Ophthalmic Plastic and Reconstructive Surgery
Vol. 22, No. 5, pp 405–407
©2006 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Letters to the Editor
Re: “Effect of Exophthalmometer Design
on Its Accuracy”
To the Editor:
We commend the attempt of Vardizer et al.1 to improve
the quality of exophthalmometry (proptometry).2 The fact
that the authors could find 8 different Hertel-type proptom-
eters to assess highlights the possibility of a flaw inherent in
the design of the Hertel proptometer, on which the subse-
quent modifications are based. From data produced by
Ameri et al.,2,3 we already know that when the distance
from the lateral orbital wall to the corneal apex is more than
20 mm, the Hertel technique is inherently flawed. The
observer can then only adjust for parallax and view the
patient’s cornea without altering his/her line of sight when
the proptometry reading approaches 20 mm.
With the Luedde proptometer, the observer adjusts for
parallax at each consecutive millimeter gradation along the
scale of the instrument. Thus, the Luedde is as accurate for
a proptometry measurement of 10 mm as it is for a reading
of 40 mm. The observer is able to adjust for parallax and
view the patient’s cornea without altering the line of sight.
Given that we have already shown that the Hertel and
Luedde proptometers are equally accurate,4 the benefits of
the Luedde proptometer are obvious. It is small, portable,
robust, cheap, reliable, and is much easier to use.
Edwin C. Figueira, M.B.B.S., M.S.
Ian C. Francis, F.A.S.O.P.R.S.
Geoffrey A. Wilcsek, F.R.A.N.Z.C.O.
REFERENCES
1. Vardizer Y, Berendschot TT, Mourits MP. Effect of exophthalmom-
eter design on its accuracy. Ophthal Plast Reconstr Surg 2005;21:
427–30.
2. Ameri H, Fenton S. Comparison of unilateral and simultaneous
bilateral measurement of the globe position, using the Hertel ex-
ophthalmometer. Ophthal Plast Reconstr Surg 2004;20:448–51.
3. Davanger M. Principles and sources of error in exophthalmometry.
A new exophthalmometer. Acta Ophthalmol (Copenh) 1970;48:
625–33.
4. Chang AA, Bank A, Francis IC, Kappagoda MB. Clinical exoph-
thalmometry: a comparative study of the Luedde and Hertel exoph-
thalmometers. Aust N Z J Ophthalmol 1995;23:315–8.
Reply re: “Effect of Exophthalmometer
Design on Its Accuracy”
To the Editor:
We thank Figueira, Francis, and Wilcsek for their com-
ments on our examination of eight different Hertel exophthal-
405
mometers.1 In our paper, we examined the effect of three
design parameters on the Hertel exophthalmometer’s accu-
racy: the parallax error, the advantage of one-mirror exoph-
thalmometers, and the straight footplate. Only the parallax
error was addressed above. Indeed, the Luedde exophthal-
mometer might be able to overcome this error. Concerning the
footplate design, the Luedde exophthalmometer might lack the
wide footplate support a Hertel exophthalmometer has, and by
that create an error in reading due to misplacement of the
instrument. The need to place the Luedde exophthalmometer
at a 90-degree angle to the globe’s equator is also not regulated
during measurements and might affect the result. These as-
sumptions might explain why, although lacking the parallax
error, the Luedde exophthalmometer was not found to be more
accurate in the writer’s comparative study.2
The Luedde exophthalmometer was introduced during the
1940s,3 but its use never became widespread because of the
need to measure each eye separately and to change the position
of the patient (or the examiner) during examination. Although
suggested by Ameri and Fenton4 to be more accurate, unilat-
eral exophthalmometric examinations are less likely to occur in
a clinical setting because they are time-consuming.
We have begun to design a new Hertel exophthalmometer
that will overcome most of these flaws. As we already have
produced a prototype and carried out most of its validity
investigations, we promise to bring our data to press soon.
Yoav Vardizer, M.D.
M. P. MOURITS, M.D., Ph.D.
REFERENCES
1. Vardizer Y, Berendschot TT, Mourits MP. Effect of exophthalmom-
eter design on its accuracy. Ophthal Plast Reconstr Surg 2005;21:
427–30.
2. Cang AA, Bank A, Francis IC, Kappagoda MB. Clinical exophthal-
mometry: a comparative study of the Luedde and Hertel exophthal-
mometers. Aust N Z J Ophthalmol 1995;23:315–8.
3. Goodside V. Modification of Luedde exophthalmometer. Am J
Ophthalmol 1950;33:793.
4. Ameri H, Fenton S. Comparison of unilateral and simultaneous
bilateral measurement of the globe position, using the Hertel ex-
ophthalmometer. Ophthal Plast Reconstr Surg 2004;20:448–51.
Re: “Clinical Features and Treatment of
Graves Ophthalmopathy in Pediatric Patients”
To the Editor:
We read with interest the paper entitled “Clinical
features and treatment of Graves ophthalmopathy in
pediatric patients,” by Durairaj et al.,1 which was pub-
lished recently in your journal. From 1662 cases, ages
406 LETTERS TO THE EDITOR
⬍18 years, with thyroid and thyroid-related eye abnor-
malities, evaluated at Mayo Clinic in Rochester, Minne-
sota, during the 15-year interval (1985 to 1999) 35
children with Graves ophthalmopathy (GO) were identi-
fied. From those, 6 patients received radioactive iodine
(RAI), 1 patient RAI plus antithyroid drugs, 9 patients
had partial or total thyroidectomy, and the rest antithy-
roid medications for their thyroid problem. Four patients
did not require treatment. From the 35 thyroid ophthal-
mopathy cases, 31 required no therapy with only sup-
portive measures, 1 had eyelid surgery, and 3 had orbital
decompression. None of the patients received steroids or
external radiotherapy. They concluded that although GO
has similar clinical manifestations in pediatric and adult
populations, the disorder is less severe in children than in
adults.
We had the opportunity to evaluate recently the fre-
quency of Graves ophthalmopathy and its management
in children and adolescents up to 18 years old with
Graves hyperthyroidism (GH).2 In this questionnaire
study (QS) among members of the European Thyroid
Association (ETA) and European Society for Pediatric
Endocrinology (ESPE), 110 questionnaire responses
were returned from 25 countries. Of 1963 patients with
juvenile GH seen by respondents in the last 10 years, 641
(33%) had GO; about one third of GO patients were ⬍10
years old and two thirds were 11 to 18 years old. The
prevalence of GO among juvenile GH was higher in
countries in which the smoking prevalence among teen-
agers and adults was more than 25%.3
When confronted with the standard case of a 13-year-
old girl with GH and moderately severe active GO,
antithyroid drugs were the treatment of choice for 94%
of respondents; 70% recommended a wait-and-see pol-
icy, and 28% recommended corticosteroids for the coex-
isting ophthalmopathy. Worsening of GO or active GO
when euthyroid would convince about two thirds of
respondents to initiate treatment of GO, preferably with
steroids.
The conclusions of our study are threefold. First, that
GO occurs in 33% of patients with juvenile GH, a much
higher prevalence when compared with the Mayo Clinic
experience (35 of 1662 patients [2.1%]). Second, anti-
thyroid drugs are the treatment of choice (94%) for GH
in childhood in Europe, although only 28.5% of pediatric
patients with similar problem received such treatment in
the United States. On the contrary, RAI seems to be a
favorable initial treatment for GH in the Mayo Clinic
data. Finally, giving steroids is the first-line treatment for
28% of pediatric cases of GO in Europe, whereas none of
the Mayo Clinic patients received systemic corticoste-
roids.
The great difference in the prevalence of pediatric GO
between the United States and Europe cannot be ex-
plained on the basis of recent findings regarding active or
Ophthal Plast Reconstr Surg, Vol. 22, No. 5, 2006
passive smoking habits.2,3 Genetic or other environmen-
tal differences may play an important role. However,
differences in the choice of the most suitable treatment
for GH and GO in children and adolescents indicate the
different medical philosophy and therapeutic approach in
the management of this debilitating disease.
Gerasimos E. Krassas, M.D., Ph.D.
KOSTAS G. BOBORIDIS, M.D.
W.M. Wiersinga, M.D.
REFERENCES
1. Durairaj VD, Bartley GB, Garrity JA. Clinical features and treat-
ment of graves ophthalmopathy in pediatric patients. Ophthal Plast
Reconstr Surg 2006;22:7–12.
2. Krassas GE, Segni M, Wiersinga WM. Childhood Graves’ ophthal-
mopathy: results of a European questionnaire study. Eur J Endocri-
nol 2005;153:515–21.
3. Krassas GE, Wiersinga WM. Smoking and autoimmune thyroid
disease: the plot thickens. Eur J Endocrinol 2006;154:777–80.
Re: “The Tetracaine Provocation Test
(TPT) for Inducing Early Involutional
Entropion”
To the Editor:
The tetracaine provocation test (TPT) is a simple
provocation test used in the assessment and follow-up of
patients with intermittent or latent involutional entro-
pion. Assessment of involutional entropion includes an
appropriate history and examination, in particular check-
ing for the components causing horizontal and vertical
eyelid laxity, and slit-lamp examination to reveal any
corneal involvement.
The pathophysiology of involutional entropion in-
cludes horizontal lower eyelid laxity, lower eyelid retrac-
tor dehiscence (vertical laxity), and overriding of the
preseptal orbicularis oculi over the pretarsal orbicularis
muscle.1 Relative enophthalmos has been also cited as a
causative factor. Kersten et al.2 attributed this to orbital
fat atrophy, particularly in association with a small globe
and supine position.
Involutional entropion is variable. It can be constant,
intermittent, or latent. Latent or intermittent entropion
can be provoked by voluntary and/or involuntary forced
closure of the orbicularis oculi muscle. It is sometimes
useful to do this with the patient lying supine or sitting
with the head tilted forward to increase the chance of
revealing intermittent or latent entropion.
Voluntary forced closure of the orbicularis oculi mus-
cle is exhibited by asking the patient to squeeze the
eyelids tightly shut. This is enhanced further by holding
the upper eyelid open while the patient closes the eyes.
The position of the lower eyelid margin is then checked
for the presence of entropion.
If voluntary forced closure is negative (i.e., there is no
 LETTERS TO THE EDITOR
lower eyelid malposition), then a simple method of
inducing involuntary forced closure of the orbicularis
oculi muscle is to perform a TPT. The test is performed
by placing a drop of tetracaine 0.5% (topical anesthetic)
in to the conjunctival sacs of both lower eyelids. The
irritative effect of tetracaine induces excessive involun-
tary orbicularis oculi muscle contraction, with overriding
of the pretarsal orbicularis by the preseptal orbicularis
muscle, and thus reveals nonmanifest entropion.
This test provides a stronger stimulus for orbicularis
contraction than voluntary forced eyelid closure.
Proxymetacaine or benoxinate drops are not effective
since they cause little ocular discomfort and do not
induce excessive involuntary orbicularis contraction.
The action with the TPT is reflexic, immediate, and
does not rely on patient compliance. Many patients with
involutional entropion are elderly with comorbidities that
may prevent them complying with voluntary forced clo-
sure (hearing deficit, dementia), and likewise reposition-
ing patients to a supine posture can be troublesome in
some cases. This test is useful both in preoperative and
postoperative assessment. We use the TPT routinely
when evaluating patients suspected of having involu-
tional entropion or following entropion surgery,3,4 when
voluntary closure testing has been negative.
407
Glatt5 stated that surgical success after surgery should
have adequate long-term follow-up, and patients should
undergo the TPT to pick up subclinical asymptomatic
cases with recurrence. We recommend the TPT as part of
the assessment of patients with suspected involutional
entropion and for long-term follow-up.
Shahram Kashani, B.Sc., M.B.B.S., M.R.C.P., M.R.C.Ophth.
Justin Friebel, M.B.B.S., F.R.A.N.Z.C.O.
Ahmed Sadiq, D.O., M.R.C.Ophth., F.R.C.S.
Jane Olver, F.R.C.S., F.R.C.Ophth.
REFERENCES
1. Rougraff PM, Tse DT, Johnson TE, Feuer W. Involutional entropion
repair with fornix sutures and lateral tarsal strip procedure. Ophthal
Plast Reconstr Surg 2001;17:281–7.
2. Kersten RC, Hammer BJ, Kulwin DR. The role of enophthalmos
in involutional entropion. Ophthal Plast Reconstr Surg 1997;13:
195–8.
3. Barnes J, Bunce C, Olver J. Simple effective surgery for involu-
tional entropion suitable for the general ophthalmologist. Ophthal-
mology 2006;113:92–6.
4. Olver JM, Barnes JA. Effective small-incision surgery for involu-
tional lower eyelid entropion. Ophthalmology 2000;107:1982–8.
5. Glatt HJ. Follow-up methods and the apparent success of entropion
surgery. Ophthal Plast Reconstr Surg 1999;15:396–400.
Ophthal Plast Reconstr Surg, Vol. 22, No. 5, 2006