Certainly, large eyes often appear attractive. However, they should not be excessively large. Otherwise, the positive impression quickly turns into the opposite. They appear glubschig, the look seems rigidly. When one or both eyes become too prominent, however, there is much more at stake than appearance: Vision can be impaired or compromised, and eye pain can also be a burden on everyday life.
What is an exophthalmos?
The technical term stands for the pathological protrusion of one or both eyes from the eye socket. The advancement of the eyeball leads, among other things, to an increase in the palpebral fire, i.e. the opening between the upper and lower eyelids. The changes must be clarified by an ophthalmologist, especially since other complaints are often added, such as double vision or other visual disturbances.
With an Exophthalmus (further technical terms: Protrusio bulbi, Proptosis bulbi or, less benevolently: Glubsch or Glotzauge) many think immediately of the
Thyroid gland. In fact Graves' disease by far the most common cause. The autoimmune disease mainly affects women, mostly between 20 and 40 years of age. It is accompanied by hyperthyroidism. In addition, protruding eyes, technical term: endocrine orbitopathy. Orbitopathy stands for disease of the eye socket, endocrine refers to organs which, like the thyroid gland, release their hormones into the blood. Other possible diseases of the eye socket, on the other hand, are much less likely to be the cause of eye protrusion. Sometimes a change of the eyes only simulates an exophthalmos.
Exophthalmos: When to see a doctor?
Dry, reddened eye, sandy feeling: If an eyeball protrudes too far, the cornea is more exposed to the air, dries out more easily and can become inflamed. Get treatment quickly to avoid worse eye damage.
Alarm sign? Immediately see an ophthalmologist in case of: Eye pain, impaired vision, severe redness of the eye, swelling of the eyelids and surrounding area, protrusion of one or both eyes, impaired motility of the eye, fever, feeling ill.
Do not put up with it any longer: Even if an exophthalmos develops gradually and is painless, an ophthalmologist should clarify it. Because a swelling behind the eye can constrict the optic nerve and endanger the eyesight.
In brief: The eye and the orbit
The diameter of the nearly spherical eyeball is about 2.5 centimeters in adults. It lies in the bony eye socket. laterally and posteriorly it is surrounded by fatty tie, connective tie and muscles. The optic nerve, other nerves of the eye, vessels and the lacrimal gland are also located in the eye socket. They fill three-quarters of the space, leaving relatively little for the eye to see. In case of swelling in the narrow surroundings, the eye has only "the escape to the front" – with the consequence of an exophthalmus.
Normally it bulges only slightly. Protected only by the thin conjunctiva, eyelids and tear film, the eye has enough room to cover a wide area.
Twelve muscles, six per eye, control the precisely coordinated movement of the eyeballs. The eyes synchronously scan their field of vision, millions of impulses reach the brain via the retina and the optic nerve. From it the thinking organ makes not only pictures, but opens spaces for perception worlds.
With the exophthalmometer, the ophthalmologist can measure how far the eyes protrude
© istock/Dario Lo Presti
If one or both eyeballs protrude more strongly, this can hardly be concealed. This is very distressing for most sufferers. It is therefore all the more important for the physician to clarify what is behind this in order to treat the change in the best possible way. The eyes and orbits are checked by an ophthalmologist, the thyroid gland by an endocrinologist. If necessary, they coordinate with each other on possible follow-up examinations.
Eyes: The examination focuses on their exact position and mobility, the condition of the conjunctiva, the position and function of the eyelids, the visual field and vision (eye test). With the help of the slit lamp and different auxiliary optics the physician can look at the front and rear eye sections including retina. If necessary, he also controls the intraocular prere.
The right eye
Whether and how far the eye protrudes, or more precisely: the distance between the cornea and the front edge of the eye socket, is measured by the ophthalmologist with the help of an exophthalmometer on both sides. The normal values vary individually only by a few millimeters. For women, the mean value is 16 millimeters, for men 17. Values of more than 20 millimeters or a lateral difference of more than two millimeters are considered pathological and thus in need of clarification. In severe exophthalmos, values up to 30 millimeters can occur.
Eye socket: Examination procedures such as ultrasound (sonography) and Doppler sonography, magnetic resonance imaging (MRI) and computer tomography (CT) provide detailed images of the eye socket, which the doctor cannot see directly. In this way, tie swelling can be confirmed and the tumor formations, which are rare but possible in principle, can be recognized. If a specific underlying disease of the eye socket is suspected, additional imaging examinations, blood tests and analyses of tie samples (biopsies) can confirm the diagnosis. Sonography is usually sufficient for monitoring benign changes. For the diagnosis of an endocrine orbitopathy, the ocular findings are decisive.
Thyroid gland: Blood values such as TSH and T4 provide information about the functional situation. In most cases, there is an overactive thyroid gland. Other symptoms may also indicate this, such as weight loss despite ravenous appetite, increased sweating, warm, moist skin, rapid heartbeat, hair loss. The detection of so-called autoantibodies called TSH receptor antibodies (TRAK) proves autoimmune disease. The thyroid gland can also be examined more closely using ultrasound and scintigraphy, for example with regard to nodules (see also "Swelling in the neck" guide), chapter "Thyroid") and functional disorders.
Behind protruding eyes there is often a thyroid disease
Protruding eyes – cause no. 1: Endocrine orbitopathy
Endocrine orbitopathy is an autoimmune disease. The tie in the eye socket becomes inflamed and thickened. As a consequence the eyes protrude. In most cases, Graves' disease with hyperthyroidism is present at the same time. There may also be a
Goiter, The thyroid gland can also become enlarged (see below, section "Symptoms").
Only ten percent of patients with endocrine orbitopathy have normal thyroid function. Nevertheless, the disease-typical antibodies are also found in the blood, especially the so-called TSH receptor autoantibodies, abbreviated TRAK. Autoantibodies are directed against the body's own tie. TRAK are expression of against thyroid glands-. Immune disorder directed at the orbital ties. Smokers, with the same hereditary predisposition, are twice as likely as non-smokers to develop the disease and are also more likely to have an eye strain.
Endocrine orbitopathy progresses differently: at the beginning sometimes without symptoms, later with constant symptoms, gradual improvement, worsening or very fluctuating. Partly it precedes hyperthyroidism, partly it occurs under its treatment or years later. Initially, the focus is often on inflammatory changes in the eyes: swelling and redness of the eyelids, reddened conjunctiva, increased tearing, feeling of prere behind the eye. Later it is usually problems such as exophthalmos, movement disorders of the eyes and visual impairment. Often both eyes are affected, but not always to the same degree. Endocrine orbitopathy suggests the presence of Graves' disease in most cases.
Goiter and protruding eyes: typical for Graves' disease
© © Biophoto/Associates Science Source/OKAPIA
– Protruding eye(s): This is more or less visible, the ophthalmologist can measure it exactly (see above "Exophthalmos: Diagnosis"). The displacement is possible in different planes, sometimes also to the side (squint).
In 1840, Karl Adolf von Basedow, a physician from Merseburg who gave the disease its name in the German-speaking world, first described the combination
Goiter, rapid pulse and protruding eyes For patients. Since then, the phenomenon is known as Merseburg Triad known. However, with Graves' disease, the thyroid gland does not always have to be enlarged or heart palpitations felt, nor do the eyes always have to protrude. Nevertheless, the three changes often occur together in the course of the disease. Upper edge of the iris. upper eyelid visible (Dalrymple sign). the palpebral fire, i.e. the distance between the upper and lower eyelid, is widened.
– The upper eyelid remains (eyelid retraction): When looking down, this is especially noticeable: More eye white is exposed below the upper eyelid (Von Graefe's sign). The Gaze appears fixed, the eyelids close incompletely, blinking is rare (Stellwag sign).
– Drying and swelling of the conjunctiva, Corneal wetting disorder: Dry, red eyes occur, especially in cold air, wind, and bright light (increased sensitivity to light). The eyelids swell considerably, those affected feel a foreign body sensation, and vision is sometimes blurred. Eyelid swelling can partially mask exophthalmos.
– Possible: a feeling of prere behind the eye; pain is rather not typical.
– Poorer eye mobility, Visual disturbances: Often occur Double vision on. They are caused by disorders of inflamed. Thickened eye muscles. However, there are other causes of double vision. Prere on the optic nerve at the back of the eye can impair vision.
Diagnosis: see section "Exophthalmos: Diagnosis further up.
Therapy: Thyroid blockers can be effective against hyperthyroidism in Graves' disease with orbitopathy. During treatment, the thyroid gland must be checked regularly. If the exopthalmos is only mild, the symptoms may improve spontaneously after some time. In addition, doctors often prescribe selenium for six months. The results of studies vary.
However, if the eye changes persist, radioiodine therapy of the thyroid gland may be considered. In more pronounced cases, however, rather not, because radiotherapy can worsen the eye disease or cause it in the case of previously absent eye problems. An alternative here is the surgical removal of the thyroid gland.
In case of dry eyes, tear substitutes ("artificial tears") are indicated. Moisturizing agents for the eyes also at night, for example as a gel or eyelid spray, tinted glasses during the day as light protection, prescription of prismatic lenses for patients who see double images, sleeping with the upper body elevated to facilitate swelling of the eyelids are other auxiliary measures. Against inflammatory complaints such as redness, swelling and increased tearing of the eyes in the context of the orbitopathy, doctors often use an anti-inflammatory drug.
If the eye disease progresses rapidly, additional therapy with cortisone is administered. In case of contraindications or insufficient effect, a so-called biological (monoclonal antibody) is used. If the symptoms continue to worsen or if there is a danger to the optic nerve due to the prere in the eye socket, surgery to relieve the prere (so-called decompression surgery) is indicated.
In general, this operation is rather at the end of the therapy, especially since the course of Graves' disease is usually not predictable at the beginning. In case of more severe exophthalmos it also serves cosmetic purposes. Except in emergencies, it is recommended that surgery be performed only after the acute phase of the disease has stopped for a longer period of time, at least about six months. Sometimes further corrective surgery on the eye – on the eyelids and eye muscles – is necessary to achieve a satisfactory result.
Radiation treatment of the orbit is also an option in severe cases, but the results are inconsistent.
! Attention: If you give up smoking, you improve your chances of treatment for Graves' disease and endocrine orbitopathy in the long term.
Rarely a sinus infection spreads to the eye socket
Exophthalmos – causes: Other diseases of the orbit
The diseases described below, most of which are rare, can also cause bulging eyes. In some cases, rheumatic diseases and immune disorders, which in turn may be interrelated, play a role.
Infection in the orbit (orbitaphlegmone,orbital cellulitis): Rarely, bacterial inflammation spreads to the orbit, i.e., the fat and muscle tie located there. The starting point can be, for example, a bacterial inflammation of the sinuses, such as the so-called ethmoid cells. This sometimes occurs in young children.In adults, injuries or surgery to the eye, inflammation of the jaw, or a facial furuncle in the area above the upper lip are more likely to be to blame.
Symptoms:The protruding eye (usually one is affected) hurts a lot, especially during movements, or it is almost impossible to move it. The eyelids are massively swollen and reddened. The infection can lead to loss of vision if it spreads to the optic nerve. Or if there is prere on it due to swelling or if blood circulation is impaired. The patients often have fever. Make a very sick impression. indications are an existing sinusitis. The clinical examination findings. Diagnosis confirmed by a magnetic resonance imaging (MRI) or computed tomography (CT) scan. Since CT is associated with radiation exposure, it is used in children only in absolutely necessary cases, for example, if there is an urgent suspicion of an infection of the eye socket or a related complication. For example, a child must be immobilized in order to undergo an MRI.
The therapy is immediately followed by intensive antibiotic administration; depending on the course and findings, surgical cleaning of the infected focus may also be necessary. Inflammation of the orbit (orbital pseudotumor): This involves various, causally unclear, usually painful inflammations of the eye socket. Because of the resemblance to a tumor they are called "pseudotumor" referred to as.
Symptoms:Common features of these diseases include a protruding eye (usually on one side, rarely on both sides) with limited mobility, double vision, pain in the area of the eye or eye socket, redness and swelling of the conjunctiva, possibly also of the eyelids.
Diagnosis: In addition to ophthalmologic examination, diagnostic imaging procedures such as MRI or CT are necessary to make the diagnosis. Sometimes it can only be confirmed by tie sampling (biopsy) with fine tie tests.
Therapy: Cortisone in high dosage usually leads to significant improvement of the symptoms. This is here also considered as confirmation of the diagnosis.
Examples of inflammatory diseases of the orbit:
Idiopathic ocular myositis: Benign, localized muscle inflammation more commonly affects one of the elongated eye muscles that turn the eye toward the nose.
Tolosa-Hunt syndrome: Rare disease in which a very painful inflammation occurs especially in the upper part of the eye socket.
Inflammation of the lacrimal gland (dacryoadenitis): It can manifest itself as an acute, usually painful disease (a typical sign: the so-called paragraph shape of the upper eyelid, more on this under "Swelling of the eyelids"). In contrast, chronic inflammation of the lacrimal gland tends to cause less pain. They sometimes also occur in rheumatic or systemic diseases such as Sjogren's syndrome and sarcoidosis, and rarely in certain forms of lymph node cancer (lymphomas, see below).
Apparent exophthalmos: Pseudoexophthalmos
If one or both eyes are apparently or actually very large, this can feign exophthalmos. Here are some causes:
– CongenitalGlaucomaon one or both eyes (so-called hydrophthalmos, also buphthalmos): The eyeball(s) are pathologically enlarged. The eyes appear "so beautifully large" at first glance; less normal, however, are the marked photophobia and increased watering eyes. Be sure to check with an ophthalmologist!
– Shallow eye sockets: Rarely, a newborn is born with too shallow eye sockets. The eyes appear enlarged. In adults
Lateral differences of the eyes: Asymmetry sometimes mistakenly gives the impression that one eye is prominent. Possible causes:
– Enophthalmos of one eye (partner eye): It is sunken (enophthalmos) or apparently sunken, for example as a too small, shrunken eye after an injury.
– Variably wide palpebral fires: The cause of an apparent exophthalmos can also be a raised upper eyelid of one eye. For example, there may be hyperactivity of the eyelid elevator muscle if another eye muscle is paralyzed. Or the upper eyelid of the partner eye hangs down increasingly. The ophthalmologist will clarify what is behind this, if necessary in consultation with a neurologist.
General tips for the eyes
The eyes are sensitive and irreplaceable. Therefore, they should always be treated with care. Keywords here: Stimulants, lifestyle, sun protection, preventive care at the ophthalmologist. Smoking attacks the vessels. Can cause damage to the retina and the optic nerve. In connection with Graves' disease, the most common cause of bulging eyes, smoking is considered a risk factor. Alcohol is by no means more harmless. Regularly excessive consumption can literally cloud the view by changes in the eye lens and retina. It is best to keep away from both.
Lifestyle: A balanced diet with lots of vegetable ingredients, especially green vegetables, regular exercise and sufficient sleep are also good conditions for the eyes to stay healthy for a long time.
Sun protection: High-quality sun glasses with broadband UV protection shield the eyes from too intense sunlight. This can be a cataract. Promote retinal damage.
Gentle eye care: The skin of the eyelids and around the eyes is sensitive and dries out quickly because protective fat pads and sebaceous glands are sparse here. Environmental influences leave their traces more easily. The skin quality deteriorates earlier. It is all the more important to take good care of your eyes, preferably with moisturizing eye creams or gels. Gently massage or dab the product around the eyes. Remove cosmetics before going to bed. Take a gentle cleanser for this purpose. Never rub or rub. You can also get advice at your pharmacy. If you suspect an allergy, you should consult your dermatologist.
Screening examinations: Ophthalmologists generally recommend having your eyes checked every two years starting at age 40. Among other things, this can check intraocular prere. However, health insurance companies do not cover this. From the age of 20, an eye test is recommended about every two years, especially if you wear a visual aid.
For eye diseases, for example, dry eyes: It is absolutely important to follow the instructions of the ophthalmologist, for example when using eye drops. And proceed hygienically. In case of intolerance or other side effects, do not interrupt the treatment by yourself, but go to the doctor.