Diagnosis and differential diagnosis of endocrine exophthalmo

Diagnosis and differential diagnosis of endocrine exophthalmos

The presence of bilateral exophthalmos if associated with a goitre and the

other manifestations of Graves' disease should present little difficulty in diagnosis.

    Where necessary the diagnosis may be confirmed by immunological

tests for thyroid peroxidase or microsomal antibodies. The main differential

diagnostic problem is from an orbital tumour, and CT and MRI scanning is

very useful in determining the involvement of extraocular muscles. Thickenedmuscle bellies, particularly of the inferior rectus and medial rectus are characteristic of this disease. In addition to these tests there are some helpful clinical pointers, such as the presence of both upper and lower lid retraction and asymmetry of exophthalmos which is rarely greater than 6mm in endocrine exophthalmos, whereas it can be more than this in many orbital tumours.

Management of endocrine exophthalmos

It is important to follow the progress of any type of proptosis by serial exophthalmometer measurements. This is a simple instrument which measures the distance forward from the lateral bony margin of the orbit to the anterior convexity of the cornea. It can be done simply by a millimetre scale but more accurate measurements are possible with one of the special instruments of which Hertel's exophthalmometer, in which an inclined mirror superimposes the corneal image on a millimetre scale, is one of the most useful  The endocrine exophthalmos may threaten vision by exposure keratitis, retinal oedema, papilloedema and optic nerve compression. Exposure of the cornea in mild cases is prevented by methyl cellulose drops or eye ointments and vaseline gauze dressings. Tarsorrhaphy is necessary if the condition is progressive and should not be long delayed as it may become difficult to accomplish when the orbital pressure is tending to separate the lids.

    When optic nerve function is threatened, treatment is urgent and is aimed at shrinkage or escape of the orbital soft tissue. This may be done medically

using high dose oral corticosteroids, or with orbital radiotherapy, or both.

Diabetes mellitus and the eyes

The size of the problem

Many features of diabetes mellitus are those of a systemic immune disease.

Although renal and arterial disease are the main causes of death in diabetics,

the ocular complications of the disease are a major determinant of disability.

Diabetics are about 15 times more likely to go blind than non-diabetics and this disease accounts for about 7% of the newly registered blind. Diabetes is now the commonest single cause of blindness in patients under 65 years in Great Britain and Diabetes UK estimate the prevalence of registerable blindness caused by diabetes to be 100 per million of the population.

Diabetic eye disease

The main causes of blindness in diabetic patients are retinal disease, accounting for about 80%, and cataract formation which accounts for the majority of the remaining 20%. Other ophthalmic conditions to which diabetics are liable include optic neuritis and extraocular muscle palsy, both of which usually have a favourable prognosis. Diabetes causes widespread changes in the tissues of the eye including degenerative changes in the epithelium of the iris and ciliary body. Although the lens and retina may be affected together they will be considered separately here for convenience.

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