Exophthalmos

Exophthalmos is an excessive shift of the eye anteriorly, caused by a retrobulbar injury or (more rarely) a shallow orbit. Asymmetry of the eye is better seen when examining the patient from above and from behind.

[1], [2], [3]

Causes of exophthalmos

The direction of exophthalmos may indicate a possible disease. For example, lesions localized within the muscle funnel, such as cavernous hemangiomas or optic nerve tumors, lead to axial exophthalmos, and lesions localized outside the muscle funnel usually lead to exophthalmos with displacement, the direction of which is determined by the localization of the formation.

[4], [5], [6], [7], [8], [9],

Symptoms of exophthalmos

Exophthalmos are divided into axial, one-sided or two-sided, symmetrical or asymmetrical, and it is often constant. Expressed exophthalmos can prevent the closure of the eyelids with the development of exposure keratopathy and ulceration of the cornea.

False exophthalmos (pseudo-exophthalmos) can be with asymmetry of the face, one-sided enlargement of the eyeball (with high myopia or bouffalm), a one-sided retraction of the eyelid or euphthalmus from the opposite side.

Diagnosis of exophthalmos

Exophthalmos expression is measured with a plastic ruler attached to the outer edge of the orbit or using the Heriel exophthalmometer equipped with mirrors in which the corneal peaks are visible and a special scale is plotted. Ideally, measurements should be made in two positions: when looking up and down. Values greater than 20 mm indicate the presence of exophthalmos, and the difference in the eye area of 2 mm is suspicious regardless of the absolute value of the exophthalmos. Exophthalmos is subdivided into a light (21-23 mm), medium (24-27 mm) and pronounced (28 mm or more). The dimensions of the width of the eye gap and any lagophthalmic should be taken into account at the same time.

[10], [11], [12], [13], [14], [15], [16]

Treatment of exophthalmos

The approach to treatment of exophthalmos is contradictory. Some offer decompression surgery in the early days, others advise to resort to surgery only after conservative methods of treatment of exophthalmos have proved ineffective or insufficient.

1. Systemic use of steroids is indicated with rapid-growing exophthalmus with pain syndrome in the edema stage, if there are no contraindications (for example, tuberculosis or peptic ulcer disease).
   • Inside prednisolone (the initial dose of 60-80 mg per day). Reduction of discomfort, chemosis and periorbital edema usually occurs within 48 hours, then the dose of steroids is gradually reduced. The maximum result is observed after 2-8 weeks. Ideally, steroid therapy should be completed within 3 months, although maintenance therapy with low doses may be necessary for a long time;
   • intravenously methylnrednisolone (0.5 g per 200 ml isotonic saline solution for 30 min). Repeat after 48 hours. This can be effective, usually recommended for compression optic neuropathy. However, there is a risk of complications from the cardiovascular system, so therapeutic control is necessary.
2. Radiotherapy is an alternative with contraindications to steroids or their ineffectiveness. The effect usually manifests itself within 6 weeks, and the maximum becomes 4 months.
3. Combination treatment with radiotherapy, azathioprine and prednisolone at low doses may be more effective than using steroids and radiotherapy separately.
4. Surgical decompression can act as the primary method or in the ineffectiveness of conservative methods (for example, with disfiguring exophthalmos in the stage of fibrosis). Decompression, which is often performed endoscopically, is of the following types:
   • two-walled - antral-etmoidal decompression with the removal of the sections of the lower and the back of the inner wall. This reduces the exophthalmos by 3-6 mm;
   • three-walled - antral-etmoidal decompression with removal of the outer wall. The effect is 6-10 mm;
   • four-walled - three-wall decompression with the removal of the outer half of the orbital arch and most of the main bone at the apex of the orbit. This makes it possible to reduce the exophthalmos by 10-16 mm, so it is used with pronounced exophthalmos.