To know about Exophthalmos & use of Exophthalmometer

1. Use of Exophthalmometer
Md.Azizul Islam
Junior Optometrist
Ispahani Islamia Eye Institute & Hospital
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2. Declaration
I have no financial interest by
presenting this presentation
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3. Aims of today,s topic
Will be able….
• General idea @ Measurement Exophthalmos
• To know about various type of Exophthalmometer
• To know the normal value of Exophthalmometer &
• How to documentation Exophthalmos finding
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4. Exophthalmometer is an instrument used
for measuring the degree of forward
displacement of the eye in exophthalmos.
The device allows measurement of the
forward distance of the lateral orbital rim to
the front of the cornea.Exophthalmometers
can also identify Enophthalmos (retraction
of the eye into the orbit), a sign of blow-out
fracture or certain neoplasms.
An Exophthalmometer
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5. Exophthalmos : Abnormal protrusion
of eye balls or Forward bulging of the
globe in endocrine disorders specially
thyroid dysfunction. Displacement of
globe relative to orbital rims .
ENOPHTHALMOS: Defined as
retrodisplacement of eye into
orbit.Inferior and posterior
displacement of globe and
intraorbital soft tissue .
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6. Causes Of Exop:/Proptosis
UNILATERAL BILATERAL
CONGENITAL - DERMOID DEVELOPMENTAL ANOMALIES -
OXYCEPHALY
TRAUMATIC- ORBITAL HAGE/IOFB OSTEOPATHIES- RICKETS /
ACROMEGALY
INFLAMMATION – ORBITAL
CELLULITIS/ABSCESS
/ CAVERNOUS SINUS
/PSEUDOTUMOR/ TUBERCULOSIS
TUMORS-LYMPHOMA / LEUKEMIA /
SARCOMA / NEUROBLASTOMA
VASCULAR-ORBITAL VARIX ENDOCRINAL - THYROID EYE
DISEASE
CYSTS-PARASITIC INFLAMMATORY -
HISTIOCYTOSIS/FUNGAL GRANULOMA
TUMOR- PRIMARY OR SECONDARY
MUCOCOELE OF PARANASAL
SINUSES
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7. HISTORY
LOCAL
EXAM:
SYSTEM
EXAM:
INVESTI
GATION
IMAGING
Examination of Exo:/proptosis
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8. HISTORY TAKING
Protrusion of eyeball: Age of Onset , duration ,
progression, Constant or intermittent, Variation
with posture / strain
Decreased vision : preceded, Stationary,
Associated field defects
 H/O: Pain
 H/O :Double vision
 H/O :Trauma
 H/O: fever , systemic symptoms
 H/O :Cancer
 H/O :Thyroid disease
 H/O:Weight loss
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9. LOCAL EXAMINATION
HB Reflex : Central or Deviation
 Globe Displacement: Downward,Upward or Other
 Lid Retruction: +(ve) or – (ve)
 Lid lag/Lagophtalmos: ..? mm
 PALPATION : Size , shape, surface, margins
consistency , tenderness , thyroid glangds, orbital
rims , regional lymph nodes
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10.  EOM MOTILITY : Decreased in thyroid
orbitopathy , extensive tum or growths and
neurological defect
 VISUAL ACUITY : Maybe decreased due to
Refractive changes due to pressure on eyeball,
Optic nerve compresssion, Exposure keratopathy
 PUPIL REACTION : RAPD suggests optic nerve
compression
 IOP : Maybe raised
 Rular Test: Horizontal with vertical
measurement
LOCAL EXAMINATION
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11. SYSTEMIC EXAM
The basis of the measurement for exophthalmos
determination using the Hertel version is the outer
orbital rim (orbital wall) and the apex of the cornea.
All instruments are meant to measure the distance
b2w the apex of cornea and lateral wall of orbit
 OPTICAL:
 Light Weight Hertels exophthalmometer
 Heavy Duty Hertel Exophthalmometer
 Naugle Exophthalmometer
 Luedde Exophthalmometer
 MECHANICAL : Gormaz Exophthalmometer
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12. Hertel exophthalmometer
is used for precise
exophthalmos
measurements (e.g.
Exophthalmic goiter).
Sturdy construction for
many years of use. Overall
dimensions are 25 x 7 x 2
cm. Weight is 117 grams .
Scale for orbital wall goes
from 75 mm to 121 mm. The
scale to measure the
proptosis ranges from 0 to
35 mm.
L.W.Hertel exophthalmometer
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13. Lowest price! Heavy Duty
Exophthalmometer has
metal construction for
many years of use. Overall
dimensions are 25 x 7 x 2
cm. Weight is 216 grams .
Scale for orbital wall goes
from 75 mm to 121 mm. The
scale to measure the
proptosis ranges from 0 to
35 mm.
Heavy Duty Exophthalmometer
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14. Naugle exophthalmometer is
superior and inferior orbital rim-
based instrument.
This superior and inferior orbital
rim-based instrument measures
the position of the globe
accurately even after lateral
orbitotomy e.g. post tumor
removal or thyroid
decompression. It delivers fast
reproducible results of highest
precision, provides best patient
comfort, thus increasing patient
cooperation.
Naugle exophthalmometer
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15. Fastest, easiest and
least expensive
method for measuring
exophthalmos. By
sighting at right
angles, this device
eliminates parallax
and allows the
clinician to measure
the amount of
protrusion or bulging
eye from its orbit.
Luedde Exophthalmometer
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16. Gormaz Exophthalmometer
 Measure
distance between
two lateral
orbital margins
 Require topical
anaesthesia
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17. The basis of the measurement for exophthalmos
determination using the Hertel version is the outer
orbital rim (orbital wall) and the apex of the cornea. The
internal refraction mirrors with millimeter scales for the
left-hand and right-hand measuring halves of the
exophthalmometer are calibrated so that the zero mark
on the scale will be located in the plane of the resting
points of the supports. For exophthalmus measurements
the supports are placed against the two temporal orbital
walls so that the orbital rim contacts the deepest point
of the supports. Prisms are clear plastic with easy to read
millimeter lines on both sides. Eye is seen through lower
half of scale and the scale is seen through the upper half,
eliminating parallax and aiding rapid determination of
protrusion.
The Measurement Procedure
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18. The Measurement Procedure
The examiner sits opposite the patient at eye level. The
exophthalmometer is then positioned with the index
points at the temporal lateral orbital walls. The
instrument hold with both hands and firmly propped
first against the patient’s right orbital wall on the
temporal side(which should be felt against the lowest
part of the support point). The moveable part on the
right side is then set in such as way that the patient’s left
orbital wall lies against the lowest part of the arched
support. The distance between the lateral orbits (on
scale 2) should be noted for future correlation.The
examiner asks the patient to look at right ahead with
eyelids wide open. The examiner measures for proptosis
in each eye.
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19. The normal range is 12–21 mm. Upper normal limit for
people of African origin is a little higher, about 23–
24 mm. A difference greater than 2 mm between the eyes
is significant.
In children and teenagers mean exophthalmometric
measurements increase with age: Less than 4 years old
(13.2 mm), 5–8 years old (14.4 mm), 9–12 years old
(15.2 mm) and 13–17 years old (16.2 mm). Depending
upon the configuration of the osseous orbit, a value of
15mm might be pathological whereas 21mm might be
normal. Axial Length of the eye affects
exophthalmometer reading. Pseudoproptosis may be
seen in severe myopia.
Normal values Of Exophthalmometer
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20. Work up of Exophthalmos Pt.
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21. Work up of Exophthalmos Pt.
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22. IMAGING
USG/ CT-Scan/ MRI/ X-Ray
INVESTIGATION
 Incisional biopsy
 Excisional biopsy
Core biopsy
Hematological : CBC , ESR, VDRL
Thyroid function test: T3,T4,TSH
Serum ANA , c- ANCA , ACE
BUN , Creatinine
FNAC
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23. Management of Exop:
 Local management: Sun glasses,Sleep in supine position with
head elevated,Taping of lids at night,Prisms in diplopia.
 Medical therapy: Topical tear substitutes,Systemic diuretics -
minimal role,Parenteral antibiotics,Pain killers.
 Radiation: Radio Therapy & Chemo Therapy (Pseudotumour,
Lymphoma, Rhabdomyosarcoma , Meningioma,Thyroid
orbitopathy ).
 Surgical options: Orbitotomy, Orbital decompression,
Combined ethmoidectomy Etc.
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24. Take Home Messages
 An Exophthalmos is an important
manifestation of a large number of
orbital diseases. Thorough clinical
examination coupled with appropriate
investigations clinches the diagnosis
and helps in management.
 A difference greater than 2 mm
between the eyes is significant.
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25. Hertel Measurement
Procedure Video….
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26. References
 The Orbit and Oculoplasty ,Dr.Agarwal
 www.ophthalmoloyweb.com
 Exophthalmometer in
TheFreeDictionary“.Farlex. Retrieved 13
April 2013.”
 Picture: Me ,Google.
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