Exophthalmos+(Benign)

In most cases, the bulging of the eyeball is enough for a physician to diagnose exophthalmos but there are other tests that will need to be ordered in order to figure out what is causing the problem. When a family physician suspects a diagnosis of exophthalmos, they will likely send the patient to an ophthalmologist and from there, other tests will be ordered. One of these tests is blood work to test the thyroid and see if it is functioning properly. A cat scan or MRI may also be ordered to evaluate the orbit and make sure there are not tumors or other abnormalities in or around the eyes. An exophthalmometer is an instrument that is used to measure the degree of protrusion of the eye as well as determining how well the patient can move their eyes. "Patients with exophthalmos will be able to look upwards without moving their eyebrows." 1 || ---the deep parotid lymph nodes which can be broken down into 2 groups: --- the submaxillary lymph nodes which are scattered over the infraorbital region. They are located from the groove between the nose and cheek to the zygomatic arch. ---the buccal lymph nodes which are scattered over the buccinator muscle . 2
 * ​Epidemiology: || Graves disease occurs most frequently in women (7:1 compared to men). It occurs most often in middle age (most commonly in the third to fifth decades of life), but is not uncommon in adolescents, during pregnancy, during menopause, or in people over the age 50. There is a marked family preponderance, which has led to speculation that there may be a genetic component. To date, no clear genetic defect has been found that would point at a monogenic cause. 8 ||
 * Etiology: || The trigger for auto-antibody production is not known. There appears to be a genetic predisposition for Graves' disease, suggesting that some people are more prone than others to develop TSH receptor activating antibodies due to a genetic cause. HLA DR (especially DR3) appears to play a significant role. 8 ||
 * Signs & Symptoms: || The most common causes of bulging eyeballs is Graves' disease. Signs and symptoms of Graves' disease are:
 * Bulging eyes
 * Pain in the eyes
 * Dry eyes
 * Eye irritation
 * Sensitivity to light (photophobia)
 * Lacrimation (eye secretions and shedding of tears)
 * Diplopia (double vision causes by weakening of eye muscles)
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Progressive blindness from optic nerve compression
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Difficulty moving the eyes because of muscle weakening.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Sometimes the eye may turn inward (amblyopia) <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">1 ||
 * Diagnostic Procedures: || <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Evaluation:
 * Histology: || <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">There is no histology related to exophthalmos itself as it is a benign condition. ||
 * Lymph Node Drainage: || <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%; vertical-align: super;">Lymph drainage from the eye is:
 * the first group is embedded in the parotid gland. Its superior border is the TMJ, posterior border is the mastoid process, inferior border is the angle of the mandible, and the anterior border is the anterior ramus.
 * the second group is the subparotid nodes which are "located deep to the gland and lie on the lateral wall of the pharynx."

<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 100%; vertical-align: sub;">Figure 1. Diagram of head and neck lymph nodes. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; vertical-align: super;">2 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 100%;"> ||
 * Metastatic Spread: || <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Exophthalmos is a benign disease. ||
 * Grading: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">There is no grading scale for this benign condition. ||
 * Staging: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">There is no staging system for this benign condition. ||
 * Radiation Side Effects: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Side effects for treatment of exophthalmos would be the same as those encountered when treating the eye for malignant disease. Erythema, depigmentation, atrophy, telangiectasia, and hair loss are some side effects. Cataract is of concern due to the sensitivity of the lens of the eye.

__Cataract:__ Single Dose: 2 Gy Fractionated Dose: 8 Gy <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 70%; vertical-align: super;">5 || - Depression - Mental and physical sluggishness - Weight loss <span style="color: #ff0000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">9 || Topical lubrication of the ocular surface is used to avoid corneal damage caused by exposure. Tarsorrhaphy is an alternative option when the complications of ocular exposure can't be avoided solely with the drops. Corticosteroids are efficient in reducing orbital inflammation, but the benefits cease after discontinuation. Corticosteroids treatment is also limited because of their many side effects. <span style="font-family: 'Times New Roman',Times,serif;">-Radiotherapy is an alternative option to reduce acute orbital inflammation. Unfortunately, there is still controversy surrounding its efficacy."<span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;"> 3 For bilateral disease both orbits are irradiated using lateral opposing fields with 6 or 10 MV. Half beam and 10 degree posterior angled fields are used to minimize the dose to the lens and posterior eye chamber. The posterior border of the field covers the ring of Zinn at the superior orbital fissue and the entire length of the eye muscles. The anterior border is located 5 to 6 mm behind the iris/ pupil. The doses used are 2.0 Gy per fraction to a total dose of 2.4 to 30 Gy in two to three weeks. Pretherapeutic corticosteriods are generally administered during radiation. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">6 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">Figure 2: Field arrangement with lens blocking. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;"> 7
 * Prognosis: || <span style="color: #ff0000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Graves disease often responds well to treatment. However, thyroid surgery or radioactive iodine usually will cause hypothyroidism. Without getting the correct dose of thyroid hormone replacement, hypothyroidism can lead to:
 * Treatments: || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">-"Even though some patients undergo spontaneous remission of symptoms within a year, many need treatment. The first step is the regulation of thyroid hormones levels by an endocrinologist.

<span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">Figure 3: Isodose distribution with 6 MV opposed lateral beams. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">7 <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">-"A simple way of reducing inflammation is smoking cessation, as pro-inflammatory substances are found in cigarettes. Surgery may be done to decompress the orbit, to improve the proptosis and to address the strabismus causing diplopia. Surgery is performed once the patient’s disease has been stable for at least six months. In severe cases, however, the surgery becomes urgent to prevent blindness from optic nerve compression. -Eyelid surgery is the most common surgery performed on Graves ophthalmopathy patients. Lid-lengthening surgeries can be done on upper and lower eyelid to correct the patient’s appearance and the ocular surface exposure symptoms. Marginal myotomy of levator palpebrae muscle can reduce the palpebral fissure height by 2-3 mm. When there is a more severe upper lid retraction or exposure keratitis, marginal myotomy of levator palpebrae associated with lateral tarsal canthoplasty is recommended. This procedure can lower the upper eyelid by as much as 8 mm. Other approaches include müllerectomy (resection of the Muller muscle), eyelid spacer grafts and recession of the lower eyelid retractors. Blepharoplasty <span style="font-family: 'Times New Roman',Times,serif;">can also be done to debulk the excess fat in the lower eyelid." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">3 || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">Table provided by Wikibooks. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; vertical-align: super;">4 || References: <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">1. Medical News Today. //What is Exophthalmos? What Causes Exophthalmos?// Available at: [] Accessed February 16, 2010. <span style="color: #008000; font-family: 'Comic Sans MS',cursive;">2. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> Washington CM, Leaver D. //Principles and Practice of Radiation Therapy.// 2nd edition. St. Louis, MO: Mosby, Inc. 2004: 389. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">3.Graves' ophthalmopathy. Wikipedia. Available at: []. Accessed on February 20,2010. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">4. Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">[]. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Accessed February 20, 2010. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">5. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2002: 180. <span style="color: fuchsia; font-family: 'Calibri','sans-serif'; font-size: 11pt; line-height: 200%;">6. Gunderson, LL & Tepper, JE. (Eds.) //<span style="color: fuchsia; font-family: 'Calibri','sans-serif'; font-size: 11pt; line-height: 200%;">Clinical Radiation Oncology //<span style="color: fuchsia; font-family: 'Calibri','sans-serif'; font-size: 11pt; line-height: 200%;">. 2nd edition. Philadelphia, PA: Elsevier, Churchill & Livingstone. 2007: 1557-1558. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">7. Bentel GC. //Radiation Therapy Planning//. 2nd edition. New York, NY: McGraw-Hill Companies,Inc. 1996: 270, 322. 8. Wikipedia. Exophthalmos. Available at: [] . Accessed on February 21, 2010. 9. Medline Plus Medical Encyclopedia. Graves Disease. Available at: [] . Accessed February 21, 2010.
 * TD5/5: || [[image:Untitled2.jpg]]