|Year : 1964 | Volume
| Issue : 4 | Page : 166-168
Willingdon Hospital, New Delhi, India
|Date of Web Publication||13-Feb-2008|
B S Jain
Willingdon Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain B S. Postural exophthalmos. Indian J Ophthalmol 1964;12:166-8
Although no such term has been used so far, it would not be inappropriate to call an exophthalmos "Postural" when it varies in degree with posture. It must be clinically differentiated from intermittent exophthalmos which may occur in angiomas liable to periodic congestion, lymphatic tissue tumours, recurrent orbital hemorrhages, orbital edema secondary to recurrent ethmoiditis, and orbital emphysema following orbital fractures, etc. In these, no postural variation can be elicited.
Sattler (1880) recognised these cases of postural exophthalmos to be due to varicose veins in the orbit and this conception was confirmed by Lowenstein (1911) at operation.
The case is reported here because of its extreme rarity as most of the cases reported are just single ones in the lifetime of an ophthalmologist.
Secondly it was on the right side, whereas it is more frequently reported on the left side.
Thirdly, the proptosis was more noticeable and troublesome with the patient recumbent than erect, whereas reverse is found to be the case in most of the reported cases.
| Case Report|| |
A lady aged 53 years reported to us in December, 1959, with the complaint of inability to sleep comfortably because on lying down, her right eyeball would protrude forward causing difficulty in closing the eye-lids. The eye, thus remaining open and exposed, used to cause pain and watering for the last three months. She could not say definitely as to when the eye was first noticed to be thus protruding. She reported that some of her friends and relations had pointed out, from time to time, for many years that her right eye looked more prominent than the left but as she did not feel any trouble or difficulty in vision, she ignored it. No history of trauma could be elicited. There was nothing unusual in the family history either.
On examination, a minor degree of exophthalmos was noticeable from the slight exposure of sclera above the right lower lid as compared with the left side. Exophthalmometry revealed a difference of 2 mm. between the position of the two eyes.
She was then made to lie down and examined after half an hour in the recumbent posture. The exophthalmos had visibly increased and now she had to exert to close the right eye and maintain it completely closed. On measurement the difference in the position of the two eyes was found to be 8 mm.
She was made to sit again and the exophthalmos was seen to recede.
The exophthalmos was also caused on the right side by bending the neck forward or by tying a tight collar around the neck so as to impair venous drainage. It was also brought about by stooping and also on forced expiration with the nose and mouth closed.
The exophthalmos was reducible, non-pulsating and no bruit was heard on auscultation, either on the closed eyelids or the temple. Also, there was no evidence of any abnormal engorgement of veins around the right eye.
The conjunctiva was normal in colour and there was no chemosis. The visual acuity (corrected with glasses) and the visual fields, were also normal. There was no abnormality of the media, iris, pupillary reactions or fundi. The eye movements were normal. There was no diplopia.
An X-Ray of the orbit (Plate 1)-[Figure - 1] was taken which showed multiple small and large densities in the right orbit, suggesting multiple phleboliths (about 10), thus confirming the diagnosis of venous angioma (varicocele) of the orbit.
It was decided to keep the patient under observation. She was directed to apply an antibiotic ointment and pressure bandage before going to bed. She found herself comfortable with this palliative treatment and was reporting regularly every 3 months.
The last time when she visited us a month ago she complained of some discomfort in closing the eye even during day time. The exophthalmos had further increased by 2 mm but the vision (acuity and fields) still continued to be normal.
We are putting off as long as possible an open operation for excision of the varicocele from the orbit which has its hazards, especially with normal visual functions in this case. We are hesitant to try retro-bulbar injections of sclerosing agents as suggested in the literature for fear of damaging normally functioning orbital structures, endangering the function of the eye.
| Discussion|| |
In literature, orbital varices have been described to follow trauma; they are either cases of arterio-venous aneurysms or periodic congestion in atrophied tissues following haematoma. No history of trauma was available in our case.
Varicoceles of the orbit have also been described in association with space-occupying lesions behind and close to the superior orbital fissure. (Walsh and Dandy 1944). They are accompaniments of conditions like carotico-cavernous fistula but in such conditions the picture of primary disease overshadows that of orbital varicocele.
The difference in the size of the superior orbital fissure (smaller on the affected side) has been described as a predisposing factor in the causation of varicocele, but it is difficult to incriminate it as a causative agent. Probably a large number of routine orbital X-Rays may show such differences in size of the superior orbital fissures without being associated with a varicocele or postural exophthalmos. Actually in the case reported by Walsh and Dandy the sphenoidal fissure is wider on the affected (left) side. However, it is possible that a narrow fissure may contribute, in the overall picture, in aiding venous engorgement. No such difference between the two superior orbital fissures was noticeable in this case.
Our case appears to be one of a solitary vascular hamartoma in the orbit. comparable in every way to venous angiomas, met within the cranium (Sturge-Weber disease), where the aberrant vessels also show a great tendency to calcification. Ocular and orbital vessels being prolongations of intracranial vessels may he subject to the same pathology.
The phenomenon of postural variation so well exhibited in the orbit, is inherent in the anatomy of this area, so that periodic variations in size of varicocele, depending upon posture are reflected in the protrusion of the eye ball in the recumbent position. The same phenomenon of postural variation, cannot be obtained in intracranial angiomas as they are surrounded by the indestensible skull and the effects are liable to be compensated, at least in part by the buffering action of cerebro-spinal fluid. These vascular hamartomas as Willis (1958, 1960) says, are anomalies of growth, distinct from anomalies of development on one side and neoplasms on the other.
| Acknowledgement|| |
I am thankful to Dr. G. S. Sarin, Radiologist for the Radiological examination of the case.
| References|| |
Duke-Elder, W. S. (1952) Text Kook of Ophthalmology. Vol. V. Henry Kimpton pp. 5397-5403.
Lowenstein (1911) Klin. Mon. Aug. 49(2) 183, quoted in 1.
Sattler. (188.5) Amer. J. Med. Se. 89. 486, quoted in 1.
Walsh and Dandy (1944). Arch. of Ophthal. 32. 1.
Willis R. A. (1958) The Border Line of Embryology and Pathology. Ch. 9. Butterworth & Co. London.
(1960) Pathology of Tumours. 3rd ed. Ch. 45. Butterworth & Co. London.
[Figure - 1]