Bilateral Inferior Rectus Research Articles

Surgical Outcomes of Bilateral Inferior Rectus Muscle Recession for Restrictive Strabismus Secondary to Thyroid Eye Disease.

This retrospective, observational study examined the surgical outcomes of bilateral inferior rectus (IR) recession in thyroid eye disease. Twelve patients who underwent bilateral IR muscle recession were included in the study. Surgical success was defined as patient achievement of the following conditions: (1) a postoperative angle of vertical ocular deviation of ≤3°; (2) a postoperative cyclotropic angle of ≤2°; (3) postoperative binocular single vision, including the primary position; and (4) postoperative enlargement of the field of binocular single vision. Linear regression analyses were performed to analyze the relationship between postoperative changes in the vertical and torsional ocular deviation angles and the amount of IR muscle recession and nasal transposition. Consequently, 9 out of 12 patients were deemed to have had successful surgical outcomes. There was a positive correlation between a change in the vertical deviation angle and a side-related difference in the amount of IR muscle recession in successful cases (crude coefficient, 2.524). A positive correlation was also found between a change in the torsional deviation angle and the amount of IR recession (crude coefficient, 1.059) and nasal transposition (crude coefficient, 5.907). The results will be helpful to more precisely determine the amount of recession and nasal transposition of the IR muscle in patients with thyroid-related bilateral IR myopathy.

Changes in Hypertropia in Patients with Asymmetric Inferior Oblique Overaction after Symmetric Inferior Oblique Myectomy

Purpose: This study assessed the effects of bilateral inferior oblique myectomy for hypertropia on the preoperative vertical deviation angle in patients with asymmetric primary inferior oblique overaction (IOOA).Methods: This study included patients who underwent bilateral inferior oblique myectomy and lateral rectus recession due to asymmetric primary IOOA and intermittent exotropia, and were followed up for at least 6 months postoperatively. Pre- and post-operative vertical deviation angles were compared. The correlation between the extent of correction of vertical deviation after surgery and residual hypertropia, according to the preoperative degree of vertical deviation and difference between bilateral IOOA, was evaluated.Results: This study included 178 eyes from 89 patients. The angle of hypertropia in the primary position was reduced from 3.2 ± 2.2 prism diopters (PD) preoperatively to 0.5 ± 2.5 PD postoperatively (Wilcoxon signed-rank test, p < 0.001). No significant correlation was observed between the preoperative interocular difference in IOOA and postoperative extent of correction of the vertical deviation (r = 0.044, p = 0.684), or between the preoperative difference in bilateral IOOA and residual hypertropia (Spearman's rank-order correlation, r = -0.084, p = 0.432). Increased preoperative hypertropia correlated with a greater extent of surgical correction of the vertical deviation (r = 0.733, p < 0.001). Preoperative hypertropia had no significant correlation with residual hypertropia (Spearman's rank-order correlation, r = 0.182, p = 0.087).Conclusions: In symmetric bilateral inferior oblique myectomy with bilateral lateral rectus recession for asymmetric bilateral primary IOOA with V-type intermittent exotropia, a positive correlation between the degree of preoperative vertical deviation and extent of correction of the vertical deviation was observed. Additionally, IOOA and hypertropia were significantly improved postoperatively.

CASE REPORT OF AN ATYPICAL PRESENTATION OF CONGENITAL FIBROSIS OF THE EXTRAOCULAR MUSCLES (CFEOM)

INTRODUCTION: CFEOM is a disorder that includes multiple extra ocular muscle restrictions. It is a rare, non –progressive, congenital condition and refers to at least eight genetically dened strabismus syndromes. Commonly presented clinical signs and symptoms in CFEOM includes- congenital nonprogressive ophthalmoplegia (inability to move the eyes) with or without ptosis (droopy eyelids) affecting part or all of the oculomotor nucleus and nerve (cranial nerve III) and its innervated muscles. Refractive errors are also common. CASE REPORT: The patient was the rst child of non-consanguineous parents. There was no similar history or any history of ocular motility disorders in family in both paternal and maternal side. There is no prior history of use of glasses, occlusion therapy, surgery or trauma. Typically, binocular vision is absent. The child had difculty looking at objects in downgaze, up gaze and laterally. They also observed outward deviation of both eyes which was more for distance. Child had normal weight for age (30 kgs) Head circumference was within normal range (57 cm) There was absence of lid crease in both eyes and chin up head posture was seen for distance. No facial asymmetry was seen. Patient was able to spontaneously alternate xate in the primary position. Patient had hypertropia of 6 prism diopters in left eye when xing with right eye and hypertropia was same in upgaze and downgaze. No evidence of globe retraction on ocular movements. Patient had history of ocular deviation since birth which had not changed over the years. Mutations in the KIF21A gene are the primary cause of CFEOM1. Patients typically have convergent-type nystagmus movements with attempted up gaze (synergistic convergence) and an A pattern with divergence of the eyes in downgaze. There was no associated neurologic abnormalities and systemic disorders. The patient was found to have bilateral lagophthalmos, limitation of elevation and depression (vertical gazes). The patient underwent two surgeries. In the rst surgery, B/L LR RC (14mm from limbus) and B/L SR RC(11mm)was done. DISCUSSION: Congenital brosis of extraocular muscles is a common condition encountered by pediatric ophthalmologists. If not properly diagnosed, it is often confused with other ocular motility disorders. The treatment of CFEOM must focus on specic pattern of decit and include management of head position, ocular alignment in primary position and maximizing outcome by preventing ambylopia. Currently no treatment has been developed to restore full functionality and range of motion of the extraocular muscles. Patients presenting with CFEOM1 usually require large bilateral inferior rectus recessions, often enhanced with bilateral superior oblique tenotomies to allow the eyes to come to vertical midline. Patient might also need multiple strabismus surgeries like with our patient. CFEOM is often associated with potential complications like strabismus, decreased binocular vision, ambylopia and facial palsy.

Clinical and imaging features of congenital and acquired isolated inferior rectus muscle hypofunction

Inferior rectus (IR) underaction may arise from various causes that are distinguishable through imaging. We investigated clinical and imaging characteristics of congenital and acquired causes of IR underaction. Cases of IR underaction were selected from data prospectively collected in a study of orbital imaging in strabismic patients. Review identified 3 cases of congenital IR underaction (2 with bilateral IR aplasia and 1 with unilateral IR hypoplasia), 12 acquired cases, including 4 due to denervation (2 idiopathic, 1 after multiple strabismus surgeries, 1 after head trauma), and 8 cases of direct IR damage (5 with orbital trauma and 3 with previous surgery, including 2 sinus surgery and 1 laser blepharoplasty). Of the 23 cases, 11 adults had high-resolution magnetic resonance imaging, and 2 children had computed tomography. Imaging identified the anatomic diagnosis in congenital cases; in acquired cases, imaging helped to identify atrophy and exclude alternative orbital causes; and in direct mechanical damage, imaging clarified the mechanism of underaction, extent of IR damaged, and the degree of retained contractility. Patients with congenital IR absence or hypoplasia exhibited A pattern exotropia that was typically absent in isolated acquired denervation or direct IR damage. Orbital imaging demonstrates a variety of abnormalities in patients with congenital or acquired IR hypofunction, helping to clarify the underlying mechanism and guide management.

Comparison of Techniques for Correction of Chin-down Vertical Abnormal Head Position Associated with Infantile Nystagmus Syndrome

We evaluated the relative effectiveness of combined recession-resection of vertical rectus muscles versus superior rectus recession with inferior oblique weakening for patients who underwent surgical correction of chin-down abnormal head position (AHP) associated with infantile nystagmus syndrome (INS). Retrospective interventional case series. This is a review of 22 patients who underwent surgical correction of chin-down vertical AHP associated with INS at an academic institution. The primary outcome was collapse of AHP. Unfavorable outcomes included repeat surgery and induced strabismus, in addition to failure of collapse of AHP. Twenty-two patients had chin-down AHP. Recession-resection (bilateral superior rectus recession 6-9mm; bilateral inferior rectus resection 5-9mm) was performed in 11 cases; weakening of both elevators (bilateral superior rectus recession 5-8mm, bilateral inferior oblique recession or myectomy) occurred in 11 cases. Unfavorable outcome rates were 64% (7/11) compared with 18% (2/11), respectively (P= .03). Reoperation was performed for 6 of 22 patients. Five patients were from the recession-resection group, namely 3 for induced V-pattern esotropia, 1 for alternating esotropia, and 1 to correct recurrent AHP. The last of the 6 who required reoperation was in the elevator weakening group, and required correction of a recurrent AHP (P= .06). While recession-resection of the vertical recti and weakening of both elevators each produce acceptable collapse of chin-down AHP, the former frequently induces a V-pattern esotropia requiring reoperation.

The Role of Superior Oblique Posterior Tenectomy Along With Inferior Rectus Recessions for the Treatment of Chin-up Head Positioning in Patients With Nystagmus.

To evaluate the clinical outcomes of bilateral superior oblique posterior 7/8th tenectomy with inferior rectus recession on improving chin-up head positioning in patients with horizontal nystagmus. Medical records were reviewed from 2007 to 2017 for patients with nystagmus and chin-up positioning of 15° or more who underwent combined bilateral superior oblique posterior 7/8th tenectomy with an inferior rectus recession of at least 5 mm. Thirteen patients (9 males and 4 females) were included, with an average age of 7.3 years (range: 1.8 to 15 years). Chin-up positioning ranged from 15° to 45° degrees (average: 30°). Three patients had prior horizontal muscle surgeries, 1 for esotropia and 2 for horizontal null zones causing anomalous face turns. Ten patients underwent other concomitant eye muscle surgery: 3 had esotropia, 1 had exotropia, and 2 had biplanar nystagmus null point requiring a horizontal Anderson procedure. Four patients underwent simultaneous bilateral medial rectus tenotomy and reattachment. All patients had improved chin-up positioning. Eight patients had complete resolution, whereas 5 had minimal residual chin-up positioning. Three patients developed an eccentric horizontal gaze null point with compensatory anomalous face turn with onset 2 weeks, 2 years, and 3 years postoperatively. Average follow-up was 42.7 months. No postoperative pattern deviations, cyclodeviations, or inferior oblique overaction were seen. No surgical complications were noted. Bilateral superior oblique posterior 7/8th tenectomy in conjunction with bilateral inferior rectus recession is a safe and effective procedure for improving chin-up head positioning in patients with horizontal nystagmus with a down gaze null point. [J Pediatr Ophthalmol Strabismus. 2018;55(4):234-239.].

Scleral Perforation During Inferior Rectus Muscle Recession in Congenital Fibrosis of the Extraocular Muscles

Purpose: We report a case of a scleral perforation during inferior rectus recession in congenital fibrosis of extraocular muscles and the management of this perforation with a scleral patch graft. Case summary: A 20-month-old female with bilateral ptosis, absence of elevation and a chin-up position was diagnosed with congenital fibrosis of extraocular muscles. Because severe esotropia in the downward gaze was observed, we first performed esotropia surgery. After 1 year, she underwent a bilateral ptosis correction. We decided to perform bilateral inferior rectus recession due to an abnormal head posture and the absence of elevation. Because the inferior rectus muscles were extremely tight and adhered to the sclera, hooking and isolating these muscles during surgery was difficult. After muscle suture placement, a portion of the sclera that contacted the left inferior rectus was chipped off as this muscle was disinserted with blunt Westcott scissors. A scleral perforation was observed, thus, we placed a scleral patch graft using the donor sclera and finished the bilateral inferior rectus recession. No abnormal findings for the vitreous or retina were detected. At 8 months after surgery, the patient exhibited exotropia of 12 prism diopters in her primary gaze. Her abnormal head posture nearly disappeared. Conclusions: Careful isolation and disinsertion of the muscle from the globe is necessary in the treatment of patients who are expected to exhibit severe adhesions between the muscle and sclera, such as patients with congenital fibrosis of extraocular muscles. J Korean Ophthalmol Soc 2016;57(3):524-527

Surgical effects of nasal transposition of inferior rectus muscle - 135 cases of acquired superior oblique palsy.

Nasal transposition of the inferior rectus (IR) muscle, which is transposed nasally with the insertion parallel to the spiral of Tillaux, could correct excyclotropia. However, as far as we are aware, there have been no reports examining the surgical effects of this procedure in multiple cases. Therefore, we examined the surgical effects of IR nasal transposition in 135 cases with acquired trochlear nerve palsy at Hyogo College of Medicine Hospital, Nishinomiya, Japan. One muscle width of IR nasal transposition corrected an average 5.6° in excyclotorsion, while bilateral IR nasal transposition corrected average 10.9°. This result shows this procedure is accurate quantitatively. Moreover, IR nasal transposition in combination with IR recession or resection can correct vertical deviation and excyclotorsion simultaneously. The results of this study suggest that IR nasal transposition should become first-line treatment for acquired superior oblique palsy.

Unmasking Bilateral Inferior Rectus Restriction in Thyroid Eye Disease: Using Degree of Cyclotropia

PurposeThyroid eye disease (TED) frequently causes strabismus and diplopia. Though the condition involves multiple extraocular muscles in both eyes, the inferior rectus (IR) muscle is particularly susceptible. TED may be so asymmetric as to mask the involvement of the contralateral IR. The purpose of this study was to determine if the degree of preoperative cyclotropia measured with an objective test could be used to predict the extent of bilateral IR disease and assist in surgical planning.MethodsAdults with TED involving the IR and demonstrating cyclotropia were enrolled. Preoperative and postoperative sensorimotor exam included quantification of cyclotropia using double Maddox rod test (DMR). Forced ductions were done intraoperatively. Degree of cyclotropia was compared to results of duction tests and surgical outcome.ResultsTwelve participating patients demonstrated excyclotropia on DMR test preoperatively (mean 16 ± 9°). Unilateral IR recession was planned based on the results of preoperative ocular rotations and forced duction testing in eight cases. The remaining four underwent bilateral IR recession. Four of the unilateral recession cases presented with reversal of the hypotropia, obvious limitation of elevation in the unoperated eye, and persistent symptomatic excyclotropia at the first postoperative visit. The mean excyclotropia of the bilateral cases was 21 ± 5°, compared to 5.5 ± 3° in the unilateral group (P < 0.005).ConclusionsPrism diopters of hypotropia, limitation of elevation, and forced duction testing evaluate muscle function relative to its yoke and may underestimate contralateral IR involvement in the case of asymmetrical disease. Duction testing and forced ductions are qualitative and subjective. Results suggest that degree of excyclotropia correlates well with severity of IR restriction, and that amounts exceeding 15° infer bilateral IR involvement.

Inferior oblique anterior transposition for the unilateral hypertropia associated with bilateral inferior rectus muscle aplasia

Bilateral inferior rectus muscle aplasia in the absence of craniofacial abnormality is a rare but possibly under-recognized form of strabismus. Unilateral hypertropia in primary position seems to be a recurrent feature of this condition. We report a case of a 20-year-old woman with left hypertropia in primary position who was found on computed tomography to have bilateral inferior rectus muscle aplasia. A unilateral inferior oblique anterior transposition resulted in correction of the vertical deviation in primary position.

New strabismus surgical techniques

Five new strabismus surgical procedures were developed by the authors and were presented as a workshop at the AAPOS annual meeting of the American Association for Pediatric Ophthalmology and Strabismus. They are summarized here to introduce these methods to the reader and provide surgeons with more options in approaching difficult strabismus problems. Diagnosis and correction of consecutive strabismus attributable to stretched scar is discussed. The pulley posterior fixation procedure is a unique approach to correct high accommodative convergence or to augment a maximal medial rectus recession. Diagnosis and repair of the partial avulsion (flap tear) of a rectus muscle allows correction of some restrictive strabismus following blunt trauma. The nasal myectomy of the inferior oblique muscle corrects persistent inferior oblique overaction without sacrificing the tether effect gained by a previous anterior transposition of the inferior oblique. The full advancement of the superior oblique tendon offers another option to strengthen a weak superior oblique muscle.

Inferior rectus tucking versus combined superior rectus recession with posterior fixation suture (faden) for the treatment of dissociated vertical deviation without inferior oblique overaction

PurposeTo compare the efficiency of inferior rectus tucking versus combined superior rectus recession with posterior fixation suture (Faden) for the treatment of dissociated vertical deviation (DVD) without inferior oblique overaction.Patients and methodsIn this prospective study, 50 consecutive patients with DVD and without inferior oblique overaction were allocated randomly in their order of presentation to two groups; each group included 25 patients. The patients in group I were subjected to combined bilateral superior rectus recession and the Faden procedure (posterior fixation) and the patients in group II were treated by bilateral inferior rectus tucking (plication).ResultsDVD improved significantly (P < 0.05) in the two groups of the study. In group I, the mean vertical deviation improved from 18.21 ± 4.73 prism diopter (PD) preoperatively to 7.82 ± 5.61 PD 9 months after surgery (P < 0.05), with a mean correction of vertical deviation of 10.21 ± 3.52 PD and a mean correction of asymmetry of 2.1 ± 1.6 PD. Four patients needed inferior rectus tucking for residual or recurrent manifest DVD. In group II, the mean vertical deviation improved from 17.97 ± 6.89 PD preoperatively to 6.97 ± 5.46 PD 9 months after surgery (P < 0.05), with a mean correction of vertical deviation of 11.34 ± 2.71 PD and a mean correction of asymmetry of 2.5 ± 1.3 PD. Five patients needed inferior rectus retucking for residual manifest DVD.ConclusionInferior rectus tucking is as effective as superior rectus recession with posterior fixation sutures for the primary treatment of DVD without inferior oblique overaction. Inferior rectus tucking can also be used effectively for the treatment of residual and recurrent DVD; further studies are recommended in this field.

Bilateral Inferior Rectus Muscle Recession in Patients With Graves Orbitopathy

To evaluate the effect of bilateral inferior rectus recession regarding improvement of elevation, reduction of abnormal head tilt and vertical squint angle in patients with Graves orbitopathy. Retrospective case series. Patients with Graves orbitopathy who underwent symmetric or asymmetric bilateral inferior rectus recession were selected for this study. Effect on change of elevation, depression cyclodeviation, and vertical squint angle was calculated 3 months and 6 to 12 months postoperatively. Forty-three patients could be included, who underwent a recession of both inferior recti by 1 of the 5 surgeons. Three months postoperatively, the elevation changed from 12° ± 6.9° preoperatively to 19° ± 6.7° postoperatively (p = 0.000) and the depression from 54° ± 6.2° preoperatively to 48° ± 9.2° postoperatively (p = 0.005). Total duction range remained stable (p = 0.728). Three months after surgery, motility did not change significantly anymore. The dose effect response on elevation was 1.7° ± 1.7°/mm, and was higher in case of severe preoperative elevation restriction (r = -0.405). Three months postoperatively, the excyclodeviation changed from 6.4° ± 6.0° to 0.4° ± 6.0° in primary position (p = 0.000). However, in downgaze 4 patients developed a significant incyclodeviation of > 5°. Muscle volume, prior decompression surgery, or performing surgeon did not influence the outcome. Bilateral recession of the inferior rectus muscles in patients with Graves orbitopathy results in a shift of vertical duction range toward upgaze and a significant decrease of excyclodeviation. Overcorrection of cyclodeviation in downgaze has to be considered before planning this type of surgery. Poor preoperative elevation contributes to higher dose-effect responses. Considering all variables, the orthoptic picture does not change after 3 months of surgery.

Clinical Course of a Pediatric Graves’ Extraocular Myopathy Patient Followed-up by Magnetic Resonance Imaging

A 14-year-old male patient with Graves' orbitopathy presented with a downward gaze restriction in the left eye. Magnetic resonance imaging (MRI) revealed an edematous left superior rectus muscle. Retrobulbar injection of triamcinolone acetonide (20 mg) was administered in the left orbit. However, edema was still evident in the left superior rectus muscle on MRI, 3 months after the injection, and new inflammation was detected in bilateral inferior rectus muscles. The patient then underwent three cycles of steroid pulse therapy (1 cycle: methylprednisolone 10 mg/kg/ day × 3 days). One week after the steroid pulse therapy, eye movement was improved and the inflammation in the left superior rectus muscle and the bilateral inferior rectus muscles subsided on MRI. However, the patient noticed diplopia during upward gaze 2 months later, and MRI showed recurrence of edematous changes in bilateral inferior rectus muscles. The patient was treated with the same protocol of steroid pulse therapy. One month after the second steroid pulse therapy, ocular motility was improved and the inflammation in both inferior rectus muscles had almost resolved. This case illustrates the detailed clinical course of edematous extraocular myopathy in a pediatric Graves' orbitopathy patient, followed-up by successive MRI.

Traitement chirurgical d’une rétraction de la paupière inférieure survenant après un recul du muscle droit inférieur: À propos d’un cas de syndrome de fibrose congénitale des muscles oculomoteurs

Lower eyelid retraction is a complication that frequently follows large inferior rectus recession. It may result in cosmetic problems or lagophthalmos with corneal exposure. We report the case of a child who had restrictive strabismus related to orbital fibrosis. He underwent bilateral inferior rectus recession and bilateral brow suspension. Retractor lysis was performed to treat a lower lid retraction that followed strabismus surgery. Lower lid retraction results from the anatomic connections between the inferior rectus muscle and the lower eyelid retractor. Several techniques have been proposed to prevent or treat lower eyelid retraction after inferior rectus recession.

A Case of General Congenital Fibrosis Syndrome With A-pattern Strabismus

Purpose: To report a case of general congenital fibrosis syndrome with A-pattern strabismus, bilateral ptosis and hypotropia. Case summary: A six-year-old girl was presented with severe bilateral ptosis and esodeviation of the left eye since birth. No levator action was presented and her chin was elevated at an angle of 25 degrees. In both eyes, an abduction defect was observed, and no vertical movement was presented. There was a left esotropia of 20 prism diopters (PD) and bilateral hypotropia of 35PD. There was an A-pattern strabismus that presents convergence movements during attempts to look upward, and orthotropia during attempts to look downward. Diagnosed as general congenital fibrosis syndrome with A-pattern esotropia, bilateral ptosis and hypotropia, bilateral inferior rectus muscle recessions were performed. After the operation, chin elevation and hypotropia in both eyes were corrected and exodeviation increased. Thus, orthotropia was observed in the primary position, and an A-pattern strabismus occurred with an exotropia of 15PD on the downgaze. Conclusions: A congenital fibrosis syndrome with an A-pattern strabismus was reported for the first time by the authors. On decisions concerningsurgical amounts of horizontal deviation, exodeviation should be considered to increase after bilateral inferior rectus muscle recessions.

Superior oblique tendon expanders with inferior rectus recessions for chin-up null point nystagmus

Three patients with chin-up head postures caused by a nystagmus null point in downgaze were treated using bilateral superior oblique tendon expanders and inferior rectus muscle recessions. Preoperative chin-up head postures measured from 25 to 45 degrees. Postoperatively, 2 patients had complete resolution of their abnormal vertical head postures, and the third showed improvement.

Surgical treatment of upgaze palsy in Parinaud's syndrome

Introduction Upgaze paralysis due to supranuclear defects can cause significant visual symptoms. There are only a few reports on the treatment of this problem in the literature. Patients with Parinaud's syndrome may also have retraction nystagmus and convergence on attempted upgaze that further complicates the treatment. Methods We performed a retrospective review of 48 patients with Parinaud's syndrome. Eleven patients were not able to elevate to the primary position and underwent surgery for the upgaze defect. Surgical treatments included transpositions in 2 patients, inferior rectus recessions in 8, which was combined with a superior rectus resection in one. Results Preoperative duction measurements demonstrated an average limitation on upgaze to −19° (−10 to −30) below midline with zero representing midline. Postoperative measurements showed marked improvement to +19 degrees above midline (15 to 30). Inferior rectus recessions were as effective as transpositions in restoring function. In addition, there was a marked reduction in the retraction nystagmus and upgaze convergence as well. Conclusions Visually significant upgaze limitation can be relieved with bilateral inferior rectus recessions in Parinaud's syndrome. Retraction nystagmus and covergence movements are also markedly improved.

Bilateral Progressive Supra-fixing Eyes with Congenital Misinsertion of Inferior Rectus Muscles: A Case Report

We report on a rare case with misinsertion of the inferior rectus muscles, that showed bilateral progressive supra-fixing eyes. A 68-year-old woman showed bilateral progressive supra-fixing eyes with low vision that was caused by microcorneas and retionochoroidal atrophy. Passive infraduction was restricted bilaterally, but the right inferior rectus muscle was innervated normally. Magnytic resonance imaging(MRI) demonstrated nasal misposition of bilateral inferior rectus muscles. The patient's eye position was improved after combined transposition of the inferior rectus muscles that were misinserted nasally to the inferior poles of the eyes and superior rectus muscle recession, without any complications. A dysfunction of bilateral depressor muscles and low vision may cause this condition. Accurate diagnosis with MRI and correction of the affected muscles to the normal anatomical position produces satisfying results in such cases.

THE SURGICAL TREATMENT OF GRAVES' ORBITOPATHY: A Decade of Progress

The total rehabilitation of the patients with Graves' ophthalmopathy is sometimes possible only with sequential surgical procedures. Elective surgical treatment is normally delayed until the inflammatory phase subsides and stability is established, usually 1 to 3 years after onset. Additionally, the metabolic status should be well controlled before elective surgical treatment. Generally, eyelid and motility measurements should remain stable for a period of 6 months before any surgical intervention. 44 Exceptions to delaying surgical repair until stability are severe exposure keratopathy requiring eyelid surgery or progressive optic neuropathy unresponsive to corticosteroid or radiation therapy, which prompts orbital decompression. The overall risk of the need for surgery was estimated as 2.5 times greater in patients older than 50 years than in younger patients. 3 This may be related to the presence of more severe ophthalmopathy in older patients. 33 A systematic surgical approach was introduced in 1986. 75 The usual sequence of reconstruction of the Graves' patient with severe orbitopathy is orbital decompression and strabismus surgery followed by eyelid retraction surgery and other eyelid surgery. Orbital decompression may influence the muscle function and eyelid position. In addition, muscle surgery especially if it involves the vertical rectus muscles; may change eyelid retraction. Despite the usefulness of a systematic conceptual approach, the treatment must be individualized to each patient, as the disease does not follow a uniform course, and the manifestations differ in severity. The first stage of surgical rehabilitation, when necessary, is the orbital decompression. It is indicated to reduce excessive proptosis, to relieve orbital congestion, and to treat compressive optic neuropathy. 6,31,53,74 The goal of strabismus surgery in Graves' orbitopathy is usually to achieve single binocular vision in the primary and reading positions. Stable motility measurements should be achieved muscle surgery. Many patients have restriction of the inferior rectus muscles and benefit from some degree of bilateral inferior rectus recessions. Adjustable sutures frequently are used. Surgery for eyelid retraction and other abnormalities follows strabismus surgery. There are numerous eyelid abnormalities described in dysthyroid ophthalmopathy. The most frequent are upper and lower eyelid retraction, lagophthalmos, ptosis, dermatochalasis, lacrimal gland prolapse and mechanical medial lower eyelid entropion. The eyebrow fat pad may also be enlarged in patients with Graves' orbitopathy. In selected cases, the brow fat may need to be debulked when performing a blepharoplasty to achieve the desired aesthetic result. 21 Cosmetic reduction of herniated fat pads and eyebrow fat pads is generally performed last.