Strabismus, 16:89–91, 2008
Copyright

c 2008 Informa Healthcare USA, Inc.
ISSN: 0927-3972 print / 1744-5132 online
DOI: 10.1080/09273970802049853
E. Hertel
University Eye Clinic, University
of Jena, Germany
Translated from: Ein einfaches
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Exophthalmometer. Hertel E.,
Graefes Arch f Ophthalmol.
1905;50:71-4.
Translation: H.J. Simonsz,
Rotterdam, The Netherlands.
For personal use only.
Accepted 20 March 2008.
Correspondence: H. J. Simonsz, MD,
Department of Ophthalmology,
Erasmus Medical Center, P.O.Box 2040,
3000 CA Rotterdam, the Netherlands.
Tel.: +31 10 7040704, beeper 33394;
Fax: +31 10 4635105.
E-mail: Simonsz@compuserve.com
HISTORICAL SECTION
A Simple Exophthalmometer
KEYWORDS Exophthalmos; Graves’ disease; proptosis; orbital tumor
In the following, I would like to draw attention to a new exophthalmometer,
which can be recommended for general use because of its simplicity together
with the utmost precision of the measurements.
The exophthalmometer that has until now definitely been the most precise
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
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-
erally exceptions—retain their validity. If one, for instance, assumes that the
distance between the axis of the eye and the orbital margin is less than 20 mm,
then the image of g cannot lie exactly on the scale, but will lie slightly in front
of it, and the image of the cornea will appear in front of the scale, accord-
ingly. Precisely speaking, in such cases, the localization of the image using the
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
of the corneas relative to the scale by estimating with
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one’s eye that is opposite to the eye being examined.
This estimation is very simple, however, and does not
need special care, because parallax shifts are excluded
by the very small distances between the images and the
scales.
The measurement procedure should be clear when
viewing Figure 2. The observer, who is standing in front
of the patient, turned towards the light, can see with-
out difficulty whether or not the person being observed
For personal use only.
has changed the initially taken “forward” direction of
gaze. Even very small movements will not go unno-
ticed by the observer after some exercise, because the
image of the iris will only lie perpendicular to the scale
when the direction is correct (Fig. 1, f  ). The observer
also sees deviations of the position of the apparatus im-
mediately from the course of the sliding rod (Fig. 1,
b), which permits detection of poor positioning of the
apparatus by the easily detectable forward or backward
tilt. Should these deviations from the normally hori-
zontal and fronto-parallel direction of the sliding rod
FIGURE 2 How the Hertel exophthalmometer should be placed on the head of a patient.
E. Hertel
not be corrected by more precise positioning of the
spurs (Fig. 1, c), then asymmetries of the skull must be
present, which thereby become manifest immediately.
In any case, in this simple arrangement, a check by a
second observer, which is so inconvenient when using
the Weiss exophthalmometer and which indeed cannot
be dispensed with when using the instrument described
by Birch-Hirschfeld, is unnecessary.
Finally, an additional scale has been placed (Fig. 2)
on the front of the sliding rod (Fig. 1, b), which per-
mits easy registration of the distance between the frames
for possible later control measurements in the same
person.
I should also mention that in the definitive version
of the apparatus, as depicted in Figure 2, the scale has
not been mounted at the posterior edge of the frame,
but at the sides, to avoid hindrance by broad skulls,
and more specifically by thick subcutaneous fat. By
means of a second mirror that crosses the first by an
angle of 45◦ (translator’s note: it is actually 90◦ ), the im-
age of the scale is transposed precisely to the posterior
edge—Fig. 1, e—so that the explanations given above as
90
 to the principle of the reading retain full validity in the
sense that the image of the cornea now lies directly on
the image of the scale in e.
Reporting the results of measurements that could il-
lustrate the precision of this apparatus could be difficult
because, as I have become convinced by numerous cases
in which all earlier measurements were confirmed, enor-
mous variations occur in the absolute values. From suit-
able cases that were carefully observed clinically over
a longer period of time, the precision of the relative
measurements obtained has appeared very good. The
increase or decrease of exophthalmos in case of inflam-
matory orbital diseases, retrobulbar hemorrhages and
foreign bodies could be assessed precisely and with great
ease and speed; also in case of tumors of the orbit and
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sinuses, and especially in assessing the exophthalmos in
Basedow’s disease before, during and after various kinds
of treatment, the apparatus has rendered good service so
For personal use only.
91
that, in view of its easy use, not only ophthalmologists
but also surgeons and internists could profit from it.
The apparatus is supplied by the firm Carl Zeiss–Jena
for 60 Deutschmark.
REFERENCES∗
Birch-Hirschfeld A. Ein neuer Exophthalmometer. Klin Mbl Augenheilk.
1900; 38:721–6.
Cohn H. Beihefte zu den Jahresberichten der Schlesischen Gesellschaft
für vaterländische Cultur. Breslau, 1865; 43:156.
Cohn H. Messungen der Prominenz der Augen mittels eines neuen Instru-
ments, des Exophthalmometers. Klin Mbl Augenheilk. 1867; 5:339.
APPENDIX
Here follows a photograph of an announcement of
the Hertel exophthalmometer from Carl Zeiss—Jena, in
which the instrument’s use is again described and illus-
trated. The price has now become 66 Deutschmark.
∗ The references were mentioned in the text but have been added by the
translator.
Hertel’s Exophthalmometer