[Exophthalmos--what now?]

Exophthalmos is most commonly due to Graves' ophthalmopathy (GO), the most frequent extrathyroidal manifestation of Graves' disease. The clinical signs and symptoms of GO are the consequences of increased orbital connective and adipose tissue volume, and of interstitial enlargement of extraocular muscles, within the confines of the bony orbits. Diagnosis of GO is usually readily established by obtaining a careful history, detailed clinical examination of the thyroid gland, eyes and orbits, few laboratory tests and ultrasonography of the thyroid gland and the orbital contents. Additional procedures such as computed tomography or magnetic resonance imaging are rarely needed. A team approach (general practitioner, endocrinologist, ophthalmologist) is essential to assure state-of-the-art management of patients with GO, and to properly select the best choices from a still limited range of therapeutic options.

Intraocular pressure and proptosis in 95 patients with Graves ophthalmopathy

PURPOSE

To study the cause of ocular hypertension in patients with Graves ophthalmopathy.

METHODS

Intraocular pressure was measured in 190 eyes of 95 patients (mean age, 42 years; range, 11 to 86 years) with Graves ophthalmopathy. In six eyes (four patients), changes in intraocular pressure were also analyzed upon orbital decompression.

RESULTS

The mean intraocular pressure +/- SD in 190 eyes was 18.36 +/- 4.02 mm Hg (range, 10 to 34 mm Hg). The intraocular pressure in 42 of the 190 eyes was 21 mm Hg or more. The intraocular pressure in 76 eyes with proptosis of 19 mm or more was 19.96 +/- 4.49 mm Hg (range, 14 to 34 mm Hg), whereas the intraocular pressure in 114 eyes with proptosis of less than 19 mm was 17.08 +/- 3.38 mm Hg (range, 10 to 28 mm Hg). The difference in the values between these two groups is statistically significant (two-tailed t test, P < .001). The mean intraocular pressure in six eyes decreased from 23.23 to 18.82 mm Hg upon orbital decompression, a difference that was statistically significant (two-tailed paired t test, P < .001). The coefficient of outflow facility was normal in these six eyes.

CONCLUSION

These findings suggest that ocular hypertension in patients with Graves ophthalmopathy is caused, in part, by increased intraorbital pressure associated with proptosis.

[Gas bubble disease of fish]

Gas bubble disease (GBD), a non-infectious, environmentally/physically induced trauma, is caused by an increase in the dissolved gas pressure above the ambient air pressure (supersaturation). Frequently the cause is an increased partial pressure of nitrogen-especially in spring-/groundwater. All fish species as well as amphibians and aquatic invertebrates are susceptible. Fish species and age groups are different sensitive; swim up fry is very endangered. The disease may occur in a chronic form at approximately 103% and in an acute form at above 110/115% total gas pressure (TGP). Fish, especially fry, with the chronic form die slowly without symptoms. The clinical symptoms of the acute form are disorientation, subcutaneous emphysema, embolism, exophthalmus mostly only on one side, swimming near the water surface with darkened skin, haemorrhages and high mortality. Losses increase with increased TGP. Generally, mortality in the chronic form increases by secondary infections of emphysematous tissue. As technical processes may be the cause for an increased total gas pressure, such as water pumping, heating water or mixing cold with warm water, in this context we could speak from a "technopathy". The following "therapeutic" measurement is recommended: avoid causal factors, transfer damaged fish in expanded water, turn off the cause, compensate the pressure in deeper water, if possible.

Central retinal venous outflow pressure

BACKGROUND

Does the venous collapse phenomenon provide the possibility of venous dynamometry?

METHOD

A technical model is presented which allows analysis of the conditions of the collapse of the central retinal vein in vitro. The conditions of the venous collapse were analysed with regard to intraocular pressure, intravasal pressure in the outflow of the central retinal vein and the overall perfusion. For clinical measurements dynamometry of the venous collapse is performed parallel to the experimental setting.

RESULTS

The experiment reveals identical results for venous outflow pressure measured by venous dynamometry and by intravasal pressure detector. Venous dynamometry in vivo means that we use the onset of the venous collapse phenomenon to register the pressure in the central retinal vein at the point where it leaves the eye. Using this technique, retroocular obstruction of the venous outflow may be assessed. The venous outflow pressure itself depends on the venous flow resistance, intracranial pressure and arterial perfusion pressure. Any disorder of these three parameters may be assessed when the absolute venous outflow pressure is registered.

CONCLUSION

The venous collapse phenomenon enables us to determine the venous outflow pressure. Clinical applications have proven promising.

Delayed suprachoroidal hemorrhage mimicking acute retrobulbar hemorrhage

The signs and symptoms of an acute retrobulbar hemorrhage include sudden ocular pain, explosive unilateral proptosis, limitation of extraocular movements and loss of vision. Retrobulbar hemorrhage is a well-described complication of retrobulbar anesthetic injection. We report an unusual case of a presumed acute retrobulbar hemorrhage following intraocular surgery which, on further testing, was found to be a delayed suprachoroidal hemorrhage.

Pleomorphic adenoma of the lacrimal gland manifesting as exophthalmos in adolescence--case report

A 16-year-old girl presented with a pleomorphic adenoma of the lacrimal gland manifesting as left painless exophthalmos which had persisted for 3 years. Computed tomography revealed a tumor about 15 mm in diameter in the superolateral site of the left orbit. The tumor was removed completely by combined orbitofrontal craniotomy through a transcranial approach. Histological examination demonstrated the growth of tumor cells as glandular cavities or sheets, with myxoid and partly chondroid connective tissue stroma. Pleomorphic adenoma of the lacrimal gland is unusual in adolescents.

[Exophthalmometry and thyroid disease. The value of the Hertel measurement evaluated by a group of patients with thyroid diseases and a control group]

Exophthalmometry values from routine referrals to a hospital eye clinic are analysed, including adult patients with and without thyroid disease. In thyroid disease without eye motility complaints (n = 90) the median exophthalmometry value was 18 mm (range 12-28 mm). Thyroid patients with eye muscle involvement (diplopia, n = 47) had significantly higher values (median 22 mm, range 15-31 mm) but did not differ significantly from a subgroup of 51 patients without thyroid disease, but with "big eyes" as a (presumably) physiological finding (median value 20 mm, range 16-25 mm). The above three categories were all excluded from the control group (n = 203) which had 16 mm as median value, range 11-23 mm. Mean values were 16.0 +/- 1.8 mm in the females and 16.5 +/- 2.3 mm in the male controls. A side difference in exophthalmometry value > or = 2 mm appeared in 34% of thyroid patients with eye muscle involvement. This appeared in only a few per cent in the three other groups. Due to the wide overlap between groups, the solitary exophthalmometry reading is of limited diagnostic value, while the importance of exophthalmometry is evident when following the individual patient with orbital disease.

Orbital decompression in Graves' disease

OBJECTIVE

The authors' experience with surgical decompression of the orbits in patients with Graves' orbitopathy is reviewed.

DESIGN

One hundred twenty-six consecutive primary orbital decompressions were retrospectively studied.

SETTING

Tertiary care university hospitals.

PATIENTS

All patients were referred by ophthalmologists for surgical decompression after failure of a trial of oral steroid therapy, and many had had orbital irradiation.

INTERVENTION

Antral-ethmoidal or transconjunctival surgical decompression was accomplished in all.

MAIN OUTCOMES

Measurements of visual acuity, ocular motility, and proptosis were accomplished preoperatively and a minimum of 3 months postoperatively. Surgical complications were tallied.

RESULTS

Mean reduction of proptosis by antral-ethmoidal decompression was 5.3 mm, and 3.6 mm by the transconjunctival approach. Visual acuity improved in 34 orbits, was unchanged in 91 orbits, and decreased in one orbit. In a subgroup of 30 patients in whom ocular motility was quantified by prism cover test preoperatively, motility was unchanged or improved in 21 and was decreased in nine. Complications were infrequent.

CONCLUSION

The antral-ethmoidal and transconjunctival approaches to orbital decompression are safe and effective.

[Chester-Erdheim's disease. A case]

We report the 32nd case of a multivisceral form of Erdheim-Chester disease. This exceptional pathology is a diffuse xanthogranulomatosis which comes within the scope of histiocytosis. The originality of this case is due to cerebral localizations and to the fact that some symptoms have been observed for a long time: diabetes insipidus, exophthalmos and stubborn intertrigo.

Plus-minus lid syndrome

A patient presented with ipsilateral ptosis and contralateral superior eyelid retraction due to a nuclear third nerve syndrome. The CT brain scan revealed a paramedian mesencephalic lesion contiguous with the oculomotor nucleus, sparing the midbrain tectum and the posterior commissure.

Neuro-ophthalmic features of carotid cavernous fistulas and their treatment by endoarterial balloon embolisation

The neuro-ophthalmic features of 11 traumatic carotid cavernous fistulas and their successful occlusion by endoarterial balloon embolisation is reported. Significant improvement in all neuro-ophthalmic signs and symptoms occurred following treatment, however, ocular motility deficits persisted in 7 patients. All 11 fistulas were occluded and the patency of the internal carotid artery was preserved in 9 patients. Though the internal carotid artery was sacrificed in 2 patients there were no permanent sequelae. Transient complications of the procedure occurred in 2 patients.

Role of magnetic resonance imaging in thyroid-associated ophthalmopathy: its predictive value for therapeutic outcome of immunosuppressive therapy

To investigate the efficacy of magnetic resonance imaging (MRI) in the assessment of thyroid-associated ophthalmopathy (TAO), 51 patients with TAO were evaluated by ophthalmologic examinations and MRI at 0.5 T. Thickness of extraocular muscles (EM) was measured by T1-weighted image. Signal intensities of EM and orbital connective tissue (OCT) were measured by short inversion time inversion recovery (STIR) image and expressed as a ratio by comparison to the signal intensity of cerebral substantia alba (SI, signal intensity ratio). Significant enlargement of one or more EM was observed in 86% of patients with TAO, and SI of EM (2.15 +/- 0.63, mean +/- SD) was significantly increased compared with control values (n = 16; 1.35 +/- 0.33; t test, p < 0.01). SI of OCT tended to be greater than that in the control group, although the difference was not significant. There was a significant positive correlation between thickness of EM and severity of ophthalmopathy, assessed as an ophthalmopathy index (p < 0.05). SI of neither EM nor OCT correlated with the severity of the eye disease. To investigate whether MRI findings could predict the outcome of methylprednisolone pulse therapy, we studied 23 patients with TAO who received this treatment. SI of EM and OCT in the 12 patients giving favorable responses were significantly greater than those in the 11 patients without good response (t test, p < 0.01). On the other hand, the thickness of eye muscles did not correlate with the outcome of treatment except for that of medial rectus muscle. There was a significant correlation between SI of EM and that of OCT (r = 0.78, p < 0.01), suggesting possible similar pathologic processes in these tissues in TAO.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomic considerations in upper eyelid retraction

A series of anatomically correct orbital drawings are created to examine the major integrating factors that determine upper eyelid position on the eye. The principal upper eyelid force planes can be identified as (1) the eyelid vertical retractor plane slightly divergent from the orbital axis, (2) the eyelid protractor plane nearly tangent to the orbital aperture, and (3) the upper eyelid tarsalligamentous plane swinging from within the horizontal orbital rims. These forces are governed by variation in orbital size and shape, globe size and position, and the length-tension characteristics of the eyelid retractors, protractors, and lamellae. Enhanced lateral upper eyelid retraction occurs in part because the eye in primary position looks away from the orbital axis and projects more lateral sclera. When the eye gazes laterally, coincident with the orbital axis, enhanced lateral upper eyelid retraction disappears.

[Ocular hydrodynamics in patients with infiltrative-edematous exophthalmos in Graves' disease]

Hydrodynamics of the eyes was investigated in 57 patients with exophthalmos, with various degree of infiltrative changes. Open angle glaucoma was not found in any case. In 12 eyes (10.5 p.c.) one observed a raised IOP (over 21 mm Hg)--checked by means, of an applanation tonometer with the patient looking straight on; in 24 eyes (18.4 p.c.) the IOP was near the upper limit of the normal pressure. Characteristic for glaucoma pathological changes of the optic disc and the visual field were absent in examined patients. All of them had the filtration angle open. The authors found a statistically significant dependency between the IOP and the degree of changes in the motor muscles, conjunctival tissue and in the lids. The authors suggest that the changes in the intraocular pressure have an external cause and stem from the disturbances of the venous circulation with exclusion of the primary hypertension.

[Ocular hypertension in patients with infiltrative-edematous exophthalmos in Graves' disease]

The increase of the IOP--5 to 30 mm Hg--was observed in patients in whom severe infiltrative changes in the motor muscles dominated the clinical picture. Characteristic for glaucoma changes of the visual field and optic papilla were not seen, the angle was open and the outflow coefficient was in normal limits. The normalization of the IOP was obtained after decompensation of the orbits when the exophthalmos and the infiltrative changes in the motor muscles of the eye receded.

[Intraocular pressure in patients with infiltrative-edematous exophthalmos in Graves' disease treated with prednisone]

Hydrodynamics of the eyes was evaluated in 29 patients in the period of one to one and a half years after completion of prednisone therapy. Open angle glaucoma was observed in 2 patients, in 3--only a raised intraocular pressure (21-25 mm Hg) in the period of exacerbation of the infiltrative changes in the tissues of the orbit.

Clinical course of an incompletely removed cavernous hemangioma of the orbit

Cavernous hemangioma is a frequent tumor of the orbit in adults. Its complete removal results in dramatic relief of proptosis. The clinical course of an incompletely removed cavernous hemangioma is seldom recorded in the ophthalmic literature. The authors report the behavior of such a tumor that was observed during an 18-year period. Serial computed tomography (CT) documented a long period of slow growth, followed by a shorter interval of arrest, with eventual involution of tumor and relief of proptosis. No treatment was administered during observation.

Long-term observation of endocrine ophthalmopathy and retrospective appraisal of therapeutic measures

The course of endocrine ophthalmopathy was investigated on the basis of clinical and biochemical parameters and in relation to different therapeutic strategies. A retrospective appraisal was made of 297 patients (44 +/- 14 yr, 249 women) with inclusion of anamnestic and clinical data as well as the results of computer tomography. At the beginning of therapy, 253 patients were hyperthyroid, 36 were euthyroid and eight were hypothyroid. The HLA typing carried out in 89 patients showed the phenotypes B8 and DR3 in 32% and 42% of the cases, respectively. Raised microsomal antibodies were present in 56% of the patients and there were raised thyroglobulin antibodies in 19%. Sixty-three % of the patients received immunosuppressants in the course of therapy: glucocorticoids in all cases, nonsteroid immunosuppressants in 15%. Eight % of the patients were irradiated retrobulbarly. The inflammatory parameters could be favorably affected, whereas eye muscle involvement and bulbar protrusion proved to be more resistant to therapy. In patients with combined immunosuppressant therapy or steroids + retrobulbar radiation, there were unequivocal successes with regard to the proptosis, vision and intraocular pressure. None of the strategies applied constitutes an optimal treatment with regard to the long-term course. Following therapy, there is an improvement of endocrine ophthalmopathy, but not complete healing.

Eye muscle membrane reactive antibodies are not detected in the serum or immunoglobulin fraction of patients with thyroid-associated ophthalmopathy using an ELISA and crude membranes

We tested sera and purified immunoglobulin (Ig) fractions from patients with autoimmune thyroid disorders (AITD), with and without ophthalmopathy, and normal subjects, for the presence of antibodies reactive with eye muscle membrane antigens in an optimized enzyme-linked immunosorbent assay (ELISA). We found no correlation between ELISA results and the presence or severity of ophthalmopathy in patients with AITD for either serum or Ig, and there were no significant differences between the mean values (+/- SE) for the three groups (AITD with ophthalmopathy, AITD without ophthalmopathy and normals) for either serum or Ig. In contrast Ig from 8 of 19 (45%) patients with thyroid-associated ophthalmopathy reacted with a 64 kDa eye muscle membrane antigen in SDS-polyacrylamide gel electrophoresis and Western blotting, while tests were positive in only one of the 8 patients with AITD without eye disease and in none of the 8 normal subjects. The presence of antibodies to a 64 kDa antigen in immunoblotting did not correlate with the levels of antibodies measured in ELISA. We conclude that the ELISA, incorporating a crude membrane fractions as antigen, is not useful as a clinical test for eye muscle autoantibodies.

Globe tenting: a sign of increased orbital tension

Globe tenting is a change in the posterior globe configuration that results in a tented or conical appearance and is objectively defined as a posterior globe angle of less than 130 degrees. Globe tenting is caused by an acute/subacute intraorbital mass effect producing significant proptosis with tethering of the globe by the stretched optic nerve. In this series of 10 patients, globe tenting was produced by subperiosteal abscess (five cases), hemorrhage into a lymphangioma (two cases), a varix (one case), traumatic carotid hemorrhage into a lymphangioma (two cases), a varix (one case), traumatic carotid cavernous fistula (one case), and multiple epithelial implantation cysts (one case). Progressive narrowing of the posterior globe angle correlated with an increase in proptosis and in optic nerve length, as well as with more severe visual impairment. Tenting with a posterior globe angle of 120-130 degrees correlated with mild visual symptoms and a good recovery. A posterior globe angle of less than 120 degrees with acute proptosis constitutes a surgical emergency; a delay in surgical decompression in these patients may prevent complete recovery of visual function. CT is useful in providing good characterization of globe tenting and, thus, in helping to determine the clinical significance of this abnormality.

Space-occupying orbital lesions: can critical increases in intraorbital pressure be predicted clinically?

Thirteen cadaver orbits were studied to determine whether noninvasive clinical measurements of globe excursion could be used to predict intraorbital pressure. Intraorbital pressure measurements, exophthalmometry, and orbitonometry (which measures resistance to globe retrodisplacement) were performed at 1-ml increments to 12 ml of added orbital volume. Orbitonometry, performed with forces of 100, 200, and 300 g, yielded both E (global position) and Y (retrodisplacement) values. Plots of orbital pressure against percentage of excursion, a function of orbital retrodisplacement (that is, orbital pressure versus [(E0 - E300)/E0] x 100), for 131 paired values over all orbits yielded a function with low percentage of excursion values associated with high intraorbital pressures. This relationship reflected both the proptosis and the increased orbital tension produced by added volumes. Comparison of clinical orbitonometry data with such experimental data may allow predictions about which patients are threatened by critical intraorbital pressure levels and may benefit from orbital decompression surgery to preserve vision.

[Behavior of the intraorbital pressure in different volumes]

Injection of 5 ml anesthetic solution into the retrobulbar space causes the eye to protrude and the intraorbital pressure to increase up to 14 Torr. Subsequent pressure on the eye leads to enophthalmos and causes the elevated retrobulbar pressure to drop. This pressure never exceeds the perfusion pressure within the retinal vessels.

Long-term follow-up of ophthalmic Graves' disease

Sixteen patients with ophthalmic Graves' disease (clinically euthyroid with ophthalmopathy or exophthalmos) were followed up for 4.3 to 14.3 (mean 9.1) years to determine whether thyroid dysfunction developed and whether their ophthalmopathy progressed, regressed or remained stable. Five patients (31%) manifested hyperthyroidism or hypothyroidism, all before the end of the fifth year of follow-up. The ophthalmopathy was mild, and none of the patients required specific treatment. The thyroid function of patients with ophthalmic Graves' disease should be periodically monitored for at least 5 years.