Exophthalmos or Proptosis is defined as an “abnormal protrusion of the eyeball.” Another resource suggests that the terms exophthalmos and proptosis can be used to describe eyes appearing to bulge out of the face due to an increase in the volume of the tissue behind the eyes. Proptosis can describe any organ that is displaced forward, while exophthalmos refers to only the eyes. Proptosis can include any directional forward displacement.
Exophthalmos are those cases of proptosis secondary to endocrinological dysfunction. Therefore, this dictum will be followed, and non–endocrine-mediated globe protrusion will be referred to as proptosis and exophthalmos will be reserved for protrusion secondary to endocrinopathies.
Pathophysiology
The etiological basis of proptosis can include inflammatory, vascular, infectious, cystic, neoplastic (both benign and malignant, metastatic disease), and traumatic factors. Some representative examples (not a complete list of proptosis from different causes) include infectious causations such as orbital cellulitis and subperiosteal abscesses.
Traumatic causations could be orbital emphysema, retro-orbital hemorrhage, and carotid-cavernous fistula. Vascular causations not traumatically related would be orbital arteriovenous malformation (AVM) varices and aneurysms.
Neoplastic causations include adenocarcinoma of the lacrimal gland, pleomorphic adenoma of the lacrimal gland, meningioma, lymphoma, and metastatic disease.
For instance, lymphangiomas, by their histologic nature, can increase in size during viral illnesses and result in an increase in orbital volume. A ruptured lymphangioma can enlarge after its rupture and sequestering of heme, which pathologically is described as a chocolate cyst. Orbital varices can result in proptosis with increased venous pressure in the orbit, as seen with a Valsalva maneuver or change in postural position.
Unusual cases are also encountered, such as bilateral proptosis due to orbital hemorrhage caused by factor IX deficiency (hemophilia B).
In children, unilateral proptosis is often due to an orbital cellulitis–type picture, and, in bilateral cases, neuroblastoma and leukemia are more likely. Other causes in children include rhabdomyosarcoma, retinoblastoma, capillary hemangioma, dermoid cyst, glioma of the optic nerve, and metastatic disease.
Thyroid related
Thyroid orbitopathy, also referred to as thyroid ophthalmopathy, is categorized as an inflammatory process that is autoimmune-mediated. As it affects the orbit, the author prefers to use thyroid orbitopathy and, more particularly, thyroid-associated orbitopathy, commonly referred to as Graves disease. In adults, it is the most common cause of unilateral and bilateral exophthalmos. Noninflammatory thyroid orbitopathy has also been reported.
The etiology of the thyroid-related orbitopathy is an autoimmune-mediated inflammatory process of the orbital tissues, predominantly affecting the fat and the extraocular muscles. Lymphocytes, plasma, and mast cells are the cellular constituents in this process. The deposition of glycosaminoglycans and the influx of water increase the orbital contents. Over time, fibrosis can occur.
Genetic factors have been associated with Graves disease. Obstruction of the superior ophthalmic vein with resultant diminished venous outflow also contributes to the orbital engorgement.
Types of thyroid related orbitopathy
Nunery has segregated patients with thyroid-related orbitopathy into type I and type II. Those with “type I” do not have restrictive myopathy, whereas those with “type II” do. Type-I was believed to be caused by a profundity of hyaluronic acid manufactured by the orbital fibroblasts, stimulating lipoid hyperplasia and edema. Patients with type-II experience restrictive myopathy and have diplopia within 20° of fixation.
Orbital emphysema can be a significant cause of proptosis and requires emergency treatment. 
Diagnosing/History
A meticulous history of the patient’s ocular and systemic systems is essential in establishing a diagnosis. The ophthalmic history should address the duration and rate of onset of proptosis, along with symptoms such as pain, changes in visual acuity or refraction, diplopia, and decreased fields of vision. Transient visual loss may signify optic nerve compromise, requiring rapid intervention.
Complaints of foreign body sensation or dry, gritty eyes may indicate corneal decompensation. Consideration should be given to orbital involvement secondary to systemic pathology in a thorough medical history and review of systems.
Past trauma and family history can also play a role in diagnosis. The rate of onset can provide valuable clues – sudden unilateral onset suggesting intraorbital hemorrhage or inflammation, a 2- to 3-week onset suggesting chronic inflammation, and a slower onset pointing to an orbital tumor. By carefully examining all these factors, a comprehensive understanding of the patient’s condition can be achieved.
Physical examination
Evaluation of the patient with exophthalmos begins with a thorough ophthalmic and medical history. When concomitant sinus disease or an intranasal source is suspected, a speculum or endoscopic intranasal examination is warranted. Special emphasis on the duration and rate of progression of the patient’s signs and symptoms is essential. Pain, diplopia, pulsation, change in effect or size with position or Valsalva maneuver, and disturbance of visual acuity are symptoms that should be explored. In general, a difference of more than 2 mm between a person’s 2 eyes is abnormal.
A comprehensive ophthalmic examination is vital for diagnosing eye conditions accurately. Periorbital changes, including hypertelorism, exorbitism, proptosis, eyelid lesions, edema, chemosis, and engorged conjunctival vessels, should be carefully observed. Additional signs like blepharoptosis, lagophthalmos, and interpalpebral fissure distance also play a crucial role in the examination process.
Palpating the anterior orbit can provide valuable information on tenderness, texture, and mass mobility, indicating possible inflammatory processes or neural invasion. Regional lymph nodes should also be assessed during the examination. Protrusion of the eye is a significant clinical sign of orbital disease, with Hertel exophthalmometry being a reliable tool for measuring proptosis.
Auscultating the orbit may help detect high flow states while examining with the bell. It is essential to note any decrease in visual acuity, changes in refraction, pupillary abnormalities, extraocular motility dysfunction, and diplopia. Forced duction testing can determine whether dysfunction is restrictive or neurogenic in nature.
Slit Lamp
Intraocular pressure, slit lamp examination, and dilated funduscopic examination are essential for identifying various eye conditions. Funduscopic examination can reveal optic disc abnormalities, retinal detachment, vascular issues, or indentation of the posterior pole. Signs of hyperthyroidism, such as eyelid retraction and lag, can also be observed in ophthalmic examinations. Prolonged exposure to air can lead to corneal drying and potential infection, underscoring the importance of a thorough examination process in diagnosing eye health issues accurately.
The following findings are especially worrisome:
- Diplopia.
- Eye pain or redness.
- Fever.
- Headache.
- Pulsating proptosis.
- Neonatal proptosis.
- Vision loss.
What other tests might patients need?
Your healthcare provider may perform or recommend other tests, including:
- Exophthalmometry: This test uses a special instrument to measure how far your eyeball protrudes from your eye socket.
- Blood tests: This will likely include a workup for thyroid disease.
- Imaging studies: Imaging tests, like an MRI (magnetic resonance imaging) or a CT scan (computed tomography scan), can check for bleeding, tumors or signs of infection.
- Other lab tests: Lab tests, like a blood or tissue culture, can confirm or rule out an infection.
Differential diagnosis
Proptosis can be the result of a myriad of disease processes resulting from primary orbital pathology or systemic disease processes. The list below is not comprehensive but can help in forming a differential diagnosis. The list only consists of adult causes since a fair amount of overlap exists in the differential diagnosis of exophthalmos in adults and children.
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Proptosis in adults
- Infectious
- Orbital cellulitis
- Mucormycosis
- Concurrent sinus disease
- Inflammatory
- Orbital inflammatory syndrome (orbital pseudotumor, benign orbital inflammation)
- Thyroidopathy
- Erdheim-Chester disease
- Endocrine
- Cushing syndrome
- Vasculitis
- Wegener granulomatosis
- Churg-Strauss syndrome
- Neoplastic
- Lacrimal
- Lymphoma
- Leukemia
- Meningioma
- Glioma
- Ossifying fibroma
- Metastatic (breast in women, lung and prostate in men, gastrointestinal, kidney)
- Dermoid cyst
- Hand-Schüller-Christian disease
- Orbital vascular disease
- Orbital varix (venous malformation)
- Orbital arteriovenous malformation (carotid-cavernous sinus fistula, arteriovenous malformation)
- Trauma
- Traumatic or iatrogenic orbital hemorrhage
- Orbital fractures
- Facial fractures
- Other
- Craniosynostosis
- Pfeiffer syndrome
- Apert syndrome
- Crouzon syndrome
- Carpenter syndrome
- Pseudo proptosis (pseudo exophthalmos)
- Buphthalmos
- Contralateral enophthalmos
- Ipsilateral lid retraction
- Axial myopia
- Contralateral blepharoptosis
- Infectious
What causes bulging eyes?
Graves disease is the primary cause of bilateral proptosis in adults. Acute unilateral proptosis typically is associated with infection or vascular disorders such as hemorrhage or cavernous sinus thrombosis, whereas chronic unilateral proptosis often is indicative of a tumor. Suspected cases of Graves disease should prompt the performance of CT or MRI scans as well as thyroid function testing. Additionally, it is important to provide lubrication to safeguard the exposed cornea.
The most common cause of bulging eyes is an autoimmune disease in which your body’s immune system attacks cells in our thyroid gland and the tissue behind our eye. Proptosis in patients with thyroid issues is also called thyroid eye disease (TED).
Other proptosis causes include:
- Eye socket infections.
- Injuries, especially if they cause bleeding behind the eye.
- Tumors, which may include neuroblastoma and some soft tissue sarcomas.
What are the complications and long-term effects of proptosis?
Most people don’t experience complications or long-term effects. In rare cases, double vision or vision loss may be permanent. It’s also possible to experience cornea damage if patient can’t blink and lubricating eye drops (allopathic) aren’t effective.
Allopathic treatment for Exophthalmos or Proptosis
How is proptosis treated?
There is no treatment for proptosis in allopathy. Patients should be monitored in intervals tailored to the degree of exophthalmos and complications arising from this ocular malady. Measurement of exophthalmos, visual and color acuities, pupillary function, extraocular motilities, and visual fields should be obtained. 
Allopathic treatment may include:
- Artificial tears, including drops or gel, to relieve dry eyes and protect corneas.
- Antibiotics if patient has an infection.
- Medical treatments for underlying conditions, for example for hyperthyroidism.
- Intravenous (IV) medications like corticosteroids (anti-inflammatory medication) or teprotumumab for thyroid eye disease.
Other nonsurgical allopathic treatments for Exophthalmos or Proptosis
Other therapies may include:
- Double vision treatments: These treatments include prisms that attach to the glasses and redirect light as it enters patient’s eyes.
- Immunosuppressive drugs: These drugs may lessen the impact of immune system attacks on patient’s eyes.
- Corticosteroids: Steroids by injection (i/v or i/m) to relieve swelling or restore eyesight.
Surgery
Patient may need surgery to:
- Create more space behind the eye in the eye socket.
- Treat double vision.
- Protect patient’s corneas if patient can’t fully close his/her eyelids.
- Remove a tumor.
Homeopathic Treatment for Exophthalmos or Proptosis
Are there other nonsurgical treatments for Exophthalmos or Proptosis?
Which is the best treatment for exophthalmos or proptosis?
With Homeopathic medications exophthalmos or proptosis is 100% curable in 30-90 days depending on stage and severity of disease.
For each cause(s) click the for links below for appropriate treatment:
- Graves disease.
- autoimmune disease
- Thyroid/hyperthyroidism
- sarcomas.
- Tumor.
- Cellulitis.
- Leukemia.
- Abscesses.
- Cancer.
No need to operate or advise steroids in any stage of exophthalmos or proptosis.
Homeopathic antibiotics
here are some Homeopathic antibiotics best in my experience (Dr. Qaisar Ahmed):
Pryogenium
Pyrogen is the best medicine for septic states, with intense restlessness. “In septic fevers, especially puerperal. Hectic, typhoid, typhus, ptomaine poisoning, diphtheria, dissecting wounds, sewer-gas poisoning, chronic malaria, after-effects of miscarriage, all these conditions at times may present symptoms calling for this unique medicine.
All discharges are horribly offensive. Great pain and violent burning in abscesses. Chronic complaints that date back to septic conditions. Influenza, typhoid symptoms, cut or injury becomes much swollen and inflamed-discolored and dry. 
Hepar Sulphuricum
Ulcers on cornea. Iritis, with pus in anterior chamber; purulent conjunctivitis, with marked chemosis, profuse discharge, great sensitiveness to touch and air. Inflammation of eyes and lids. Pain in the eyes, as if pulled back into the head. Boring pain in upper bones of the orbits. Eyeballs sore to touch. Objects appear red and too large. Vision obscured by reading; field reduced one-half. Bright circles before eyes. Hypopyon.
Suits especially scrofulous and lymphatic constitutions who are inclined to have eruptions and glandular swellings. Unhealthy skin. Blondes with sluggish character and weak muscles. Great sensitiveness to all impressions. Croupous catarrhal inflammation, profuse secretion, also easy perspiration. Infected sinus with pus forming. The lesions spread by the formation of small papules around the side of the old lesion. Pellagra (material doses required). Syphilis after anti specific gross allopathic medication.
Silicia Tera
Organic changes: it is deep and slow in action. Increased susceptibility to nervous stimuli and exaggerated reflexes. Diseases of bones, caries and necrosis. Silica can stimulate the organism to re-absorb fibrotic conditions and scar-tissue.
Periodical states; abscesses, quinsy, headaches, spasms, epilepsy, keloid growth, tuberculosis etc. Side effects of vaccination. Suppurative processes. Fistulous borrowings. Ripens abscesses.
Angles of eyes affected. Swelling of lachrymal duct. Aversion to light, especially daylight; dazzling sharp pain through eyes; eyes tender to touch; worse when closed. Vision confused; letters run together on reading. Styes. Iritis and irido-choroiditis, with pus in anterior chamber. Perforating or sloughing ulcer of cornea. Abscess in cornea after traumatic injury. Cataract. After-effects of keratitis and ulcus cornea.
Calcarea Carbonica
Sensitive to light. Lachrymation in open air and early in morning. Spots and ulcers on cornea. Lachrymal ducts closed from exposure to cold. Easy fatigue of eyes. Far sighted. Itching of lids, swollen, scurfy. Chronic dilatation of pupils. Cataract. Dimness of vision, as if looking through a mist. Lachrymal fistula; scrofulous ophthalmia. Swelling of glands, scrofulous and rachitic conditions. Incipient phthisis. Abscesses in deep muscles; polypi and exostoses. Pituitary and thyroid disfunction.
Mercsole
A lifesaving Homeopathic medicine. Every organ and tissue of the body is more or less affected by this powerful medicine. Decrepit, inflamed and necrotic wrecks. Decomposed blood. Infections and inflammation of lymphatic system, all membranes and glands, and internal organs, bones etc. Syphilis. Ulcerations of mouth and throat, eyes, bullae, abscesses, snuffles, marasmus, stomatitis or destructive inflammations etc. Sensitive to heat and cold. Parts are much swollen, with raw, sore feeling; the profuse, oily perspiration does not relieve. Breath, excretions and body smell foul. Tendency to formation of pus, which is thin, greenish, putrid; streaked with thin blood.
Lids red, thick, swollen. Profuse, burning, acrid discharge. Floating black spots. After exposure to glare of fire; foundrymen. Parenchymatous keratitis of syphilitic origin with burning pain. Iritis, with hypopyon.
Tuberculinum
Rapid emaciation. Chronic cystitis. Enlarged tonsils. Skin affections, acute articular rheumatism. Eyes infections. Tumors. Cysts. Cornial opacity. Swollen lids. Conjunctiva inflamed. Dullness and heaviness of eyes; darkness before eyes. Obscuration of vision. Breaking down of cicatrices of old corneal ulcers. Corneal opacity, the result of old tuberculous cornetites. Tuberculosis of eyelids, small grey and yellow nodules, existing in conjunctiva of outer sections of lids, increased in size, ran together, then suddenly disappeared. Conjunctivitis; herpes on lids. Amblyopia with irregularity and complete paralysis of pupils. 
Bacillinium
A best antiseptic and antibiotic. Tuberculosis. Enlarged glands. Consumptiveness Growth. Hydrocephalus. Idiocy. Insanity. Joints affections. Phthiriasis. Pityriasis Ringworm. Scrofulous glands. Teeth defective, infections, pitted.
Arsenicum Album
A profoundly acting remedy on every organ and tissue. Peculiar irritability of fiber, burning pains. Ptomaine poisoning, stings, dissecting wounds, infections, inflammations, itching, burning, swellings; oedema, eruption, papular, dry, rough, scalyetc. Degenerative changes. Burning in eyes. Acrid lachrymation. Lids red, ulcerated, scabby, scaly, granulated. Edema around eyes. External inflammation, with extreme painfulness; burning, hot, and excoriating lachrymation. Corneal ulceration. Intense photophobia; better external warmth. Ciliary neuralgia, with fine burning pain. Malignant pustules. Ulcers with offensive discharge. Anthrax. Poisoned wounds. Urticaria, with burning and restlessness. Psoriasis. Scirrhous. Gangrenous inflammations.
Antimunium Crudum
Dull, sunken, red, itch, inflamed, agglutinated eyes. Canthi raw and fissured. Chronic blepharitis. Pustules on cornea and lids. Eczema. Pimples, vesicles, and pustules. Sensitive to cold bathing. Thick, hard, honey-colored scabs. Urticaria; measle-like eruption. Itching when warm in bed. Dry skin. Warts. Dry gangrene. Scaly, pustular eruption with burning and itching.
Phosphorus
Destructive metabolism. Irritates, inflammation and degeneration of mucous membranes, irritation and inflammation of serous membranes, spinal cord and nerves, paralysis, destroyed bones. Muscular pseudo-hypertrophy, neuritis. Wounds bleed very much, even if small. Cataract. Black points seem to float before the eyes. Green halo about the light. Letters appear red. Atrophy of optic nerve. Edema of lids and about eyes. Pearly white conjunctiva and long curved lashes. Partial loss of vision. Pain in orbital bones. Paresis of extrinsic muscles. Diplopia, due to deviation of the visual axis. Amaurosis. Glaucoma. Thrombosis of retinal vessels and degenerative changes in retinal cells. Degenerative changes where soreness and curved lines are seen. Retinal trouble with lights and hallucination of vision.
Myristica Sebifera
A remedy of great antiseptic powers. Inflammation of skin, cellular tissue and periosteum. Traumatic infections. Parotitis. Fistulas. Carbuncles. Specific action in panaritium. Pain in the fingernails with swelling of the phalanges. Hands are stiff, as if from squeezing something a long time. Coppery taste and burning in throat. Tongue white and cracked. Phlegmonous inflammations. Hastens suppuration and shortens its duration. Often does away with use of the knife. Inflammation of middle ear, suppurative stage. Anal fistulas.
PS: This article is only for doctors having good knowledge about Homeopathy and allopathy, for learning purpose(s).
For proper consultation and treatment, please visit our clinic.
Location, address and contact numbers are given below.
Dr. Sayyad Qaisar Ahmed (MD {Ukraine}, DHMS) ; senior research officer Dnepropetrovsk state medical academy Ukraine; is a leading Homeopathic physician practicing in Al-Haytham clinic, Umer Farooq Chowk Risalpur Sadder (0923631023, 03119884588), K.P.K, Pakistan.
Find more about Dr. Sayyad Qaisar Ahmed at:
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