Bulging eyes is a condition in which one or both eyes protrude from a person’s eye socket, giving off an appearance of having abnormally large, strained or wide-open eyes.

Formally known as exophthalmos, bulging eyes can be caused by a number of factors, primarily thyroid eye disease but sometimes cancer. The condition mostly affects smokers and middle-aged women.

Treatment depends on the cause and the severity. Doctors start with medication, usually steroids, but they also recommend reversing personal habits, such as smoking, that can help the condition go away on its own. There are also surgical options for more severe cases.

In some cases, mild treatment is enough to reduce the bulging. In other cases, extensive treatment and surgery may be necessary. Severe cases can lead to permanent disfigurement that may misalign the eyes (although this can usually be at least partially fixed with surgery). Doctors especially watch for any compression of the optic nerve. That situation calls for immediate medical help and resolution.

The prognosis for recovery depends on the root cause of the exophthalmos, the severity, and how quickly you were able to get your symptoms under control. Your doctor will be able to give you a specific idea of what to expect.

What Are Bulging Eyes?

exophthalmos

Bulging eyes, or exophthalmos, is a condition in which one or both eyes begin to bulge or protrude. The bulging can lead to double vision.

In some cases, exophthalmos may render you unable to drive safely (or legally). If your vision is affected, talk to a doctor about whether it would still be safe to drive or otherwise operate heavy machinery. Refer to local law enforcement about whether you can do so legally. If driving is legal but still deemed unsafe by a doctor, you should still avoid it.

If you notice your eyes bulging or protruding, even if you are not certain it is the case, see a doctor. Permanent vision problems are usually avoidable if you are quick to seek medical help for exophthalmos.

Causes of Exophthalmos

The main cause of exophthalmos is Graves' ophthalmopathy, also known as thyroid eye disease.

This disease affects one in three people who suffer from an overactive thyroid gland. It is most common among middle-aged women and smokers.

Thyroid eye disease causes the immune system to attack fatty tissue and muscles around the eye. This then causes inflammation, which leads to the characteristic bulge.

In some cases, a person with an underactive thyroid gland can experience a similar problem. It is rare for someone with a normal thyroid gland to have thyroid eye disease, but it is possible.

Newborns, who have shallower eye sockets, can also have exophthalmos.

Other Causes of Bulging Eyes

While an overactive thyroid gland or hyperthyroidism manifesting in the form of thyroid eye disease is the most common cause of exophthalmos, there are other notable causes. Those include:

  • Cancerous tumors near the eye
  • Blood vessel abnormalities in the eye
  • Eye injury
  • Infection of eye socket tissue
  • Bleeding behind the eye

Cancers

Several types of cancers may also cause bulging eyes. These cancers include leukemia, neuroblastoma, rhabdomyosarcoma, and lymphoma. Leukemia is a type of cancer that affects white blood cells. Neuroblastoma is a cancer that affects the sympathetic nervous system. Rhabdomyosarcoma is a rare type of cancer that affects soft tissues.

Lymphoma affects the lymphocytes, which are found in bone marrow, lymph nodes, spleen, and other body parts. There are two types of lymphoma: Non-Hodgkin’s and Hodgkin. Most people develop the Non-Hodgkin’s type, which is the most likely to lead to exophthalmos.

Orbital Tumors and Orbital Cellulitis

Orbital tumors are abnormal tissue growth that occurs in the structures surrounding the eyes. Cancerous tumors, hemangiomas, and malignant tumors can also cause exophthalmos.

If a tumor is growing behind your eye, it can cause eye-bulging and requires immediate medical treatment. Orbital cellulitis refers to an inflammation of orbital tissues. The resultant swelling can cause bulging eyes.

Hemangiomas

Abnormal growth of blood vessels can lead to a benign tumor known as hemangioma. There are two types of hemangiomas: capillary and cavernous hemangiomas. Capillary hemangiomas can develop on the eye's surface, on the eyelid, or in the eye sockets.

When it occurs in the eye socket, it can lead to eye problems, including exophthalmos, glaucoma, and amblyopia (lazy eye). Hemangiomas are more likely to form in developing babies. Hemangiomas affecting the eye can lead to serious problems and require immediate medical attention.

Internal Bleeding

During orbital trauma of any kind, some bleeding may occur in the eye socket. The eye can be pushed forward as the socket fills with blood. Immediate medical attention is needed in these cases to relieve pressure on the optic nerve. The resultant pressure in the eye socket may lead to optic nerve damage.

Treating Exophthalmos

The correct treatment for exophthalmos is dependent on the cause. Regardless of the root cause, you should first see a doctor. From there, the doctor will help you determine what the problem is.

The initial treatment to the most common cause of exophthalmos, thyroid eye disease, is to correct your thyroid hormone levels. Medication can help your problem from worsening, but it will not always solve your eye symptoms.

The following may also be recommended by a doctor:

  • Stop smoking
  • Wear sunglasses if you suffer from photophobia
  • Raise your head using additional pillows while lying in bed
  • Avoid irritants, such as dirt and dust, as much as possible
  • Use eye drops to lubricate your eyes as needed

woman using eyedrops in her eye

In some cases, this may be all you need, and your exophthalmos will go away with time. For more severe cases, you may need corticosteroids. These are often administered via an injection. Severe side effects are uncommon, but some people may experience agitation, headache, and sleep problems while on corticosteroids.

If corticosteroids prove ineffective, orbital or retrobulbar radiotherapy may be used on its own or in conjunction with corticosteroids. This type of treatment uses high levels of radiation to destroy cells and reduce swelling. When done correctly, the risks are mostly controlled to your eyes. Risks include short-term vision problems, cataracts, and (in rare cases) retinopathy, which can threaten eye sight.

In cases of severe or persistent exophthalmos, surgery may be necessary to reduce the swelling, improve vision, or improve the appearance of the eye. Generally speaking, this surgery will take one of three forms.

  • Eyelid surgery: This is when the eye is surgically altered to improve its appearance, position, or closure.
  • Eye muscle surgery: This surgery adjusts the muscles around the eye to align your eyes, helping to lessen double vision.
  • Orbital decompression surgery: Done to improve the appearance of the eye and reduce pressure on the optic nerve, this surgery involves removing a small amount of bone from the eye socket.

While some of the above applies to treating all causes of exophthalmos, it is generally assumed that thyroid eye disease causes the condition. If this is not the case, the treatment may be different.

Infections are generally treated with antibiotics, and abscesses sometimes need to be drained. The best way to approach cancerous tumors varies, but treatment can involve chemotherapy, radiotherapy, and surgery.

As with any treatment plan, always listen to your doctor. The long recovery time from exophthalmos can sometimes be disheartening, but following your doctor’s advice gives you the best chance of full recovery.

Preventing Bulging Eyes

There are some self-care actions that you can undertake to prevent exophthalmos. They include:

  • Quitting smoking as smoking increases the risk of aggravating eye problems.
  • Regular blood test to check for the proper functioning of the thyroid glands.
  • Treating the underlying causes of thyroid problems to stabilize hormones.
  • Avoid trauma to the eye as much as possible (wearing protective eyewear during activities)

Prognosis

If you are quick to see a doctor once you notice a problem, exophthalmos usually does not lead to permanent vision loss. The first goal is to get the inflammation under control. The appearance of the eye, the recovery timeline, and the potential for permanent damage depend on the severity of the exophthalmos.

If permanent damage is likely, even if only in terms of appearance, there are surgeries available to alter appearance and fix any misalignment of your eyes.

References

Overview: Exophthalmos (Bulging Eyes). (October 11, 2016). UK NHS.

Treatment: Exophthalmos (Bulging Eyes). (October 11, 2016). UK NHS.

What Eye Problems Does Graves’ Disease Cause? WebMD.

Graves’ Eye Disease. American Thyroid Association.

Bulging Eyes (Exophthalmos). WebMD.

Everything You Need to Know About Exophthalmos. (May 2017). MedicalNewsToday.

What Is Hemangioma? (April 21, 2020). American Academy of Ophthalmology.

What is Lymphoma? (February 7, 2020). WebMD.

What You Should Know About Bulging Eyes. (August 1, 2019). Healthline.

Understanding mechanisms of pressure-induced optic nerve damage. (March 2005). National Center for Biotechnology Information.

Treatment: Exophthalmos (bulging eyes). (October 29, 2019). National Health Service.

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