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Exophthalmos in the Newborn
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NOTES, CASES, INSTRUMENTS
appearance of the eyes in September, 1942. In December, 1942, the condition of the eyes was as shown in figures 3A and 3B (schematic), representing the mate rial progress. At the last examination, with the patient looking straight ahead, no lens tissue whatever was seen. With the eye looking upward a small remnant can be found, as depicted in figure 3A. The last examination was made on April 8, 1943, when the vision, corrected (R. = + 1 4 . 0 0 D . sph.=C=+2.00D. cyl. ax. 90°; L. = +13.50D. s p h . O + 2 . 0 0 D. cyl. ax. 90°), was 20/15 in both eyes. Bifocals are now being worn and contact lenses will be considered later. The pa tient has, during this time, been undergo ing intensive orthoptic training. To all appearances the eye is now normal in every respect, except aphakia, and the pa tient was permitted to take up his school work and studies which had been discon tinued during the treatment. It now ap pears to be an ideal case of rehabilitation. Two other children have been so operated on with the same degree of success.
In a consideration of the causes of proptosis in the infant, we should include (1) birth injuries from the use of ob stetrical forceps, when severe pressure may be made over the malleable bones of the face so as to compress the orbital contents; (2) retrobulbar hemorrhage in cluding infantile scurvy; (3) orbital cellulitis ; (4) congenital vascular tumors ; (5) dermoids and malignant tumors ; (6)
From this limited experience the au thors suggest that possibly these cases of congenital dislocations stand a better chance of a return to near normal vision by early surgery than would be the case if they were allowed to go on to adult life with impaired vision, lack of retinal edu cation, and later be subjected to much more difficult surgery when the lens be comes hard. Wolfe Cataract Clinic.
cranial sinus thrombosis; (7) meningocele and orbital abscess; (8) inflamma tory pseudotumor of the orbit; (9) the Schüller-Christian syndrome ; (10) syphi lis and tuberculosis; and (11) parasitic diseases. The pre- and postnatal history of the infant, the delivery, blood studies includ ing the serology and vitamin-C content, X-ray studies, and a general physical ex amination should serve to exclude the majority of the differential conditions. Windham 1 reported a case of exophthal mos in a six-day-old infant which prompt ly subsided within 20 days following Xray therapy. No definite diagnosis could be made. The following case report has a marked similarity to the one just cited. D. S., a brown female infant, three days old, was brought to Gorgas Hospital on April 25, 1942, because of a marked
E X O P H T H A L M O S IN T H E NEWBORN REPORT OF A CASE ROBISON D. HARLEY, CAPTAIN
(MC), A.U.S. Panama, Canal Zone
The occurrence of unilateral exophthalmos in the newborn infant is unusual.
Fig. 1 (Harley). Exophthalmos in a newborn infant, 11 days old. Complete closure of the lids of the left eye was present only when the infant cried. Fig. 2 (Harley). Complete recession of the exophthalmos in a newborn infant, aged 32 days. Note edema of the left upper lid, which disap peared a few days later.
NOTES, CASES, INSTRUMENTS exophthalmos of the left eye. The mother stated that the infant's eyes were per fectly normal following birth but that on the first day after birth the left eye began to protrude noticeably. The mother had been in regular attendance at the Gorgas prenatal clinic, but was delivered in her home at the last minute by a midwife, due to the distance from the Hospital. The delivery was reported to have been normal, as had been two previous ones in 1936 and 1940. The prenatal record was normal in every respert. The mother's Wassermann test was negative and there was an adequate intake of citrus fruits in her well-rounded diet. A complete physical examination by the pediatrician revealed a normal healthy infant except for the prominent left ex ophthalmos. Laboratory examinations in cluding blood studies and serology were all normal. On April 27th the patient was seen at the Eye Clinic, where the in traocular tension, pupillary reflexes, extraocular motility, and fundi were found to be within normal limits. No exophthalmometer was available, but by meas uring the summit of the cornea from the outer margin of the orbit, it was found to be O.D. 6 mm. and O.S. 17 mm. There was no ecchymosis nor inflammation about the lids, but an incomplete closure of the eyelids on the left side was noted. No bruit or pulsation of the eye could be demonstrated. Two X-ray pictures of the skull, orbits, and optic foramina were
1315
taken and reported negative. The infant was seen in the Eye Clinic every two days until May 5th. The proptosis measured the same but lid closure appeared increas ingly more difficult. Because of the danger of desiccation to the cornea, the mother was instructed to use boric-acid drops every 15 minutes and report back in one week. A diagnosis of orbital hemorrhage probably subperiosteal was made at this time, although there was no evidence of scurvy. The infant was returned to the Clinic on May 15th, and the mother re quested more drops since "they had ap parently made the baby's eye well." The proptosis now measured O.D. 6 mm., O.S. 8 mm. The mother stated that the exoph thalmos had subsided within the past few days. The infant was seen again on May 24th, at which time both eyes measured 6 mm., just 32 days since the proptosis had first been noted. Four months later the eyes were still perfectly normal. Comment. In view of the normal gen eral physical examination, the normal lab oratory and roentgenographic studies, and the rather prompt recession of the uni lateral proptosis in this case, it would appear that we were dealing with a case of orbital hemorrhage probably subperi osteal. The lack of evidence for scurvy strongly suggests birth trauma as the most likely etiology. The question of any amelioration in this case from two ex posures to the X ray is a debatable point. Gorgas Hospital.
REFERENCE 1
Windham, R. E. A case of exophthalmos in a newborn infant. Amer. Jour. Ophth., 1942, v. 25, Oct., p. 1236.
NOTES, CASES, INSTRUMENTS
appearance of the eyes in September, 1942. In December, 1942, the condition of the eyes was as shown in figures 3A and 3B (schematic), representing the mate rial progress. At the last examination, with the patient looking straight ahead, no lens tissue whatever was seen. With the eye looking upward a small remnant can be found, as depicted in figure 3A. The last examination was made on April 8, 1943, when the vision, corrected (R. = + 1 4 . 0 0 D . sph.=C=+2.00D. cyl. ax. 90°; L. = +13.50D. s p h . O + 2 . 0 0 D. cyl. ax. 90°), was 20/15 in both eyes. Bifocals are now being worn and contact lenses will be considered later. The pa tient has, during this time, been undergo ing intensive orthoptic training. To all appearances the eye is now normal in every respect, except aphakia, and the pa tient was permitted to take up his school work and studies which had been discon tinued during the treatment. It now ap pears to be an ideal case of rehabilitation. Two other children have been so operated on with the same degree of success.
In a consideration of the causes of proptosis in the infant, we should include (1) birth injuries from the use of ob stetrical forceps, when severe pressure may be made over the malleable bones of the face so as to compress the orbital contents; (2) retrobulbar hemorrhage in cluding infantile scurvy; (3) orbital cellulitis ; (4) congenital vascular tumors ; (5) dermoids and malignant tumors ; (6)
From this limited experience the au thors suggest that possibly these cases of congenital dislocations stand a better chance of a return to near normal vision by early surgery than would be the case if they were allowed to go on to adult life with impaired vision, lack of retinal edu cation, and later be subjected to much more difficult surgery when the lens be comes hard. Wolfe Cataract Clinic.
cranial sinus thrombosis; (7) meningocele and orbital abscess; (8) inflamma tory pseudotumor of the orbit; (9) the Schüller-Christian syndrome ; (10) syphi lis and tuberculosis; and (11) parasitic diseases. The pre- and postnatal history of the infant, the delivery, blood studies includ ing the serology and vitamin-C content, X-ray studies, and a general physical ex amination should serve to exclude the majority of the differential conditions. Windham 1 reported a case of exophthal mos in a six-day-old infant which prompt ly subsided within 20 days following Xray therapy. No definite diagnosis could be made. The following case report has a marked similarity to the one just cited. D. S., a brown female infant, three days old, was brought to Gorgas Hospital on April 25, 1942, because of a marked
E X O P H T H A L M O S IN T H E NEWBORN REPORT OF A CASE ROBISON D. HARLEY, CAPTAIN
(MC), A.U.S. Panama, Canal Zone
The occurrence of unilateral exophthalmos in the newborn infant is unusual.
Fig. 1 (Harley). Exophthalmos in a newborn infant, 11 days old. Complete closure of the lids of the left eye was present only when the infant cried. Fig. 2 (Harley). Complete recession of the exophthalmos in a newborn infant, aged 32 days. Note edema of the left upper lid, which disap peared a few days later.
NOTES, CASES, INSTRUMENTS exophthalmos of the left eye. The mother stated that the infant's eyes were per fectly normal following birth but that on the first day after birth the left eye began to protrude noticeably. The mother had been in regular attendance at the Gorgas prenatal clinic, but was delivered in her home at the last minute by a midwife, due to the distance from the Hospital. The delivery was reported to have been normal, as had been two previous ones in 1936 and 1940. The prenatal record was normal in every respert. The mother's Wassermann test was negative and there was an adequate intake of citrus fruits in her well-rounded diet. A complete physical examination by the pediatrician revealed a normal healthy infant except for the prominent left ex ophthalmos. Laboratory examinations in cluding blood studies and serology were all normal. On April 27th the patient was seen at the Eye Clinic, where the in traocular tension, pupillary reflexes, extraocular motility, and fundi were found to be within normal limits. No exophthalmometer was available, but by meas uring the summit of the cornea from the outer margin of the orbit, it was found to be O.D. 6 mm. and O.S. 17 mm. There was no ecchymosis nor inflammation about the lids, but an incomplete closure of the eyelids on the left side was noted. No bruit or pulsation of the eye could be demonstrated. Two X-ray pictures of the skull, orbits, and optic foramina were
1315
taken and reported negative. The infant was seen in the Eye Clinic every two days until May 5th. The proptosis measured the same but lid closure appeared increas ingly more difficult. Because of the danger of desiccation to the cornea, the mother was instructed to use boric-acid drops every 15 minutes and report back in one week. A diagnosis of orbital hemorrhage probably subperiosteal was made at this time, although there was no evidence of scurvy. The infant was returned to the Clinic on May 15th, and the mother re quested more drops since "they had ap parently made the baby's eye well." The proptosis now measured O.D. 6 mm., O.S. 8 mm. The mother stated that the exoph thalmos had subsided within the past few days. The infant was seen again on May 24th, at which time both eyes measured 6 mm., just 32 days since the proptosis had first been noted. Four months later the eyes were still perfectly normal. Comment. In view of the normal gen eral physical examination, the normal lab oratory and roentgenographic studies, and the rather prompt recession of the uni lateral proptosis in this case, it would appear that we were dealing with a case of orbital hemorrhage probably subperi osteal. The lack of evidence for scurvy strongly suggests birth trauma as the most likely etiology. The question of any amelioration in this case from two ex posures to the X ray is a debatable point. Gorgas Hospital.
REFERENCE 1
Windham, R. E. A case of exophthalmos in a newborn infant. Amer. Jour. Ophth., 1942, v. 25, Oct., p. 1236.