|Year : 1966 | Volume
| Issue : 6 | Page : 246-249
Intermittent exophthalmos- report of three cases
BH Chatterjee, PK Ghosh
Ophthalmic Deparrment of the Nil Ratan Sarcar Medical College, Calcutta, India
|Date of Web Publication||17-Jan-2008|
B H Chatterjee
Ophthalmic Deparrment of the Nil Ratan Sarcar Medical College, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chatterjee B H, Ghosh P K. Intermittent exophthalmos- report of three cases. Indian J Ophthalmol 1966;14:246-9
Intermittent exophthalmos is a condition characterised by transitory proptosis. The causes responsible for this morbid condition are varied. On analysing the causes, Duke-Elder has found that orbital varices constitute about 90% of the cases. Besides this, the other causes as collected by DukeElder are: (1) highly vascular neoplasms of the orbit which are liable to periodic congestion,-as for example angioma, lymphangioma, lymphosarcoma, (Franklin and Cordes), (2) recurrent orbital hemorrhages, (3) venous congestion during menstruation, parturition or intense muscular effort: (4) laxity of the orbital tissues following absorption of orbital ha matoma, (5) periodic orbital cedema particularly of the angioneurotic type: (6) recurrent emphysema of the orbit. (7) intermittent ethmoiditis, (8) intermittent otitis, (9) rarely a pituitary tumor and intracranial arterio-venous aneurysm. Recently Srivastava and Jain (1963) have reported a case of intermittent exophthalmos, the underlying cause being orbital varix.
| Case Report|| |
Case 1. D.K.M., Hindu male aged 31, a member of the Police armed force, was examined at the S.S.K.M. Hospital, Calcutta on 4-7-59 and again on 20-3-62 at the Nil Ratan Sarkar Medical College, Calcutta. The history was that at about the middle of 1958, his friends noticed that his left eye used to bulge forwards slightly when he was crawling on the ground for police exercises and he used to feel a dragging sensation in the left orbit. Henceforth whenever he used to bend his head forwards, he felt that his left eye was protruding forwards. There was no history of trauma to the left orbit.
On examination -- In erect posture the left eyeball was found to be slightly more deep seated than the right and the orbit appeared to be more sunken. On measurement with exophthalmometer, there was enophthalmos of the left eyeball for 3 mm. [Figure - 1]. On bending the head forwards there was immediate proptosis of the left eye to the extent of 8 mm. [Figure - 2],[Figure - 3]. The conjunctival blood vessels became congested but there was neither any pulsation of the eyeball nor any bruit over the temple. On resuming the erect posture the exophthalmos disappeared quickly and the appearance of enophthalmos was produced again. The same proptosis could be effected by expiratory effort with closed nostrils and by prolonged pressure on the left jugular vein but not to the same extent as produced by bending the head forwards. The vision in the left eye was normal with no abnormality in the fundus or in the ocular movements.
The right eye was normal in every aspect.
Special Investigations --A skiagram of the left orbit revealed no abnormality, Left sided carotid angiography was done by the neurological department of the S.S.K.M. Hospital, but no sign of any abnormal intracranial vessels or a space occupying lesion was visible.
The angiography of the angular vein could not be done due to technical difficulties
Case 2. R.B., Hindu female 17 years, attended the Eye Department of the Nil Ratan Sarkar Medical College Hospital on 15-6-62. She felt that during convalescene from an attack of paratyphoid fever about one year ago, her left eyeball was coming out whenever she bent her head forwards. That feeling used to be relieved as soon as she took up the erect posture. There was no history of any injury to the left orbit.
On examination-In erect posture there was no abnormality in the position of the left eyeball [Figure - 4], but on bending the head forwards for a few seconds, there was immediate proptosis of the left eyeball for about 5 mm. with slight congestion of the conjunctival vessels [Figure - 5],[Figure - 6]. There was not any pulsation of the proptosed eye nor there was any bruit over the left temple. This exophthatmos however could not be produced to the same extent on forcible expiration after closing the nostrils or by compressing the jugular veins of the same side. The proptosis immediately disappeared on regaining erect posture. There was no limitation of movements of the eyeball. The fundus was normal and the vision corrected with glass was 6/6. The right eye was normal in every aspect.
Special Investigations--Skiagram of the left orbit did not reveal any abnormality. Carotid angiography or angiography of the angular vein was not allowed by the patient.
Case 3. S.K.M., Hindu male 25 years, came to the Eye Department of the Nil Ratan Sarkar Medical College Hospital, complaining of a dragging sensation in his right eye which protruded forwards on bending his head or on stooping down. Sometimes it occurred when lying on his right side also. There was no history of trauma to the right orbit.
On examination--There was slight enophthalmos of the right eye. On bending the head down for 2 minutes, there was 4 mm. proptosis of the right eye. There was no congestion of the lids or conjunctiva. There was slight protosis also on compressing the right jugular vein. In erect position the proptosis disappeared and enophthalmos appeared again in the right eye. The ocular movements were normal.
The fundus was normal and the vision was 6/6.
There was no abnormality in the left eye.
Special Investigations-Skiagram of the right orbit showed no abnormality.
| Discussion|| |
An average eye on bending the head forwards suffers an immediate proptosis of 0.7 mm. which increases to 1.7 mm. after sometime (Duke Elder). In the reported cases the proptosis was much beyond the normal limits and it was undoubtedly caused by venous congestion. As stated by Duke-Elder, 90% of the cases of intermittent exophthalmos are due to orbital varix as a result of dilatation of orbital veins. As the exophthalmos in the reported cases was produced by induced venous congestion, in all probability they were cases of orbital varix. The characteristic features of intermittent exophthalmos due to orbital varix are rapid protrusion of one eye when stasis in orbital veins is produced either by the action of gravity as by bending the head forwards or by causing obstruction to venous return as by hyperextension of the neck, forced expiratory effort or by pressure on the corresponding jugular vein and immediate disappearance of the protrusion as soon as venous congestion is relieved (Walsh). Intermittent proptosis due to causes other than orbital varix is not relieved in a similar way excepting laxity of orbital tissues when proptosis may occur on bending the head forwards due to the action of gravity, but there was no obvious cause for unilateral laxity of orbital tissues in the cases reported above.
The cause of dilatation of the orbital veins is obscure. The venous drainage of the orbit occurs along three routes---posteriorly through the superior ophthalmic vein into the cavernous sinus, inferiorly through the inferior ophthalmic veins into the pterygoid venous plexus and anteriorly by communication through the angular vein with the facial vein. The narrowing of the superior orbital fissure, the lesser diameter of the jugular vein on the left side explaining the preponderance of the lesion on this side and finally the presence of predisposition evidenced by frequent occurrence of varicose veins elsewhere have been suggested by various observers as the causative agents. The rontgen diagnostic technique advocated by Yasargil (1957) for detecting orbital lesions,-particularly the angiography of the angular vein and considering at the same time the diagnostic value of orbital angiography as stated by Krayenbuhl (1958) would certainly help to show the condition of the orbital veins. But actual visual examination of the orbital veins by transcranial orbitotomy is perhaps the surest way of ascertaining the underlying pathology.
| Summary|| |
Three cases of intermittent proptosis are reported two of which are males and one female. In two cases the left eye was affected and in the other the right eye. In each case proptosis could be produced by induced venous congestion. Presumably the proptosis was due to orbital varix.
| References|| |
Duke-Flder. Text-Book of Ophthalmology Vol. V, p. 5397-5403, p. 5376 and 5627-32.
Srivastava and Jain. J. All-India Ophthal. Soc. (1963) 11, 82-83.
Walsh. Clinical Nero-ophthalmology, 1947. William & Wilkins Baltimore. p. 988-992.
Walsh and Dandy (1924) Arch. Ophthalhology, 32, 1-10.
Yasargil. (1957) Bib. Ophth. (Supp.), 1-68.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]