Abstract
BackgroundGraves’ disease is a common autoimmune inflammatory condition of the thyroid. About one in four of affected patients also develop orbital symptoms like exophthalmos, proptosis and diplopia - called Graves’ Ophthalmopathy. Not all patients respond well to the standard therapy of systemic glucocorticoid administration. The inflammatory swelling of the intraorbital muscles can lead to pressure-induced damage of the optic nerve.Orbital decompression surgery is a therapeutic option for these patients with varying success. Other symptoms like the extreme malposition of the ocular globe are poorly addressed by decompression surgery and demand for different therapeutic approaches.Case presentationPresented is the case of a 46-year old patient with an acute exacerbation of Graves’ ophthalmopathy. Clinically apparent was a convergent strabismus fixus with severe hypotropia of both eyes. The patient suffered from attacks of heavy retrobulbar pain and eyesight deteriorated dramatically. Since neither systemic glucocorticoid therapy nor orbital decompression surgery had helped to halt the progress of the disease, a decision was made in favour of the surgical release and repositioning of the inferior and medial rectus muscle as a final therapeutic option. Surgery of both eyes was performed consecutively within one week. Detailed descriptions and illustrations of the surgical steps and treatment outcome are provided supplemented by a discussion of the current literature.ConclusionsGraves’ Ophthalmopathy is a variant and therapeutically challenging disease. Exceptional courses of the disease call for therapeutic approaches off the beaten track. Surgical extraocular muscle repositioning, which has not been described before in the context of Graves’ Ophthalmopathy, proved to be effective in improving the patient’s eyesight and quality of life. Furthermore, we regard the measurement of extraocular muscle volume as a valuable method to monitor the course of Graves’ Ophthalmopathy.
Highlights
Graves’ disease is a common autoimmune inflammatory condition of the thyroid
That B cell depletion may be beneficial to Graves’ ophthalmopathy (GO), the systemic application of the antiCD20 monoclonal antibody Rituximab has been promising in a recently published controlled study [8]
Three wall orbital decompression via various surgical techniques is a common treatment modality used in advanced stages of GO to prevent complete vision loss due to local pressure
Summary
The described procedure is definitely not the first choice method. After the failure of all conventional therapeutic measures, extraocular muscle repositioning helped, in this case, to prevent acute loss of vision and tremendously improved the patient’s life quality. We regard the measurement of the extraocular muscle volume as a valuable tool for monitoring the course of the disease and the timing of treatment steps. Squint surgery, in terms of a precise readaption of the extraocular muscles, will be postponed to the future, when a more stable stage of the systemic autoimmune disease will be reached
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