Severe Exophthalmos Research Articles

Thyrotoxicosis factitia complicating Graves' disease.

A patient with Graves' disease remained clinically and biochemically hyperthyroid after intravenous therapeutic(131)I, although thyroidal uptake fell to normal. Previously she had taken antithyroid drugs irregularly and vomited twice after oral(131)I. She was treated with carbimazole and thyroxine 0.2 mg daily because of severe exophthalmos. However, she maintained her hypermetabolic state by surreptitiously taking thyroxine in excess of the prescribed dose. When drug treatment was stopped under supervision she rapidly became euthyroid. By tracing prescriptions supplied to the patient it was shown that she had obtained amounts of thyroxine grossly in excess of her requirements.

Surgical management of ocular complications of Graves' disease.

Surgical plastic procedures can alleviate some of the ocular disability and cosmetic defects related to ocular complications of Graves' disease. These operations may include (1) maximal recession of a fibrotic inferior rectus to relieve hypotropia from its leash effect, (2) bilateral recession of inferior rectus muscles to relieve restriction to upward gaze, (3) recession of other extraocular muscles to correct heterotropia and diplopia, (4) orbital decompression for severe exophthalmos by multiple routes, including inferior orbital decompression into the antrum, (5) block recession of levator, Mueller's muscle, and conjunctiva for marked lid retraction, (6) excision of pockets of fat from bulging upper and lower lids, (7) tightening of loose redundant lid skin by blepharoplasty, and (8) lateral tarsorrhaphies. Combined operations using these principles to correct multiple defects are justified by the good results reported in a series of patients.

Observations on the Therapeutic Merit of Thyroid Radioablation for Treatment of Malignant Exophthalmos

7 malades atteints par une exophthalmie sévère ont été traités par des doses elevées de 131I pour les symptômes oculaires. Dans 6 malades on a obtenue une amélioration. Dans 1 malade les conditions restaient stables malgré la persistance de function de la Atyroide demontrée par la scintigraphic. Les résultats obtenues semblent de montrer que l’élimination radiologique pour traitement de l’exophthalmine maligne n’offre pas des avantages sur les formes de thérapie actuellement en usage.

ABSENCE OF SUPERIOR RECTI IN CRANIOFACIAL DYSOSTOSIS.

Premature synostosis of cranial bones has prompted the description of multiple clinical entities such as craniofacial dysostosis (Crouzon's Disease), acrocephalosyndactylia (Apert's disease), oxycephaly, and many others. The main ocular findings described in these syndromes have been shallowing of the orbits with orbital divergence, exotropia without limitation of ocular movements, exophthalmos, papilledema, optic atrophy, iris and choroidal colobomas, nystagmus, congenital cataract, vitreous opacities, subluxation of the lens, and retinal detachment. Little has been reported about extraocular muscle anomalies. The most common surgical intervention has been orbital decompression to relieve severe exophthalmos and papilledema. The craniostenoses have been described in greater detail by Howell,¹Koziak,²Parks and Costenbader,³Crouzon,^4,5Monthus et al,⁶and Garcin et al.⁷ A case of craniofacial dysostosis with syndactyly (Apert's disease) is presented with unusually interesting extraocular muscle findings which have not been previously reported. <h3>Report of Case</h3> A boy, born in

EFFECT OF THROXINE ON EXOPHTHALMOS IN THYROTOXICOSIS.

Exophthalmos is found in approximately 75% of patients with thyrotoxicosis (Buchanan et al., 1962). In a few patients the exophthalmos is severe and associated with chemosis, periorbital oedema, and ophthalmoplegia (Brain, 1959), whereas in the majority of patients the exophthalmos is of mild degree and constitutes little more than a cosmetic problem. The distinction between these two forms of exophthalmos is, however, arbitrary, since the mild form may occasionally progress to the severer variety (Werner, 1960). There is a tendency for both mild and severe exophthalmos to increase after treatment of thyro toxicosis, whether by surgery (Bartlett, 1962), radioiodine (Hamilton et al., 1960), or antithyroid drugs (Beierwaltes, 1948 ; Alexander et al., 1961), although clinical recognition of this tendency may be masked in the milder form by improvement in other eye signs such as lid-retraction (Hales and Rundle, 1960). Thyroxine has been claimed to be of benefit in the treat ment of severe exophthalmos (McCullagh et al., 1958). It has been suggested that thyroxine might also be of value in prevent ing increase in exophthalmos when administered along with antithyroid drugs in the treatment of thyrotoxicosis (Fraser, 1956 ; Bergfeit et al., 1961). In tne present paper we have studied the effect of L-thyroxine on the exophthalmos of thyro toxic patients treated with antithyroid drugs or radioiodine.

Removal rate of Na24 from human orbit in exophthalmic patients.

Graves' disease is generally associated with a typical ophthalmopathy. The occurrence and intensity of this ophthalmopathy are not related to the course of hyperthyroidism. Pituitary ophthalmotropic factors, other than thyrotropic hormone, are considered to be the cause of the exophthalmos. 3 Two principal clinical types of exophthalmopathy have been described, namely, the simple and the malignant exophthalmos; however, most of the patients show a mixed picture, presenting some characteristics of each one. In severe exophthalmos, underlying edema and cellular infiltration of the conjunctiva and structures about the eye are clinically obvious. There have been many hypotheses on the mechanism of the ophthalmopathy of Graves' disease. It is now generally accepted that the proptosis is due to an increased volume of the retrobulbar tissues of the eye. 3,9 Several factors may play a part in the filling of the orbit: an increase in retrobulbar fat, 5,9 an increase in the size

ASSAY OF THE EXOPHTHALMOS-PRODUCING SUBSTANCE IN THE SERUM OF PATIENTS WITH PROGRESSIVE EXOPHTHALMOS*†

Assays of the exophthalmos-producing substance (EPS) in the serum of patients with progressive exophthalmos were performed using Fundulus hetroclitus, an Atlantic minnow. The assay consists of measurement of the exophthalmic response in fish after injection of the patient's serum. A variety of factors affecting the responsiveness of the fish were partly controlled by the use of standard pituitary extract. The serum of certain patients produced pronounced exophthalmos in the fish. There was no strict correlation between the degree of response in the fish and the severity of clinical progressive exophthalmos. A better correlation was observed in patients early in the development of the disease. Several impressive responses were elicited by the scrum of patients with Graves' disease preceding the onset of severe exophthalmos. Late in the course of progressive exophthalmos no high assay values were found. Mild degrees of response were occasionally elicited by the serum of normal subjects. Pituitary stalk sect...

Peculiar response of toad larvae to thiourea treatment.

Tadpoles of Bufo vulgaris formosus were kept in a 0.05% thiourea solution for 87 days, and the effects on the eye-balls, thyroid glands and gonads were histologically examind.Exophthalmos produced by a striking enlargement of the eye-ball was observed in different degrees in the majority of the treated tadpoles. The thyroid glands of those tadpoles remarkably increased in size, and grew into Struma parenchymatosa.Gonadal differentiation was more advanced as compared with the frogs of the same age collected in the field, although degenerative changes were observed in the ovaries of some tadpoles. Development of Bidder's organ was considerably inhibited. Sex ratio was 1:1 as a whole, although severe exophthalmos was mostly observed in females.Masculinization of the genetic female following treatments with goitrogens seems to occur easily only in higher anurans such as Rana and Rhacophcrus, and such a reversal seems to be difficult to occur in urodeles and lower anurans.

Exophthalmic goiter in children.

ABSTRACT A total of 253 children less than 15 years of age who had exophthalmic goiter have been seen at the Mayo Clinic during the 48-year period, 1908 through 1955. There were 217 girls and 36 boys, a ratio of about 6:1. Observations in this series indicate that the disease in children does not appear to differ significantly from that in adults, although there is less tendency for children to have severe exophthalmos. Exophthalmos that occurs during childhood may persist for years after thyrotoxicosis has been relieved. Diabetes mellitus is observed more frequently among children with exophthalmic goiter than would be expected as a chance occurrence. Exophthalmic goiter during childhood, if adequately treated, does not alter adolescent development. Subtotal thyroidectomy is a satisfactory and safe method of treating exophthalmic goiter in children. There were only 4 hospital deaths among 196 children treated by this means. No surgical death has occurred since 1933 among children treated by this method. ...

THE FUNCTION OF THE THYROID IN EUTHYROID PATIENTS WITH EXOPHTHALMOS

In the presence of severe exophthalmos it has been known that the basal metabolic rate, serum concentration of protein-bound iodine, and radioiodine uptake may be normal or compatible with either hypo- or hyperthyroidism. These findings have defied the clinician to relate exophthalmos directly to thyroid function. However, in a recent study of ten clinically euthyroid patients, Werner (1955) found all tests of function normal except for suppression of uptake by administration of triiodothyronine; here the patients with exophthalmos responded like thyrotoxic patients in that their uptake was not suppressed. In an attempt to elucidate further the function of the thyroid gland in clinically euthyroid patients with exophthalmos, eight such patients have been studied. Measurements included basal metabolic rates, serum concentration of protein-bound iodide (PBI), uptake of I131 by the thyroid, and the conversion ratio of I131 in serum (PBI131). Paper chromatographic analyses were made of the serum

The early recognition of premature cranial synostosis.

The characteristic roentgen findings in a child with a fully developed craniostenosis are known to most radiologists. These older children have misshapen heads and various neurological disorders, and the roentgenographic picture is typi cal. For example, closure of all the sutures gives rise to oxycephaly. Such a case is shown in Figure 1. The patient was a female of two and one-half years who was admitted because of a peculiarly shaped skull and a severe exophthalmos. Her vision was already impaired, and she was mentally retarded. The roentgenograms reveal closure of all the sutures. The skull has a turricephalic contour, indicating that the region of the anterior fontanel was probably the last to close. The digital markings are increased; the floor of the middle fossa is depressed and bulges forward. Another fully developed case of premature cranial synostosis is shown in Figure 2. This patient was a three-year-old female who also had a peculiarly shaped skull. At the time of admission her mentality was...

Relation of Steroid Hormones to the Development of Experimental Exophthalmos

It has always been accepted that the two sexes are not affected with equal frequency or severity by thyrotoxicosis or exophthal­ mos. Whereas, such ratios as four females to one male are quoted in the incidence of ex­ ophthalmic goiter, the occurrence of severe exophthalmos, especially of the postthyroidectomy type, has been found greater in men (Marine, Oppenheimer, Means). Such statistics strongly suggest some relation of the sex steroid hormones to exophthalmos. In addition, the clinical reports (Brain and Mann/ Halpern) on the occasional use of sex hormones in the treatment of exoph­ thalmos, and the experimental studies of Marine, stimulated us to evaluate the effect of some of the steroid hormones of the gonads and adrenal glands on the experi­ mental exophthalmos produced by pituitary extracts, which simulates clinical exophthal­ mos. One hundred and 54 guinea pigs of both sexes were used in these studies. All were thyroidectomized when they attained 270 to 290 gm. of body weight. Exophthalmos was produced by injection of pituitary extracts subsequent to thyroidectomy, as reported in previous articles (Smelser '). In some experiments it was desired to de­ termine if absence of the gonads played any role in the development or degree of exoph­ thalmos to be produced. In these cases both sexes were gonadectomized at approximately weaning age (190 to 220 gm. in weight) long before thyroidectomy was performed. A portion of both the spayed female and the castrated male guinea pigs were reserved as control animals and the others were in­ jected with anterior pituitary extract for 15 to 34 days. Paired experimental and control

The Treatment of Graves’ Disease with Severe Exophthalmos

The Treatment of Graves’ Disease with Severe Exophthalmos