Experiences with malignant exophthalmos. Relationship of the condition to thyrotoxicosis and to the pituitary thyrotropic hormone.

ANYONE confronted with a case of severe malignant exophthalmos, who searches the literature for guidance in therapy, must soon perceive the confusion of thought and experience that exists regarding this condition, the solution of which is one of the most pressing problems facing thyroid surgery today. By some, the administration of thyroid is claimed to cure the condition, while others recommend such measures as orbital decompression, the administration of sex hormones, and irradiation of the pituitary. None of these remedies, however, produces consistently good results, and there are authorities who will disclaim each one of them. Even the aetiological basis of the condition is in dispute. Undoubtedly there is a connection between malignant exophthalmos, the secretion of the pituitary thyrotropic hormone, and thyrotoxicosis, but the relationship seems to be indirect and the connecting linkages are unknown. The current theories concerning the condition will, therefore, be reviewed. Fortunately malignant exophthalmos is uncommon. It may be defined as that type or phase of Graves' disease in which the eye component is more noticeable than the thyrotoxic (Means, 1948). In the common form of " exophthalmic goitre " there may be, besides a goitre and manifestations of thyrotoxicosis, a retraction of the upper eyelid which gives the appearance of stare. The degree of protrusion of the eyeballs however is slight, and not sufficient to endanger them. Further, the stare recedes after thyroidectomy pari passu with the relief of thyrotoxic symptoms; but in a very small minority of patients the protrusion of the eyeballs may increase and be associated with varying degrees of weakness of the oculomotor muscles (ophthalmoplegia). Indeed the protrusion may become so marked that the eyeball is endangered from exposure of the cornea. We then have the condition known widely as " malignant exophthalmos" (Rosenbaum, 1937; Robertson, 1945), and also under other