlook and prognosis
The prognosis of exophthalmos is always dependent on the underlying disease and proper treatment. In some cases, complete regression of exophthalmos may occur if the underlying disease is successfully treated. For example, abscesses located behind the eyeballs are treated with antibiotics and sometimes surgically. Tumors in the eye socket must be surgically removed. If hyperthyroidism in Graves’ disease is responsible for the protrusion of the eyeballs, this must be treated as a priority. However, the eyes should additionally be artificially moistened and cared for to prevent dehydration. Without these measures, ulceration of the cornea may occur. In severe cases, the optic nerve is also affected. This can lead to visual loss or even complete loss of vision. Further complications may include conjunctivitis, increased intraocular pressure (glaucoma) or even malignant exophthalmos. Malignant exophthalmos is characterized by painful and progressive protrusion of the eyeballs. As a consequence, the closure of the eyelids is disturbed.The cornea dries out very severely. If left untreated, exophthalmos rarely resolves on its own. Above all, irreversible eye damage usually occurs. However, with successful treatment of the underlying disease and simultaneous intensive eye care, an exophthalmos can heal without consequences. Eye care consists primarily of moistening the eyes with artificial tears.
Prevention
Exophthalmos cannot be prevented in every case. However, underlying diseases such as Graves’ disease or thyroid disease should be treated consistently to minimize the risk of manifestation of exophthalmos.
Follow-up
Options for follow-up care are not available to the affected person in most cases of exophthalmos. In this regard, the condition must be properly treated by a physician in all cases, as it severely limits the affected person’s daily life and also significantly reduces the patient’s quality of life. To prevent further complications, early treatment of exophthalmos is very important. Furthermore, however, treatment of the underlying disease should also be carried out in order to completely alleviate the complaint. The treatment itself is usually supported with the help of antibiotics. Those affected should ensure that these medications are taken correctly and regularly. In this context, side effects or other interactions with other medications may also need to be taken into account, although a doctor should be consulted. When taking antibiotics, alcohol should be avoided so as not to weaken their effect. Furthermore, many patients depend on artificial moistening of the eyes to treat the symptoms of exophthalmos. The eyes should be moistened regularly to prevent the cornea from drying out. In most cases, the condition can be treated relatively well, with no reduction in the patient’s life expectancy.
Here’s what you can do yourself
In most cases, unfortunately, no type of self-help is possible for this disease. It is also not possible to prevent the disease in all cases. This is especially the case if this complaint and a complication or a secondary disease of another disease. In this case, the underlying disease must be properly treated and treated. As a rule, an ophthalmologist should always be consulted in order to avoid further discomfort or visual impairment. Since the disease itself is treated with the help of antibiotics, these drugs must be taken according to instructions. Other medications or alcohol, which may reduce the effect of the antibiotic, should not be taken. Likewise, care of the eyes and skin should be taken, as these dry out in many cases. Various ointments and creams can be used, which lead to the desired success. In the case of a tumor, unfortunately, there is no possibility of self-help. If thyroid disease is suspected, appropriate diagnosis and therapy is necessary. Furthermore, surgical interventions may also be necessary, which cannot be replaced by self-help options.
