The term exophthalmos simply implies protrusion of the eyeball beneath and even between the lids. Usually it is in a downward and outward direction. In some cases the displacement is accompanied by an easily recognizable pulsation, and occasionally by a bruit or audible sound. The latter instances are spoken of as pulsating exophthalmos. They are connected in most cases with vascular tumors or intra-orbital aneurysms, although sometimes the aneurysm may be primarily intracranial. For instance, arteriovenous aneurysms, by communication of the internal carotid artery with the cavernous sinus, will produce pulsating exophthalmos. Whatever be its cause exophthalmos is an expression of pressure from behind. This is true even of the ocular symptoms accompanying Graves’ disease or exophthalmic goitre, only here the protrusion is permitted by general fulness of the vessels and undue vascularity of the orbital tissues.
In proportion to the amount of projection there will be swelling and edema of the upper lid, the skin being more or less shiny and the veins distended. In extreme cases the lids are everted and the conjunctiva extremely chemotic, while by exposure of the cornea it becomes vascular, infected, and often necrotic. Should it be possible to replace the globe by pressure it will protrude so soon as pressure is removed. In vascular cases a bruit may be heard and pulsation detected with the finger. Audible sounds are lost by making firm compression on the common carotid of the same side, and return instantly when this pressure is removed. By the ophthalmoscope both arterial and even venous pulsation may be perceived at the fundus. Vision is only slightly affected by a well-marked protrusion, especially when the latter has occurred slowly. The pulsating forms will frequently give subjective symptoms of sound and sense, e. g., vertigo.
A history of injury, coupled with external evidences, may give a clue to some of these cases as an indication of traumatic aneurysm or communicating vascular tumor. Soft and vascular tumors, without history of injury, are usually malignant, this being true also of multiple growths.
Treatment.
—The treatment of exophthalmos should depend entirely on its nature. When due to arteriovenous aneurysms, or to the consequences of injury alone, a ligation of the common or of the internal carotid will give the best result. When compression of the carotid gives temporary relief to at least some of the features of the case its permanent ligation is indicated. Bilateral exophthalmos implies a more serious condition, especially in Graves’ disease. When thyroid symptoms are prominent a thyroidectomy is indicated. When the thyroid participates but slightly such a case may be treated by excision of the cervical sympathetic on both sides.
INTRA-OCULAR TUMORS.
These tumors may assume most of the known types and may spring from practically all of the tissues of the eye.
From the iris there may develop cysts of traumatic or even of congenital origin. In the former such a foreign body as an eyelash may be found, having entered through an external wound of the cornea. Vascular tumors are occasionally met with, many of which are full of pigment, while melanomas, with a minimum of vascular structure, are also observed. The actively malignant tumors of the iris usually assume the sarcomatous or endotheliomatous type, and when melanotic assume an exceedingly rapid and serious phase and course. In the iris, also, tuberculous or syphilitic granulomas are occasionally encountered.
In the choroid are seen expressions of tuberculosis, especially the more acute, as a complication of tuberculous meningitis. The most common malignant tumor here is sarcoma of the melanotic variety. Of the retina, glioma is the most common as well as the most malignant tumor, occurring usually in the young. All of these tumors when malignant spread from their primary site to the adjoining tissues. When extremely malignant they kill too quickly to show many metastatic expressions. At other times they will appear in other parts of the body.
All intra-ocular tumors tend to impair, and the malignant to quickly destroy vision. Tension is increased and the natural contour of the globe may be lost. Fixation to and involvement of the surrounding orbital tissues depend in some measure on the rapidity of growth and its location. They occur sooner or later in malignant cases.