bubble_chart Overview

The onset is gradual, not accompanied by acute or severe systemic or local symptoms. This type of exophthalmos, which is distinctly different from inflammatory exophthalmos, is primarily caused by orbital tumors or systemic diseases.

bubble_chart Etiology

Intraorbital varices, cavernous sinus arteriovenous fistula, traumatic eyeball dislocation, or massive intraorbital hemorrhage.

bubble_chart Clinical Manifestations

1. Traumatic Exophthalmos

Some are caused by trauma, orbital or skull fractures, or intraorbital hematoma, while others result from retrobulbar injections during surgery or treatment leading to massive intraorbital bleeding. Pain is often acute or subacute. The eye is highly protruded, with subcutaneous eyelid and subconjunctival hemorrhage and edema. After occurrence, a bandage must be applied to compress and prevent continued bleeding, as long-term optic nerve compression leading to edema can easily cause atrophy.

2. Intermittent Exophthalmos

This type of exophthalmos occurs when bending forward or holding breath, i.e., under venous stasis, causing the eye to protrude. It completely disappears when standing or lying supine and can be a result of impaired orbital venous return.

3. Pulsatile Exophthalmos

(1) Disease Cause

The most common causes are head trauma, skull base fractures, carotid artery atherosclerosis, or carotid artery aneurysms, where the internal carotid artery may rupture and communicate with the cavernous sinus leading to arteriovenous fistula. It is more common in males than females. Congenital defects in the orbital roof accompanied by meningocele can also produce pulsatile exophthalmos.

(2) Clinical Manifestations

This condition often occurs suddenly, is unilateral, and has spontaneous pulsations. Thus, when the artery contracts, the eye impulsively protrudes, and when the artery relaxes, the eye slightly retracts. The eyelid and bulbar conjunctiva show vascular congestion and edema, retinal veins are tortuous and dilated with hemorrhage, and the optic disc is edematous, severely affecting vision. Patients may complain of hearing a continuous rumbling sound, which can also be heard with a stethoscope placed on the eyelid. If a finger is pressed near the eye, pulsations can be felt, and the degree of exophthalmos can be significantly reduced. Compression of the ipsilateral common carotid artery can make it completely subside. Due to traction on the trigeminal nerve endings, significant pain can also be caused.

Fundus examination may reveal tortuous and engorged retinal veins, static blood, and optic disc edema.

bubble_chart Diagnosis

Proptosis caused by tumors generally progresses slowly, except in cases of secondary infection or high malignancy. Ocular motility disorders are often not significant, and there is usually no local pain, tenderness, congestion, edema, systemic fever, or leukocytosis. Except for tumors located within the muscle cone causing forward protrusion of the eye, the eye usually deviates to the opposite side of the tumor. If the edge of the mass can be palpated deep in the orbital rim, the diagnosis is relatively clear. Otherwise, further diagnostic tests such as ultrasound, X-ray, or CT scans can be performed to confirm the diagnosis.

bubble_chart Treatment Measures

Pulsating exophthalmos is relatively difficult to treat. Some advocate the use of an elastic bandage with gradually increasing pressure, which involves compressing the common carotid artery on the affected side with an elastic bandage. Initially, this is done 4 to 6 times a day, each session lasting 20 to 30 minutes, and then gradually increasing to 45 minutes per session. The aim is to promote the establishment of collateral circulation. Additionally, ligation of the common carotid artery may be considered, but this carries the risk of cerebral accidents and should be approached with caution.