Strabismus, 16:89–91, 2008

Copyright

c 2008 Informa Healthcare USA, Inc.
ISSN: 0927-3972 print / 1744-5132 online
DOI: 10.1080/09273970802049853

HISTORICAL SECTION

A Simple Exophthalmometer
E. Hertel
University Eye Clinic, University KEYWORDS Exophthalmos; Graves’ disease; proptosis; orbital tumor
of Jena, Germany
Translated from: Ein einfaches
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Exophthalmometer. Hertel E., In the following, I would like to draw attention to a new exophthalmometer,
Graefes Arch f Ophthalmol. which can be recommended for general use because of its simplicity together
1905;50:71-4. with the utmost precision of the measurements.
Translation: H.J. Simonsz,
The exophthalmometer that has until now definitely been the most precise
Rotterdam, The Netherlands.
is the one described by Birch-Hirschfeld in the Klinische Monatsblätter für Augen-
heilkunde, vol. 38, p. 721, from the clinic in Leipzig. The apparatus—provided
with microscopic reading and crosswire adjustment—leaves nothing to be desired
in regard to accuracy but is, however, too complicated in its use to allow for
general implementation, apart from the fact that its price—225 Deutschmark—is
For personal use only.

quite considerable.
The exophthalmometer that was constructed, according to my instructions,
by the company Zeiss with their known care consists in essence of two frames
that can be moved relative to each other (a, Fig. 1) and that carry mirrors (d)
that are tilted 45◦ relative to the axes of the eyes, plus scales (e). The frames
are positioned with spurs (c) against the outer angles of the orbit. The principle
of how the scale should be read will be immediately clear from Figure 1. The
corneas of the eyes (f ) project in the mirrors; the mirror images (f  ) appear
at equal distances behind the mirrors and are seen on the scales e, because
the device has been constructed in such a way that the axes of the eyes (g) are
projected in g  to coincide with the scales. In doing so, the images of the corneas
of the eyes project on the scales and can be localized by the observer without
difficulty.
The measurements for the distance between the axes of the eyes and the
lateral orbital margins that form the basis of this construction had to be ap-
proximated with average values. For this distance, a value of 20 mm was found
after measurements in 221 adults; in children it was less, according to age, and
in persons with particularly broad skulls it was occasionally somewhat larger.
However, the measurements with our apparatus in these cases–which are gen-
Accepted 20 March 2008. erally exceptions—retain their validity. If one, for instance, assumes that the
Correspondence: H. J. Simonsz, MD, distance between the axis of the eye and the orbital margin is less than 20 mm,
Department of Ophthalmology,
Erasmus Medical Center, P.O.Box 2040, then the image of g cannot lie exactly on the scale, but will lie slightly in front
3000 CA Rotterdam, the Netherlands. of it, and the image of the cornea will appear in front of the scale, accord-
Tel.: +31 10 7040704, beeper 33394;
Fax: +31 10 4635105.
ingly. Precisely speaking, in such cases, the localization of the image using the
E-mail: Simonsz@compuserve.com scale cannot therefore be assessed with a simple reading, as described above.

89
 FIGURE 1 Diagrammatic illustration of the construction of the Hertel exophthalmometer.

Rather, in these cases, one should assess the position not be corrected by more precise positioning of the
of the corneas relative to the scale by estimating with spurs (Fig. 1, c), then asymmetries of the skull must be
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one’s eye that is opposite to the eye being examined. present, which thereby become manifest immediately.
This estimation is very simple, however, and does not In any case, in this simple arrangement, a check by a
need special care, because parallax shifts are excluded second observer, which is so inconvenient when using
by the very small distances between the images and the the Weiss exophthalmometer and which indeed cannot
scales. be dispensed with when using the instrument described
The measurement procedure should be clear when by Birch-Hirschfeld, is unnecessary.
viewing Figure 2. The observer, who is standing in front Finally, an additional scale has been placed (Fig. 2)
of the patient, turned towards the light, can see with- on the front of the sliding rod (Fig. 1, b), which per-
out difficulty whether or not the person being observed mits easy registration of the distance between the frames
For personal use only.

has changed the initially taken “forward” direction of for possible later control measurements in the same
gaze. Even very small movements will not go unno- person.
ticed by the observer after some exercise, because the I should also mention that in the definitive version
image of the iris will only lie perpendicular to the scale of the apparatus, as depicted in Figure 2, the scale has
when the direction is correct (Fig. 1, f  ). The observer not been mounted at the posterior edge of the frame,
also sees deviations of the position of the apparatus im- but at the sides, to avoid hindrance by broad skulls,
mediately from the course of the sliding rod (Fig. 1, and more specifically by thick subcutaneous fat. By
b), which permits detection of poor positioning of the means of a second mirror that crosses the first by an
apparatus by the easily detectable forward or backward angle of 45◦ (translator’s note: it is actually 90◦ ), the im-
tilt. Should these deviations from the normally hori- age of the scale is transposed precisely to the posterior
zontal and fronto-parallel direction of the sliding rod edge—Fig. 1, e—so that the explanations given above as

FIGURE 2 How the Hertel exophthalmometer should be placed on the head of a patient.

E. Hertel 90
 to the principle of the reading retain full validity in the that, in view of its easy use, not only ophthalmologists
sense that the image of the cornea now lies directly on but also surgeons and internists could profit from it.
the image of the scale in e. The apparatus is supplied by the firm Carl Zeiss–Jena
Reporting the results of measurements that could il- for 60 Deutschmark.
lustrate the precision of this apparatus could be difficult
because, as I have become convinced by numerous cases REFERENCES∗
in which all earlier measurements were confirmed, enor- Birch-Hirschfeld A. Ein neuer Exophthalmometer. Klin Mbl Augenheilk.
mous variations occur in the absolute values. From suit- 1900; 38:721–6.
Cohn H. Beihefte zu den Jahresberichten der Schlesischen Gesellschaft
able cases that were carefully observed clinically over für vaterländische Cultur. Breslau, 1865; 43:156.
a longer period of time, the precision of the relative Cohn H. Messungen der Prominenz der Augen mittels eines neuen Instru-
measurements obtained has appeared very good. The ments, des Exophthalmometers. Klin Mbl Augenheilk. 1867; 5:339.

increase or decrease of exophthalmos in case of inflam-

matory orbital diseases, retrobulbar hemorrhages and APPENDIX
foreign bodies could be assessed precisely and with great
Here follows a photograph of an announcement of
ease and speed; also in case of tumors of the orbit and
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the Hertel exophthalmometer from Carl Zeiss—Jena, in

sinuses, and especially in assessing the exophthalmos in
which the instrument’s use is again described and illus-
Basedow’s disease before, during and after various kinds
trated. The price has now become 66 Deutschmark.
of treatment, the apparatus has rendered good service so
For personal use only.

∗ The references were mentioned in the text but have been added by the

translator.

91 Hertel’s Exophthalmometer