MEASUREMENT

• A measurement of the distance

between a point on the temporal
orbital rim and the apex of the
cornea is made.
• Measurement is made in
millimeter
• Eyes are compared to each other.
• Eyes are compared to “normal”.
 HISTORY
• Exophthalmometry is the term
derived from the orbital condition
called Exophthalmos which can
be detected by utilizing
exophthalmometer.
• This term was coined by Cohn in
1867,who originated the concept
of measuring the distance from
the lateral orbital rim to the
anterior surface of the cornea.
• Based on Cohn concept, Hertel developed
“Hertel Exophthalmometer” in 1905.
• Still there was a use of millimeter ruler to
roughly determine the amount of displacement
of the globe was wide spread, in 1938.
• In 1967, Watson described an instrument
called ocular topometer.
– This instrument designed to measure displacement
in any direction other than along an anterior to
posterior axis.
– Watson states that his topometer was no better than
a Hertel for measurement of exophthalmos
 INDICATIONS

• Detection of exophthalmos.
• Detection of enophthalmos.
• Suspect of Orbital cellulitis.
• Monitoring by serial-reading the progression of
exophthalmos.
• Detection and monitoring of Grave’s disease.
• To assist in differentiating the pseudo from true
exophthalmos and enophthalmos.
• Neoplasm
• Trauma
 DEFINITIONS
• EXOPHTHALMOS.

• ENOPHTHALMOS.

• PROPTOSIS.
 EXOPHTHALMOS
• Exophthalmos is an abnormal
forward displacement or axial
protrusion of the globe with
in the orbit.
• It occurs when there is an
imbalance between the
volume of the orbit and
volume of orbital contents.
• Any increase in the volume
of orbit results in a forward
displacement of the globe.
 CAUSES
• Graves eye disease (hyperthyroidism).
• Orbital pseudo-tumor.
• Cavernous sinus thrombosis.
• Orbital infiltration from leukemia.
• Wagner's granulomatosis.
• Metastatic neuroblastoma.
 Pseudo-Exophthalmos

• Globe is either displaced anteriorly with

corresponding high exophthalmometry
readings or the globe merely appears to
protrude abnormally.
 Causes
• Long axial length of the globe
– High axial myopia.
– Congenital glaucoma.
• Orbital asymmetry
– Congenital
– Traumatic
• Asymmetry of palpebral fissures
– Lid retraction
– Contralateral ptosis
– Contralateral enophthalmos
– Entropian and Ectropian
• Loss of tonus in EOM
• Third nerve palsy
TREATMENT
 ENOPHTHALMOS
• Defined as an abnormal posterior displacement
of the globe or a relative sinking of the globe
posteriorly in to the orbit.
• It is typically caused by a degeneration and
shrinking of orbital fat.
• A herniation of orbital contents particularly
orbital fat ,through a break in the orbital wall,
such as in blow out fracture may also result in
a posterior displacement of the globe
 CAUSES
• Orbital blow out
fracture
• Age related
degeneration of
orbital fat.
• Progressive hemi
facial atrophy.
 Pseudo enophthalmos
• Globe merely appears to sinks posteriorly in to
the orbit.
Causes :
– Contra lateral lid retraction.
– Ptosis.
– Microphthalmos.
 PROPTOSIS
• Defined as an abnormal
protrusion of the eye
ball with in the orbit in
any direction (upward,
downward or oblique).
• Presently it is said that
proptosis is used
synonymously with
exophthalmos.
 COMMERCIALLY AVAILABLE
INSTRUMENTS
BASIC DESIGNS :
• LUEDDE EXOPHTHALMOMETER.
• HERTEL EXOPHTHALMOS.
– Mirror type.
– Prism type.
 PRE-REQUISITES
• A Careful observation of the
– facial symmetry.
– Symmetry of the globe and orbits
– External eye.
– Globe and corneal size.
– Refractive error.
– Lid position and functions
 LUEDDE EXOPHTALMOMETER
• It consists of a clear ,square
plastic rod that is about a
centimeter in thickness.
• The rod is ruled in millimeter
on both sides, with scale
from 0 to 40mm.
• The zero point of the scale at
the tapered end of the rod.
• The mm scale on each side
of the rod when viewed from
the proper position and
coinciding with the corneal
apex should be seen as
superimposed to minimize
parallax error.
• Total length of the rod is 10cm.
• Facial asymmetry is very common, such that the two
lateral orbital margin are often not symmetric in position.
This may cause significant error in Luedde
exophthalmometry.
• The instrument must be positioned parallel to a sagittal
plane through the eye and roughly parallel to the line of
sight when the eyes are in the primary position.
• When this is done, the examiner’s line of sight should be
perpendicular to the plane of the instrument and
perpendicular to the sagittal plane

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 Clinical Procedure
• Palpate the lateral orbit
rim to locate the deepest
angle of the rim.
• Place the notched end
firmly against the deepest
point on the lateral orbit
margin.
• Align the
exophthalmometer
parallel to the patients
visual axis.
• View from the temporal side of the patient.
• Slightly adjust the position of your head to
superimpose the markings on both sides of the
ruler to minimize parallax error.
• Note the position of apex of cornea on scale.
• Repeat the reading and record the reading in
mm as well as name of the instrument used for
example
• Luedde R 17, 18
L 17, 18
 Sources of error
• Instrument not oriented to parallel to sagittal plane
(5 degree deviation from parallel to the sagittal
plane produces a 1.7mm error in the reading and a
10 degree deviation produces approx. twice as
much).
• Parallax error in reading the scale.
• Asymmetry in position of lateral orbit of the rim.
• Manufacturing error.
• Excessive or prolonged pressure on lateral orbital
rim.
 Hertel Exophthalmometer
• Originally described in 1905 by Hertel.
• It is designed such that both lateral orbital margins and
corneal apices are visible to the examiner in rapid
succession.
• There is adjustable foot plates that rests at the lateral
orbital margins of the both eyes.
• This enhances the recognition of inter-ocular
asymmetry.
• It is constructed in either of two ways
– Prism type.
– Mirror type.
Prism-type (Marco, Rodenstock)
 Instrumentation
• Adjustable two horizontal prisms are placed on
foot plate attached to a rod on which readings are
engraved in mm.
• Side of the prism which is inclined at 45 degrees
from the sagittal plane is mirror coated.
• Side of the prism which is parallel to the visual
axis consist of scale engraved in mm with red line
in the center.
• Side of the prism which is perpendicular to the
visual axis has a red line in the centre.
• These red lines are to avoid parallax errors during
the procedure
 Clinical Procedure
• Palpate the lateral orbital rim of each eye to
locate the deepest angle of the rim.
• Slide the prisms along the horizontal bar to
adjust location of the lateral orbital rim.
• Place the footplates firmly against the
deepest point on the lateral orbital rims and
adjust the prisms to the proper location so
that the footplates are positioned firmly on
the deepest point and symmetrically.
• Note the reading on the cross bar, this is the
base reading .
• Examiners head should be positioned directly
in front of the patient and adjust his head to
superimpose the two red lines (parallax lines)
in the prism to minimize parallax error.
• With the patient looking straight a head note
the markings on the ruler that is tangent in the
corneal apex in the right eye (right prism).
• Examiner head should be shifted to the left
prism and repeat the same procedure.
 Recordings
• Note and record the reading for
each eye, the base (crossbar)
setting, and the instrument used .
• Subsequent measurements should
be made with the same separation
(Base reading).
• Record each of these as follows,
for example
MARCO (105mm base) 18mm
18mm
 Mirror-type (Bausch & Lomb)
• The mirror is inclined at about 45
degrees from the sagittal plane.
• A mm ruler oriented roughly parallel to
the sagittal plane is viewed similarly
through a mirror inclined at 45 degrees
to its plane.
• Corneal profile is seen in the bottom
mirror, while a mm rule with zero point
at the lateral orbital rim is seen
immediately above the corneal profile.
• With Western Optical's Bausch & Lomb Type
Exophthalmometer, two pair of first surface mirrors inclined
at 45 degrees permanently mounted in plastic yokes,
eliminate parallax and reflect legible millimeter scales and
images. Etched aluminum scales are easily read, and resist
wear.
 Clinical Procedure
• Palpate the lateral orbital rim to locate the
deepest angle of the rim.
• Loosen the setscrew to allow the mirrors to be
adjusted farther or closer together.
• Place the foot plates firmly against the deepest
point on the lateral orbital rims and adjust the
mirror to the proper location so that the foot
plates are positioned firmly in the deepest
point and symmetrically.
• Note the readings on the cross bar (distance
between the two lateral orbital margins).
• With the patient looking straight ahead, Look
into the two mirrors located at each end of the
exophthalmometer. Note where the apexes of
the corneas, seen in the lower mirror, align
with the measuring scale seen in the upper
mirror.
• Note and record the readings for each eye, the
base setting, and the instrument used. record
each of these as follows for example
• B&L(105mm)18mm
18mm
 Sources of Error
• Asymmetry in the position of the lateral orbital
rim.
• Positioning of the footplate on the orbital rim.
– If the footplates are placed too far medially
(separation too narrow) the readings will be lower
side. If the footplates are placed too far temporally
(separation too wide) the readings will be high.
• Parallax error due to sagittal plane to orbit
margin distance.
• Parallax error in reading the scale.
• Excessive or prolonged pressure on lateral
orbital rim.
CLINICAL INTERPRETATION
• Consider three types of exophthalmometry
measurements and interpretations, they are
– Comparative exophthalmometry.
– Relative exophthalmometry.
– Absolute exophthalmometry.
 COMPARATIVE
EXOPHTHALMOMETRY
• It is the comparison of serial
exophthalmometry measurements with
previous measurements.
• Compare the readings when the same
instrument is used in the last time.
• A change in readings of greater than 2mm is
highly suggestive orbital disease.
 REALATIVE
EXOPHTHALMOMETRY
• It is the comparison of the exophthalmometry
measurements between the two eyes at the
same measurement to detect an inter-ocular
asymmetry.
• Inter-ocular asymmetry of 3mm or more needs
further evaluation.
 ABSOLUTE
EXOPHTHALMOMETRY
• It is the comparison of exophthalmometry
readings to known, normal values.
• There is a wide range of normal values owing
to the very common inter-ocular asymmetry.
• Normal range 10mm to 21mm or 22mm.
• Average adult measurement in the 15mm to
17mm.
• These are significantly affected by numerous
factors.
 Factors affecting the readings
• RACE :
– Blacks tend to have higher readings then the
Whites of about 2mm to 3mm due to there
shallower orbits.
– Normal range in blacks 12mm to 24mm.
• SEX :
– Males tend to have higher readings then females
by about 1mm.
• AGE :
– Children have an average readings about 14.5mm.
– From age 10 to 18yrs, there is an increase of 3mm
in exophthalmometry readings.
– In older age, there appears to be slight lowering of
the normal reading of about 1mm.This may be due
to a degeneration of orbital fat.
• REFRACTIVE ERROR
– High axial myopia, such as buphthalmos may
produce increased exophthalmometric readings.
• POSTURE AND HEAD POSITION :
– The normal globe will sink in to the orbit
approximately 1 to 3mm when the patient is in the
supine position.
– It has been suggested that this does not occur ,even
in the apparently normal, non-proptotic eye of
patients with Grave’s disease.
– This may be useful on the differentiation of
Grave’s eye disease from a Retro-bulbar mass
lesion.
 Reliability
• Accuracy relies on careful
and proper alignment of
the instrument.
• Reliability may be
affected by:
– poor fixation ,coverage,
parallax errors, head
movement and
Blepharospasm.