[Progressive exophthalmos in Graves' disease--an ever-present clinical problem].
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Graves Disease↗
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[Endocrine exophthalmos].
The basedowian exophthalmy is a self-immune originating affection, in which the antigen remains still unknown. It may appear besides the Basedow disease, evoluating in a total independent manner. The clinical diagnosis is done on the basis of small ocular characteristic signs: exopthalmy, oculomotor deficit, optical neuropathy, corneo-conjunctival alterations, being of course supplemented with the complementary endocrinological and immunological explorations. The endocrine exophthalmy represents a serious complication because of the visual risks it implies, and afterwards because of the implied esthetical prejudice. A spontaneous amelioration is possible, but the treatment often proves to be necessary. It will be medical, local and general, and also orbitar radiotherapy and surgical treatment.
Autoimmune Diseases↗
[Exophthalmos and chronic meningitis in a 49-year-old male].
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Brain Diseases↗
Original acquisition in the pathogenesis and the treatment of endocrine ophthalmopathy.
In the present work, we demonstrate in the serum of patients with progressive exophthalmos, the presence of circulating immunoglobulin which is able to induce an experimental exophthalmos in goldfish. This immunoglobulin disappears when exophthalmos becomes residual. In parallel, we describe an easy technique for the measurement of delayed hypersensitivity which is positive for thyroid or retroorbital antigens in progressive exophthalmos but negative in residual exophthalmos. We also demonstrate in patients with exophthalmos an increase in urinary glycosaminoglycans. We propose a new therapeutic approach in treatment of acute exophthalmos which consists of intensive plasma exchange followed during a few months, by the administration of small amounts of corticosteroids. The plasma exchange mechanism consists of the extraction of the antibody directed against retroorbital eye muscle antigen. In addition, plasma exchange produces the extraction of glycosaminoglycans from retroorbital tissue. These hygroscopic molecules are responsible for the marked oedema in retroorbital tissue.
Adult↗
[Orbital decompression in Graves-Basedow disease--preliminary report].
UNLABELLED: The aim of the paper is to present our initial experience in surgical treatment of patients with malignant exophthalmos. MATERIAL AND METHOD: from 2001 to 2004, 11 patients with malignant exophthalmos were treated in our Department. Preoperative exophthalmos ranged from 22 to 40mm, asymmetric exophthalmos was diagnosed in 5 cases. Orbital decompression was indicated in patients with ophthalmopathy (11), decreased visual acuity (4), lagophthalmos (3). Decompression included orbital floor, medial and lateral wall in 8 patients, orbital floor and medial wall in 3. RESULTS: in 5 patients exophthalmos decreased 5-8 mm, in 5 cases 2-3 mm, 1 patient remained without improvement. CONCLUSIONS: 1. The treatment of malignant exophthalmos requires multidisciplinary approach. 2 Orbital decompression should be followed by surgical correction of eyelids and eyeball muscles.
Decompression, Surgical↗
Choice of surgical treatment for Graves' disease.
Functional and cosmetic ophthalmic complications of Graves' (1835) disease are dysthyroid optic neuropathy, exophthalmos, eyelid retraction and oculomotor disturbances. This paper describes and elaborates on the surgical procedures used when these complications are present. In severe exophthalmos and optic neuropathy we use an orbital decompression of the orbital floor sometimes combined with the medial wall, via an anterior approach. In eyelid retraction, we perform a recession of the levator muscle with scleral graft implantation. In concomitant strabismus, surgery is usually limited to recessions of the involved muscles, most of the surgery is directed to the inferior and medial rectus, as these are the most commonly affected muscles. The indications depend on the status of the patient at the time of referral. For severe exophthalmos with true retraction of the upper eyelid, we begin by treatment of the retraction and if this is not sufficient, we perform orbital decompression. For severe exophthalmos with oculomotor disturbances, we perform orbital decompression and later, the strabismus surgery. For oculomotor disturbances with eyelid retraction, we perform the strabismus surgery at the first and the eyelid retraction at the second stage. When there is a combination of exophthalmos, eyelid retraction and oculomotor disturbance, the indications and the choice of treatment are difficult and depend on numerous factors. If orbital decompression is indicated, it will be done first, followed by the strabismus surgery and at a later stage, the eyelid retraction. If only the eyelid retraction is treated, it will be done after the strabismus surgery. The chronological order of treatment depends on the modification we observe on the other components of the ophthalmopathy.
Exophthalmos↗
Role of sympathetic system in morphine-induced mydriasis in rat.
The effects of three doses (5, 30, and 60 mg/kg) of morphine on pupillary diameter (PD) were studied in rats that were either normal, neurotransmitter antagonist pretreated, guanethidine pretreated, cervical sympathectomized, or adrenalectomized. Morphine produced a dose-dependent increase in PD and exophthalmos. In addition, the PD concurrently underwent fluctuations. alpha-Adrenergic antagonists blocked both mydriasis and exophthalmos, whereas a beta-adrenergic antagonist had no significant effect. This suggested a role for the sympathetic nervous system. However, cervical sympathectomy or guanethidine pretreatment only partially blocked the increase in PD or exophthalmos. Adrenalectomy also partially blocked the mydriasis and exophthalmos. Adrenalectomy combined with guanethidine pretreatment completely blocked morphine-induced mydriasis but no exophthalmos. Thus, the results suggest that both direct sympathetic innervation and hormonal action from the adrenals are involved in morphine-induced mydriasis in the rat.
Adrenalectomy↗
[Analysis of anthropometry on head and eye for stipulating of children's spectacle frames].
OBJECTIVE: To investigate the normal value of six parameters of head and eye in Chinese children, including interorbit distance (IOD), interpupillary distance (IPD), superior otobasion-ectocochion distance (obs-ec), intersuperior otobasion distance (obs-obs), exophthalmos and nasal basis angle, for stipulating the sizes of children spectacle frames. METHODS: The value of these six parameters in 10 171 children ages 5 to 17 years old were measured with caliper in four cities and the results were analyzed. RESULTS: The IOD, IPD, obs-ec and obs-obs were increased and positively correlated with the age. The differences of these parameters among different ages were statistically significant (F = 0.97, P < 0.01), especially in IPD before 15, IOD before 13, obs-ec and obs-obs before 12 and exophthalmos before 12 years old. The fastest growth age in IPD, IOD, exophthalmos, obs-ec and obs-obs was 10, 11, 5, 7 and 11 years old, respectively. The growth period of IPD, IOD, exophthalmos, obs-ec and obs-obs was 5 - 15, 5 - 13, 5 - 8, 5 - 12 and 5 - 15 years old. The difference of these six parameters among children in 4 cities were statistically significant (t = 3.1, P < 0.01). CONCLUSIONS: The most active growth period of IPD, IOD, obs-obs, obs-ec and exophthalmos lies between 5-15 years old in Chinese children 5-17 years old. Although the differences of these six parameters between male and female and among children in four cities are statistically significant, practically they are not important for stipulating the sizes of children's spectacle frames.
Adolescent↗
[Surgical treatment of the sequelae of Basedow's ophthalmopathy].
Functional and cosmetic ophthalmic complications of Graves' disease are exophthalmos, eyelid retraction and oculomotor disturbances. This paper describes and takes over the surgical procedures used when these complications are associated. In severe exophthalmos, we used an orbital decompression of the orbital floor sometimes combined with the medial wall by an anterior approach. In eyelid retraction, we perform a recession of the levator muscle with scleral graft implantation. In incomitant strabismus, surgery is usually limited to recessions of the involved muscles, most of the surgery is directed to the inferior rectus and medial rectus, as these are the most commonly affected muscles. The indications depend on the status of the patient at the time of referral. For severe exophthalmos with true retraction of the upper eyelid, we begin at the first stage by treatment of the retraction and if it is not sufficient, we perform an orbital decompression at the second stage. For severe exophthalmos with oculomotor disturbances, we perform at the first stage the orbital decompression and at the second stage the strabismus surgery. For oculomotor disturbances with eyelid retraction, we perform the strabismus surgery at the first stage and the eyelid retraction at the second stage. When there is the association of exophthalmos, eyelid retraction and oculomotor disturbances, the indication and the choice of treatment are difficult and depend on numerous factors. If an orbital decompression is indicated, it will be done first, followed by the strabismus surgery and at a later stage, the eyelid retraction. If only the eyelid retraction is treated, it will be done after the strabismus surgery. The chronology of the treatment depends on the modification we observed on the other components of the ophthalmopathy when one stage treatment is performed on one component: for example orbital decompression can modify the oculomotor disturbance and oculomotor surgery can modify eyelid retraction.
Diplopia↗
Orbital floor reconstruction with flexible Ethisorb patches: a retrospective long-term follow-up study.
OBJECTIVE: The purpose of the study was to investigate whether a flexible, biodegradable material (Ethisorb) shows better long-term results with regard to diplopia, bulbus motility, and exophthalmos/enophthalmos compared to the use of lyophilized dura-patches and polydioxanone (PDS) foils. METHODS: During a period of 6 years 435 patients with an orbital fracture were investigated retrospectively. Inclusion criteria were patients with fractures of the orbital floor with a maximum size of 2 x 2 cm. Bulbus motility, exophthalmos, enophthalmos, and diplopia were investigated during a period of 2 years. RESULTS: One hundred twenty orbital floors were reconstructed by lyophilized dura-patches, 81 by PDS, and 136 by Ethisorb. An exploration without an implantation was performed in 91 patients. The long-term investigation 12 to 15 months after surgery showed an exophthalmos and enophthalmos incidence of 1%, whereas a reduced bulbus motility and diplopia were found in 5% and 4%, respectively. Fifteen to 24 months after surgery 2% of the patients had an exophthalmos and 1% had an enophthalmos. A reduction of bulbus motility was found in 4% of the patients, and diplopia was found in 3%. The use of Ethisorb resulted in a significantly lower incidence of exophthalmos 3 months after surgery compared to PDS. CONCLUSION: The low rate of acquired bulbus motility demonstrates acceptable results in using Ethisorb in the floor of the orbit.
Absorbable Implants↗
Serum thyroglobulin and its autoantibody following subtotal thyroid resection of Graves' disease.
Thyroid surgery leads to marked changes of the levels of serum thyroglobulin and its autoantibodies in the subsequent 3 postoperative weeks. Furthermore in Graves' disease progression of exophthalmos has sometimes been seen following thyroidectomy. Nineteen medically pretreated patients with Graves' disease and no signs of exophthalmos were studied systematically up to 6 months postoperatively. Nine patients had thyroglobulin antibodies. Mean values rose to 3.5 times pretreatment values within 2 months (P less than 0.001) followed by a gradual fall below pretreatment level after 6 months. None of the antibody negative patients reverted to positive or vice versa. Serum thyroglobulin (n = 10) was elevated preoperatively (mean 309 micrograms/l, SD 251), their values being normalized within 1-2 months (mean 19.4 micrograms/l, SD 7.3). The preoperative serum thyroglobulin correlated to the weight of the removed thyroid tissue (r = 0.87, P less than 0.01). Three patients showed elevated thyroid stimulating hormone after 1 month. Of these, two developed myxoedema, the third remained euthyroid with persistently elevated serum thyroglobulin. None showed recurrence or developed exophthalmos within the period of observation. In spite of rising levels of thyroglobulin antibodies in all patients with antibodies none developed exophthalmos and only one patient with thyroglobulin antibodies had clinical myxoedema.
Adolescent↗
Regression of thyrotoxic ophthalmopathy following lithium withdrawal.
The case of a bipolar patient who developed thyrotoxicosis with severe exophthalmos while on lithium therapy is described. The patient had required two surgical decompressions of the right orbit to relieve pressure, which occurred secondary to progression of the exophthalmos, and was scheduled for further surgery. Lithium therapy was discontinued because of poor compliance to the medication and intolerable polyuria. The exophthalmos improved dramatically within 72 hours of the withdrawal of lithium. A severe form of exophthalmos resulting from lithium therapy has not been described in the literature. The case described here adds to the body of information about the possible causes of thyrotoxic ophthalmopathy.
Bipolar Disorder↗
Increased retinal blood flow in patients with Graves' disease: influence of thyroid function and ophthalmopathy.
OBJECTIVE: Graves' ophthalmopathy (GO), resulting from the inflammation of retro-orbital tissue, is one of the major complications of Graves' disease (GD). We investigated the clinical usefulness of the measurement of retinal blood flow (RBF) in the evaluation of GO and its activity. MEASUREMENT: RBF was quantitated by pulsed Doppler mode at just below the branch of central retinal artery, from which the resistance index (RI) was calculated. PATIENTS: Forty-seven euthyroid GD patients and 70 gender- and age-matched normal controls were measured for RI to investigate the effect of GO on RBF. To investigate the effect of hyperthyroidism, 20 GD patients were measured for RI changes during antithyroid drug (ATD) therapy. Furthermore, 17 GD patients with clinically overt GO were measured for RI changes during treatment with glucocorticoid plus retro-orbital radiation. RESULTS: RI and exophthalmos showed a significant positive correlation in 47 treated euthyroid GD patients without clinically overt GO (r=0.307, P<0.05), but not in 70 age- and sex-matched normal subjects (r=0.185, P=0.161). Furthermore, RI, but not exophthalmos, significantly correlated with serum TSH receptor antibodies, an indicator for the disease activity of GO. ATD therapy significantly reduced RI in GD patients from 0.719+/-0.041 in the hyperthyroid state to 0.661+/-0.051 in the euthyroid state, but not to the levels observed in normal subjects having the similar exophthalmos (0.640+/-0.049). The fractional reduction of RI during ATD therapy significantly correlated with those of pulse pressure and ultrasonographic distensibility in carotid artery, but not with those of serum vascular injury markers. In 17 GD patients with clinically overt GO, all four patients having adipose tissue enlargement but not extraocular muscle hypertrophy (inactive GO) showed RI within the mean +/- 1 s.d. for treated GD patients without GO. In the other 13 GD patients having extraocular muscle hypertrophy (active GO), four and eight patients showed RI outside mean +/- 2 s.d. and mean +/- 1 s.d. respectively. Treatment with glucocorticoid plus radiation moved RI in 8 out of 10 patients toward the mean values of GD patients without GO, in spite of little improvement of exophthalmos. CONCLUSIONS: It was suggested that GD patients showed altered retinal hemodynamics, possibly resulting either from the cardiovascular effect of hyperthyroidism or from retro-orbital inflammation, particularly in extraocular muscle.
Adult↗
[Rapidly progressive T-cell angiocentric lymphoma with CD56+ phenotype involving bilateral orbits and skin in a patient with anti-HTLV-I antibody].
A 57-year-old woman was admitted to our hospital complaining of left exophthalmos in July, 1991. Biopsy specimen of a tumor in the left orbit suggested an inflammatory pseudotumor. The orbit was irradiated and the exophthalmos disappeared. During admission, an erythema was noted on her anterior chest wall. After discharge, right exophthalmos and generalized skin eruptions developed. The skin eruption on her anterior chest wall was histopathologically diagnosed as angiocentric lymphoma and she was readmitted. Since her serum was positive for anti-HTLV-I antibody, adult T-cell leukemia/lymphoma was suspected. Chemotherapy yielded limited relief of the right exophthalmos and transient fading of the skin eruptions. She died due to progression of the disease. Close examination of the skin eruption on the calf revealed that the lymphoma cells were CD56-positive immunohistochemically and electron microscopy revealed that they had large membrane-bound granules. Rearrangement of the T-cell receptor beta chain gene was observed. Incorporation of HTLV-I proviral DNA was not observed. Re-examination of the left orbital tumor confirmed the infiltration of these lymphoma cells. This is a rare case of T-cell lymphoma with NK cell phenotype involving orbits and skin, and showing a rapid clinical course.
CD56 Antigen↗
Effect of prostaglandin synthetase inhibitors on non-analgesic actions of morphine.
The present study investigates the results of pretreatment with five prostaglandin (PG) synthetase inhibitors on effects of morphine on body temperature, pupillary diameter, body movement and production of exophthalmos in rat. Hyperthermia, induced by a low dose of morphine, was inhibited in animals pretreated with any of the PG synthetase inhibitors. However, PG synthetase inhibitors had no clear effect on hypothermia induced by higher doses of morphine. The duration of morphine-induced catalepsy was attenuated by pretreatment with the PG synthetase inhibitors in a dose-related manner. The exophthalmos induced by all doses of morphine was either shortened in duration or inhibited by sulindac, paracetamol or ibuprofen. Morphine-induced mydriasis was either attenuated or inhibited by paracetamol, ibuprofen or meclofenamic acid. The results suggest that endogenous PGs play a role in morphine-induced hyperthermia, catalepsy, exophthalmos and mydriasis whereas a physiological role for PGs in morphine-induced hypothermia was not indicated.
Animals↗
Graves' disease complicating myelopathy.
BACKGROUND: Exophthalmos, supraventricular arrhythmias, and myxedema have been noticed among patients chronically paralysed due to myelopathy. A survey was conducted to document and explain the observation. METHOD: A long term care population of 77 male myelopathy patients aged 59 +/- 14 years (mean +/- 1 standard deviation), paralysed 19 +/- 11 years, were compared by exophthalmometry (Hertel instrument) with 53 male non myelopathy patients and hospital employees, aged 57 +/- 15 years, by review of electrocardiograms (EKGs) of record with 91 male non myelopathy hospital patients, aged 59 +/- 13 years, and by thyroid function tests with standard values. RESULTS: Abnormal ocular protrusion (greater than 22 mm) was found in 9 myelopathy patients (12%) and in none of the controls. Exophthalmos was bilateral in 7. The mean ocular protrusion was 17.2 +/- 3.6 mm for myelopathy patients and 14.9 +/- 3.9 mm for controls (p less than 0.001). Three exophthalmic patients had atrial fibrillation. Arrhythmias had been recorded in 186 of 1390 EKGs in 34 myelopathy subjects and in 63 of 377 EKGs in 25 controls. The ratios of supraventricular to ventricular arrhythmias were 2.8 for myelopathy patients and 0.7 for controls (p less than 0.02). Hypothyroidism was found in 2 of 74 patients tested, 2.7%. CONCLUSION: Exophthalmos, supraventricular arrhythmias, and myxedema are unusually common among chronic myelopathy patients. Preceding Graves' disease with residual effects can be suggested as the explanation.
Adult↗
[Indication and technique of orbital enlargement in the treatment of endocrine ophthalmopathy].
Typical symptoms in endocrine ophthalmopathy are a result of an interstitial swelling of the ocular muscles and of the volume increase of the postbulbar fat and connective tissue. Clinically, we find a spectrum that reaches from infiltration of the eyelid and conjunctival tissue, exophthalmos, swelling of the muscles with diplopia, damage to the cornea till to involvement of the optic nerve with loss of vision. Regarding functional impairment of the optic nerve, orbital decompression represents an operative ultimate ratio. The surgical principle is based on the decompression within one or usually several orbital walls occasionally in combination with a sagittal enlargement of the eye socket by osteotomy and advancement of the orbital rims. As rule of thumb is considered: The reduction of the exophthalmos is proportional to the number of decompressed walls and amounts to 2-3 mm per decompressed orbital wall. A reduction of exophthalmos going beyond that can be obtained by advancement of the orbital rims.
Conjunctiva↗
Taenia coenurus in the orbit of a chinchilla.
A 4-year old, male intact, captive-bred chinchilla (Chinchilla lanigera) was presented due to progressive exophthalmos of the right eye over a 5-month period. Ophthalmic examination revealed exophthalmos with dorsal displacement of the right globe. Retropulsion was decreased and a fluctuant, subcutaneous mass could be palpated posterior and dorsal to the central aspect of the zygomatic bone. Transdermal ultrasonography revealed a fluid-filled mass consistent with a cyst located within the ventral right orbit. Computed tomography demonstrated dorsal displacement of the globe, lateral displacement of the zygomatic arch, and numerous mineral-dense foci within the lumen of the cyst. The cyst was removed en bloc by ventral transpalpebral orbitotomy. Histopathology revealed a single capsulated cyst with multiple invaginated protoscolices, characterized by a prominent scolex with refractile hooklets, suckers, and abundant calcareous corpuscles consistent with a Taenia coenurus. Exophthalmos resolved with surgical therapy and there was no evidence of recurrence or postoperative complications over a period of 2 years. To the authors' knowledge, this is the first reported case of an orbital cyst of parasitic origin in a chinchilla.
Animals↗