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Year : 1966  |  Volume : 14  |  Issue : 6  |  Page : 246-249

Intermittent exophthalmos- report of three cases

Ophthalmic Deparrment of the Nil Ratan Sarcar Medical College, Calcutta, India

Date of Web Publication17-Jan-2008

Correspondence Address:
B H Chatterjee
Ophthalmic Deparrment of the Nil Ratan Sarcar Medical College, Calcutta
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How to cite this article:
Chatterjee B H, Ghosh P K. Intermittent exophthalmos- report of three cases. Indian J Ophthalmol 1966;14:246-9

How to cite this URL:
Chatterjee B H, Ghosh P K. Intermittent exophthalmos- report of three cases. Indian J Ophthalmol [serial online] 1966 [cited 2023 Dec 8];14:246-9. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1966/14/6/246/38665

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 Top

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 Top

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 Top

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.[5]

  References Top

Duke-Flder. Text-Book of Ophthalmo­logy Vol. V, p. 5397-5403, p. 5376 and 5627-32.  Back to cited text no. 1
Srivastava and Jain. J. All-India Oph­thal. Soc. (1963) 11, 82-83.  Back to cited text no. 2
Walsh. Clinical Nero-ophthalmology, 1947. William & Wilkins Baltimore. p. 988-992.  Back to cited text no. 3
Walsh and Dandy (1924) Arch. Oph­thalhology, 32, 1-10.  Back to cited text no. 4
Yasargil. (1957) Bib. Ophth. (Supp.), 1-68.  Back to cited text no. 5


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]


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