Bulging, protruding eyes (exophthalmos) as a symptom of Basedow's disease?

Bulging, bulging or protruding eyes: exophthalmos is also often referred to in this way. Basically, it is the protrusion of the eyeball (the whole eye) forward.

Protrusion of the eye = protrusion of the eyeball.
Protrusion = pushing out, protruding, or protruding forward.
Exophthalmos = protrusion of the eyeball forward.
Enophthalmos = an intrusion, a dropping of the eyeball deeper into the orbit.

The eyeball is pushed forward, resulting in a protrusion. The eye is therefore convex and more or less prominently bulging.

This condition is not just an aesthetic problem, but can pose a real threat to the eyeball, the eye and vision itself, although visual impairment is rare.

There is usually a protrusion of only one eye or both eyes, even in multiple directions.

+ The most common cause of exophthalmos is thyroid problems.

The thyroid gland and its normal function affects almost every process in the human body. Excessive or insufficient function results in typical symptoms. It is the excessive function (hyperthyroidism) that causes the condition that bears the professional name Graves-Basedow disease.

You are often interested in:
What is exophthalmos and Basedow's disease?
What causes it?
What are the ocular symptoms of thyroiditis and what is hyperthyroidism?
When are both eyes bulging, when only one?
What is the treatment?

The exact basis of an eye or eye protrusion must of course be properly investigated and then adequately treated. This is precisely to avoid late complications.

Briefly about the eye...

The eye is housed in an area that is pyramid-shaped. It is surrounded on almost every side by a hard skeleton (bone). Therefore, any condition that results in a reduction of the eye's accommodation area will also result, for example, in its protrusion.

In addition to the eye, the so-called protective and accessory parts of the eye are also mentioned in this context.

These include:

• the palpebrae
• orbit, orbital cavity
• eye muscles - musculi bulbi, eye muscles
• lacrimal apparatus - apparatus lacrimalis
• conjunctiva - tunica conjunctiva

The eye is located in the orbit and the orbit is a paired quadrilateral cavity with a pyramidal shape. Its base is at the orbital entrance and the apex faces the optic canal, which connects it to the cerebral part of the skull.

The capacity of the orbit is approximately 35-40 ml.
20% fills the eye (bulbus oculi).
The rest is reserved for adipose tissue, fascia, ligamenta, muscles, blood vessels, nerves, lacrimal gland and lacrimal ducts.

What are the possible causes of protrusion of the eyeball?

The pathological process can affect any part and structure in the region of the eye, the orbit.

Since the space of the orbit is solid, made up almost entirely of bone, when the space shrinks, the pressure on the eye (bulbus) increases.

An increase in the volume of tissue in the orbit leads to an increase in pressure. The cause is an autoimmune inflammatory process involving the accumulation of cells in the orbital tissue.

This is a reaction with a fatty and connective tissue component, plus an accumulation of inflammatory components. As a result, swelling (edema) occurs.

Enlargement and swelling of the orbicularis oculi + difficult blood drainage + accumulation of venous blood in the orbital area + impaired blood supply to the muscles and nerve = increased pressure on the eyeball to visual impairment

Possible causes of eye protrusion:

• most cases are due to thyroid dysfunction
  • especially for hyperthyroidism, Graves' ophthalmopathic disease
  • more rarely, it also occurs in hypofunction - underactivity
  • both eyes are bulging
• expansion in the area behind the eye
  • for bleeding
  • tumor (benign, malignant - cancer, neuroblastoma, sarcoma, hemangioma, glioma)
  • thrombosis - blood clot
  • only one eye may be bulging
• abnormal vascular malformation behind the eye, varicose veins of the orbit, arteriovenous malformation (pathological connection of artery and vein), pulsatile form
• infections in the eye and in the orbital region - orbital cellulitis, phlegmon, abscess
• disease processes in the nearby area, brain - tumour, cancer
• eye injuries

What problems are associated with bulging eyes?

Bulging eyes may not be the only symptom that occurs. Depending on the degree and severity, other problems are associated, which may be more or less severe.

Accompanying symptoms:

• Eye pain
  • pain behind the eye, through the eye
  • feeling of pressure behind the eyes
  • eye pain to the touch
• headache
• dry eye/eyes
• eye irritation
• increased sensitivity to light - light blindness, photophobia
• increased tearing
• double vision - diplopia
• blurred vision
• to blindness due to optic nerve oppression
• weakness of the eye muscles, swelling of the muscles
• murmur common to the pulse
• swelling of the eyelids
• inability to close the eyelids and a visible slit between the eyelids
  • eyelid retraction
  • excessive drying of the surface of the eye
  • which can lead to tears and even ulcers of the eye, cornea
  • with consequent visual impairment
• reddening of the conjunctiva, increase in blood vessel filling
• swelling of the conjunctiva
• change in the position of the eyeball, squinting

Graves-Basedow disease as the most common cause
Bulging eyes in thyroid...

Hyperthyroidism (overactive thyroid) is a serious problem. Thyroid function affects almost everything that happens in our body, such as even metabolism or energy management.

Overproduction affects mostly women. Smoking worsens the overall course. Therefore, people with thyroid problems should not smoke at all.

Hyperthyroidism means that the thyroid gland overproduces its hormones, thyroxine (T4) and triiodothyronine (T3).

It arises from many causes, however, most commonly an autoimmune disease. This is referred to as Graves-Basedow disease.

Manifestations are:

• weight loss, weight loss
• excessive appetite and overeating
• or, conversely, nausea, straining to vomit, lack of appetite
• frequent diarrhoea
• menstrual disorders in women and erectile dysfunction in men
• fatigue, increased tiredness
• sleepiness
• weakness, muscle weakness
• increased sweating
• trembling of limbs, body
• nervousness, irritability
• hot flushes, hypersensitivity to heat
• heart palpitations and tachycardia, i.e. increased heart rate
• high blood pressure
• fine, sparse hair and breakage of hair and nails
• eye protrusion
• permanent change in the shape of the eye and face, with a decrease in quality of life
• enlarged thyroid gland, but may not be a condition

You can also read more in the articles:
Hyperthyroidism and Thyroid: what are the symptoms of decreased or increased dysfunction?

What is endocrine orbitopathy?

The term endocrine orbitopathy is associated with Graves-Basedow disease (Graves-Basedow thyroiditis).

Endocrine glands = endocrine glands whose hormones are secreted into the blood.
Orbitopathy = disease changes involving the orbit.

Chronic (long-term) disease leads to certain changes that affect the orbit and the inside of the orbital region. The problem affects structures such as the fatty connective tissue, the orbicularis oculi, blood vessels or nerves and the lacrimal apparatus.

It develops in approximately 50% of people with Graves-Basedow disease.

The autoimmune process behind the disease can take three forms.
The mild form usually does not require treatment.
The moderate form requires treatment, otherwise there is a risk of complications.
The severe form is characterised by muscle and nerve involvement, which affects visual function.

Severity rating of endocrine orbitopathy according to EUGOGO (European Group on Graves' orbitopathy)

The course of the disease is characterised by a gradual enlargement of soft structures, tissues, resulting in the eye being pushed forward, i.e. exophthalmos or protrusion of the eyeball.

In addition to the visible aesthetic aspect, there are problems with the outflow of blood from the area. As a consequence, the eyelids become swollen, the conjunctiva becomes red and even swollen. A serious condition is the increase in intraocular pressure.

The disorder of the eye movement muscles leads to a change in the position of the eye and therefore to squinting. This subsequently leads to double vision.

The first symptoms are...

The first symptoms are the so-called eyelid symptoms. They are followed by conjunctival and corneal symptoms and the disorder of the eye movement muscles.

Eyelid symptoms:

• eyelid retraction, in one or both eyes.
  • eyelids not closing and an enlarged eyelid fissure
  • affects up to 90% of cases with endocrine orbitopathy
• swelling of the eyelids, eyelid edema
• lack of eyelid-eye contact
• expression of bulging, protruding eyes, for eyelid retraction related to fixation to a point
• also referred to as (by):
  • Dalrymple - retraction of the upper eyelid and failure to close the eyelids
  • Graefe - lack of eyelid alignment when looking down
  • Jellinek - eyelid hyperpigmentation - brown discoloration of the skin
  • Enroth - swelling of the eyelids
  • Gifford - difficulty or impossibility of upper eyelid eversion
  • Stellwag - decrease in blinking frequency
  • Rosebach - eyelid fluttering when eyelids are closed

Conjunctival-corneal symptoms:

• redness of the conjunctiva - increased injection
• swelling of the conjunctiva - chemosis
• cutting of the eye and a feeling of sand in the eye
• dry eye to corneal damage by tears, ulcers

Eye muscle disorders:

• 30-50% of cases
• impaired eye movement
• misalignment of the eye
• squinting
• double vision

Exophthalmos:

• unilateral/bilateral
• symmetric/asymmetric
• exophthalmic/myopathic (ophthalmoplegic) form

Optic neuropathy:

• Occurs in 3-5%
• severe optic nerve oppression condition
• late treatment leads to permanent visual impairment
• Initially, blurred vision and loss of colour saturation may be present
• defects and visual field defects and scotomas follow

Diagnosis and treatment

Even in the case of this condition, early diagnosis and early treatment is important. This is in order to prevent progression of the disease and visual impairment.

The medical history, i.e. information directly from the affected person, is important. About what kind of problems, diseases or family history.

This is followed by an examination, both by a general practitioner and an ophthalmologist. Various signs and symptoms of the disease are assessed, including measurements with a Hertel exophthalmometer.

The vision and perimeter are examined, and the anterior segment of the eye is also assessed, or a slit-lamp examination to evaluate the retina. Intraocular pressure is also evaluated.

Laboratory testing of blood and thyroid hormones is of great importance.

Imaging methods such as X-ray, CT, MRI, as well as ultrasound and angiography are added.

Other diseases such as diabetes, heart and kidney disease (mainly due to eyelid swelling), eye inflammation and dry eye syndrome, glaucoma, cranial nerve palsy, allergies, toxic causes, etc. must be differentiated for exclusion and differential diagnosis.

For this reason, the cooperation of doctors from other disciplines, such as a neurologist, internist or ENT, is sometimes necessary.

Treatment is chosen based on the degree of difficulty and course.

It is important not to smoke. Smoking significantly worsens the course of thyroid disease.

An example is malignant exophthalmos, i.e. a severe degree that requires immediate treatment. Otherwise, there is a risk of permanent and irreversible damage to the optic nerve, blindness.

The mild stage usually does not require special treatment. However, sometimes it is necessary to administer corticosteroids or immunosuppressants to suppress autoimmune processes.

In the treatment of hyperthyroidism, it is necessary to administer thyreostatics (drugs that suppress the function of the thyroid gland). Alternatively, treatment with radioiodine is chosen, which knocks it out of function completely (for 1, 2 or 3 processes). Subsequently, however, it is necessary to administer hormones artificially.

Sunglasses are helpful.

If the eyelids do not close, it is necessary to moisten the eye with artificial tears and eye ointments or gels. This prevents drying of the cornea, which is risky in terms of the formation of cracks and ulcers on the surface of the dry eye.

Furthermore, the treatment focuses on reducing fat in the area behind the eyeball. Sometimes irradiation of the fat or muscles is chosen.

When conservative procedures fail, surgical reduction and decompression of the pressure in the orbit is an option. Reducing the pressure in the orbit is important to protect the nerve and vascular supply.

Orbital decompression + orbital muscle and eyelid surgery.
This may have additional aesthetic, cosmetic significance.

Due to overproduction of thyroid hormones, the invasive surgical method of choice is total thyroidectomy, removal of the thyroid gland, enlarged glands/struma.