Exophthalmos

137 Exophthalmos



Instruction


Examine this patient’s face.


Perform a general examination of this patient.



Salient features



History




• Obtain history of thyrotoxicosis (see p. 516)


• History of smoking (opthalmopathy more common in cigarette smokers; Lancet 1991;338:25–7).



Examination




• Prominent eyeballs (Fig. 137.1).


• Look at the patient’s eyes from behind and above for proptosis.


• Comment on lid retraction (the sclera above the upper limbus of the cornea will be seen); this is Dalrymple’s sign (Fig. 137.2).


• Comment on the sclera visible between the lower eyelid and the lower limbus of the cornea (i.e. comment on the exophthalmos). Most patients have bilateral exophthalmos with unilateral prominence.


• Check for lid lag (ask the patient to follow your finger and then move it along the arc of a circle from a point above the patient’s head to a point below the nose—the movement of the lid lags behind that of the globe); this is von Graefe’s sign. Voluntary staring can result in a false lid lag, and the patient must be suitably relaxed before eliciting this sign.


• Check for extraocular movements and comment on the cornea.


• Look for the five important signs of exophthalmos:


• Eyelid swelling

• Eyelid redness

• Conjunctival swelling (chemosis)

• Conjunctival redness

• Inflammation of the plica or caruncle, which both lie at the inner corner of the eye medial to the conjunctiva

• Look for:


• signs of thyrotoxicosis: fast pulse rate, tremor and sweating

• goitre (listen for a bruit)

• post-thyroidectomy scar.

image

Fig. 137.1 Characteristic signs of Graves’ orbitopathy: thyroid stare, asymmetry, proptosis, and periorbital oedema.


(With permission from Larsen et al. 2003.)


image

Fig. 137.2 Dalrymple sign: retraction of upper eyelids in the primary gaze.


(With permission from Kanski 2001.)



Diagnosis


This patient has marked exophthalmos with ophthalmoplegia (lesions) with signs of thyrotoxicosis (functional status) caused by Graves’ disease (aetiology).



Advanced-level questions




What eye signs of thyroid disease do you know?


Werner’s mnemonic, NO SPECS (J Clin Endocrinol Metab 1977;44:203–4):



• No signs or symptoms


• Only signs of upper lid retraction and stare, with or without lid lag and exophthalmos


• Soft tissue involvement


• Proptosis


• Extraocular muscle involvement


• Corneal involvement


• Sight loss from optic nerve involvement.



How would you investigate this patient?




• History and clinical examination for signs of thyrotoxicosis and thyroid enlargement and bruit


• Serum thyroxine (T4), triiodothyronine (T3), thyroid-stimulating hormone (TSH)


• Thyroid antibodies.

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Dec 4, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Exophthalmos

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