Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Exophthalmos Workup

  • Author: Michael Mercandetti, MD, MBA, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: May 13, 2016
 

Laboratory Studies

Patients with thyroidopathy should undergo the appropriate thyroid function studies, even though some patients are euthyroid at the time of presentation with exophthalmos. Approximately 80% of those with Graves disease manifest orbital signs within 18 months, supporting the need for ophthalmic evaluation.

Any patient suspected of having a neoplasm as the cause of the proptosis should undergo imaging studies (see Imaging Studies). The imaging results should direct further laboratory studies. For example, in a patient with proptosis due to lymphoma, hematologic studies, further body imaging, and a bone marrow biopsy may be indicated.

In patients with proptosis due to orbital cellulitis, complete blood counts, blood and nasal cultures, and sinus imaging studies may be warranted.

Next

Imaging Studies

CT scan, first used in the 1970s, is the product of tissue density calculations. X-rays with different vectors are emitted, penetrating through target tissues with resulting radioabsorbencies. These differences in radioabsorbencies are assigned value-specific gray shades to create the 2-dimensional image. CT scan can produce detailed axial and coronal views of soft tissue and bony structures. Image windows from 1.0-3.0 mm in thickness allow for detailed evaluation of orbital masses. Contrast-enhanced images may be obtained and can help in identifying inflammatory processes, vascular tumors, and engorged vessels. Calcified lesions are discernible without the addition of contrast.

Magnetic resonance imaging (MRI) excites protons by applying a radio frequency with a strong magnetic field. Hydrogen nuclei emit signal intensities that are assigned specific gray tones to create an anatomical reproduction. Three-dimensional views can be gained directly, in any anatomical plane, offering excellent spatial resolution of orbital masses and soft-tissue enhancement. MRI may provide excellent soft-tissue resolution, but CT scan is superior for gleaning details about orbital bony structures.

Ocular ultrasonography can be used to visualize anterior and middle orbital lesions. Sound waves of 5-15 MHz breech orbital tissues that reflect echogenic energy captured by an oscilloscope. A-scan ultrasonography allows for a 1-dimensional description of echoes, while B-scan ultrasonography provides a 2-dimensional image. C-scan ultrasonography affords coronal views, and D-scan ultrasonography creates 3-dimensional orbital views. With the advent of CT scan, C- and D-scan ultrasonography remains unpopular. Doppler ultrasonography may be used to evaluate orbital vasculature and blood flow.

Previous
 
 
Contributor Information and Disclosures
Author

Michael Mercandetti, MD, MBA, FACS Private Practice

Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, Sarasota County Medical Society, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Cohen, MD Assistant Professor of Ophthalmology, Section Director of Oculoplastic and Reconstructive Surgery, Rush Medical College of Rush University Medical Center

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: BioD, Poferious<br/>Serve(d) as a speaker or a member of a speakers bureau for: IOP<br/>Received income in an amount equal to or greater than $250 from: IOP for speaking.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Brian A Phillpotts, MD, MD 

Brian A Phillpotts, MD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, National Medical Association

Disclosure: Nothing to disclose.

References
  1. medical-dictionary.thefreedictionary.com. Available at http://medical-dictionary.thefreedictionary.com/exophthalmos. Accessed: 5/1/2016.

  2. Henderson JW. Orbital Tumors. 3rd ed. New York: Raven Press; 1994.

  3. Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthalmol. 2012 Mar-Apr. 60(2):87-93. [Medline]. [Full Text].

  4. Ing E. Thyroid-Associated Orbitopathy. Medscape Reference. January 29, 2014. [Full Text].

  5. Brix TH, Kyvik KO, Christensen K, Hegedüs L. Evidence for a major role of heredity in Graves' disease: a population-based study of two Danish twin cohorts. J Clin Endocrinol Metab. 2001 Feb. 86(2):930-4. [Medline].

  6. Nunery WR. Ophthalmic Graves' disease: a dual theory of pathogenesis. Oph Clin N Amer. 1991. 4:

  7. Bartley GB, Fatourechi V, Kadrmas EF, Jacobsen SJ, Ilstrup DM, Garrity JA, et al. The incidence of Graves' ophthalmopathy in Olmsted County, Minnesota. Am J Ophthalmol. 1995 Oct. 120(4):511-7. [Medline].

  8. Tellez M, Cooper J, Edmonds C. Graves' ophthalmopathy in relation to cigarette smoking and ethnic origin. Clin Endocrinol (Oxf). 1992 Mar. 36(3):291-4. [Medline].

  9. Epstein O, Perkin D, Cookson J, deBono DP. Clinical Examination. 3rd ed. Mosby; 2003.

  10. Migliori ME, Gladstone GJ. Determination of the normal range of exophthalmometric values for black and white adults. Am J Ophthalmol. 1984 Oct 15. 98(4):438-42. [Medline].

  11. Dunsky IL. Normative data for hertel exophthalmometry in a normal adult black population. Optom Vis Sci. 1992 Jul. 69(7):562-4. [Medline].

  12. Bolaños Gil de Montes F, Pérez Resinas FM, Rodríguez García M, González Ortiz M. Exophthalmometry in Mexican adults. Rev Invest Clin. 1999 Nov-Dec. 51(6):341-3. [Medline].

  13. Kashkouli MB, Nojomi M, Parvaresh MM, Sanjari MS, Modarres M, Noorani MM. Normal values of hertel exophthalmometry in children, teenagers, and adults from Tehran, Iran. Optom Vis Sci. 2008 Oct. 85(10):1012-7. [Medline].

  14. Tsai CC, Kau HC, Kao SC, Hsu WM. Exophthalmos of patients with Graves' disease in Chinese of Taiwan. Eye (Lond). 2006 May. 20(5):569-73. [Medline].

  15. Preechawai P. Anthropometry of eyelid and orbit in four southern Thailand ethnic groups. J Med Assoc Thai. 2011 Feb. 94(2):193-9. [Medline].

  16. Beden U, Ozarslan Y, Oztürk HE, Sönmez B, Erkan D, Oge I. Exophthalmometry values of Turkish adult population and the effect of age, sex, refractive status, and Hertel base values on Hertel readings. Eur J Ophthalmol. 2008 Mar-Apr. 18(2):165-71. [Medline].

  17. Mourits MP, Lombardo SH, van der Sluijs FA, Fenton S. Reliability of exophthalmos measurement and the exophthalmometry value distribution in a healthy Dutch population and in Graves' patients. An exploratory study. Orbit. 2004 Sep. 23(3):161-8. [Medline].

  18. Bartalena L, Pinchera A, Marcocci C. Management of Graves' ophthalmopathy: reality and perspectives. Endocr Rev. 2000 Apr. 21(2):168-99. [Medline].

  19. Wiersinga WM, Bartalena L. Epidemiology and prevention of Graves' ophthalmopathy. Thyroid. 2002 Oct. 12(10):855-60. [Medline].

  20. Ahmadi H, Shams PN, Davies NP, Joshi N, Kelly MH. Age-related changes in the normal sagittal relationship between globe and orbit. J Plast Reconstr Aesthet Surg. 2007. 60(3):246-50. [Medline].

  21. Dijkstal JM, Bothun ED, Harrison AR, Lee MS. Normal exophthalmometry measurements in a United States pediatric population. Ophthal Plast Reconstr Surg. 2012 Jan. 28(1):54-6. [Medline].

  22. Zhang M, Hong R, Fu Z, Ye M, Yang H. [The measurement of normal values of exophthalmos, interpupillary distance and interorbital distance of children and adolescence in Xiamen and the rule of their development]. Zhonghua Yan Ke Za Zhi. 2000 Nov. 36(6):462-6. [Medline].

  23. Ramli N, Kala S, Samsudin A, Rahmat K, Abidin ZZ. Proptosis--Correlation and Agreement between Hertel Exophthalmometry and Computed Tomography. Orbit. 2015. 34 (5):257-62. [Medline].

  24. Genders SW, Mourits DL, Jasem M, Kloos RJ, Saeed P, Mourits MP. Parallax-free exophthalmometry: a comprehensive review of the literature on clinical exophthalmometry and the introduction of the first parallax-free exophthalmometer. Orbit. 2015 Feb. 34 (1):23-9. [Medline].

  25. Apaydin M, Calli C, Gunay Yardim B, Sarsilmaz A, Varer M, Uluc E. A rare cause of exophthalmos: cemento-ossifying fibroma. Kulak Burun Bogaz Ihtis Derg. 2008 May-Jun. 18(3):185-7. [Medline].

  26. Lam AK, Lam CF, Leung WK, Hung PK. Intra-observer and inter-observer variation of Hertel exophthalmometry. Ophthalmic Physiol Opt. 2009 Jul. 29(4):472-6. [Medline].

  27. Bastion ML, Wong YC. A case of sneezing-related orbital emphysema treated by aspiration-decompression in the office. Ophthal Plast Reconstr Surg. 2006 Nov-Dec. 22(6):500-1. [Medline].

  28. Burde RM, Savino PJ, Trobe JD. Proptosis and adnexal masses. Clinical Decisions in Neuro-ophthalmology. 2nd ed. St. Louis: Mosby; 1992. 379-416.

  29. Christiansen E, Kofoed-Enevoldsen A. Graves' ophthalmopathy. J Clin Endocrinol Metab. 2001 May. 86(5):2327-8. [Medline].

  30. Cohen AJ, Mercandetti M, Weinberg DA. Cavernous hemangioma. Medscape Reference Journal [serial online]. Mar 7, 2013. [Full Text].

  31. Devi B, Bhat D, Madhusudhan H, Santhosh V, Shankar S. Primary intraosseous meningioma of orbit and anterior cranial fossa: a case report and literature review. Australas Radiol. 2001 May. 45(2):211-4. [Medline].

  32. Good KS, Bloch RB. Proptosis of left eye: frontoethmoid mucocele. Ann Emerg Med. 2008 Oct. 52(4):337, 343. [Medline].

  33. Lin LK, Andreoli CM, Hatton MP, Rubin PA. Recognizing the protruding eye. Orbit. 2008. 27(5):350-5. [Medline].

  34. Mercandetti M, Cohen AJ. Tumors, orbital. Medscape Reference Journal [serial online]. October 14, 2013. [Full Text].

  35. Nunery WR, Martin RT, Heinz GW, Gavin TJ. The association of cigarette smoking with clinical subtypes of ophthalmic Graves' disease. Ophthal Plast Reconstr Surg. 1993 Jun. 9(2):77-82. [Medline].

  36. Philips PH. The orbit. Oph Clin N Amer. 2001. 14:109-27.

  37. Piest K. Exophthalmos. Decision Making in Ophthalmology. 2nd ed. St. Louis: Mosby; 2000. 132-3.

  38. Spence CA, Duong DH, Monsein L, Dennis MW. Ophthalmoplegia resulting from an intraorbital hematoma. Surg Neurol. 2000 Dec. 54(6):447-51. [Medline].

  39. Vardizer Y, Berendschot TT, Mourits MP. Effect of exophthalmometer design on its accuracy. Ophthal Plast Reconstr Surg. 2005 Nov. 21(6):427-30. [Medline].

  40. Giugni AS, Mani S, Kannan S, Hatipoglu B. Exophthalmos: A Forgotten Clinical Sign of Cushing's Syndrome. Case Rep Endocrinol. 2013. 2013:205208. [Medline].

  41. Cugati G, Singh M, Pande A, Ramamurthi R, Vasudevan MC. Hand Schuller Christian disease. Indian J Med Paediatr Oncol. 2011 Jul. 32 (3):183-4. [Medline].

  42. Roverano S, Gallo J, Ortiz A, Migliore N, Eletti M, Paira S. Erdheim-Chester disease: description of eight cases. Clin Rheumatol. 2016 Apr 23. [Medline].

  43. Rubio EI, Blask A, Bulas DI. Ultrasound and MR imaging findings in prenatal diagnosis of craniosynostosis syndromes. Pediatr Radiol. 2016 May. 46 (5):709-18. [Medline].

Previous
Next
 
Bilateral exophthalmos and upper lid retraction secondary to Graves disease.
Exophthalmos due to thyroid dysfunction. The patient has significant forward protrusion of the eyes with bilateral upper- and lower-lid retraction. Image courtesy of Adam J. Cohen, MD.
Exophthalmos due to thyroid dysfunction. The patient has significant forward protrusion of the eyes and bilateral upper- and lower-lid retraction. Also note conjunctival injection, especially of the right inferomedial conjunctiva. Image courtesy of Adam J. Cohen, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.