Dysthyroid Orbitopathy Research Articles

Corticosteroid therapy in dysthyroid orbitopathy: about 53 cases

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

A Case of Endoscopic Transnasal Orbital Decompression for Unilateral Ocular Protrusion due to Dysthyroid Orbitopathy

A Case of Endoscopic Transnasal Orbital Decompression for Unilateral Ocular Protrusion due to Dysthyroid Orbitopathy

Recurrence of Exophthalmos after 10 Years from Orbital Floor Decompression for Dysthyroid Orbitopathy: A Case Report.

Dysthyroid orbitopathy or Graves' ophthalmopathy (GO) is an autoimmune disease with a complex pathogenesis that usually occur in patients with hyperthyroidism. Surgical decompression of the orbit is an accepted and validated treatment of thyroid eye disease (TED). This is a case of a patient with left exophthalmos and ipsilateral maxillary sinusitis after 10years from the surgical bone decompression of the orbital floor for TED.

Traitement de la rétraction palpébrale supérieure associée à l’ophtalmopathie dysthyroïdienne en phase active inflammatoire avec l’injection de toxine botulique A

To evaluate the efficacy of transconjunctival botulinum toxin type A (BTX-A) in the treatment of upper eyelid retraction in the active inflammatory phase of dysthyroid orbitopathy, establish the ideal dose, and evaluate side effects. This is a comparative, prospective study in patients with thyroid orbitopathy, conducted at the Conde Ophthalmology Institute in Valenciana, Mexico. The patients included had dysthyroid orbitopathy in the inflammatory phase, and they were treated with subconjunctival injection of botulinum toxin type A (BTX-A) in the upper eyelid. Five units (group 1) and ten units (group 2) of BTX-A, in a single subconjunctival dose were applied to the non-dominant eye. We evaluated visual acuity, margin-to-reflex distance (RPM1), crease height, ocular motility, diplopia and keratitis, before and after administration of the toxin. The patients were followed at one, 4 and 16 weeks, with the Student t-test as a statistical analysis. At week 4, 15 patients (100%) showed a reduced margin to reflex distance. The mean result for group 1 was -1.75mm (range -1 to -2.5mm) and group 2 was -2mm (range -1 to -4mm). Statistically significant differences were seen between pre-treatment and week 4 in both groups, but no differences between doses. Complete improvement of keratitis and lagophthalmos was observed in 5 and 2 patients, respectively. Visual acuity, ocular motility and crease height did not change in 93% of the patients. One patient (group 1) exhibited complete ptosis and vertical diplopia, which resolved spontaneously at week 6. Transconjunctival BTX-A application is safe and effective for the treatment of eyelid retraction in dysthyroid orbitopathy. No difference was found between doses. No severe side effects were reported.

Management of moderate and severe dysthyroid orbitopathy: about 22 cases

Décrire la prise en charge thérapeutique des orbitopathies dysthyroidiennes modérées et sévères et évaluer par une étude statistique les facteurs associés à la neuropathie optique ainsi que les facteurs de mauvais pronostic visuel. Nous avons mené une étude rétrospective sur 22 patients présentant une ophtalmopathie dysthyroidienne modérée à sévère sur au moins un oeil, hospitalisés au service d'ophtalmologie du CHU Farhat Hached Sousse, sur une période s'étalant de 1998 à 2015. Les indications thérapeutiques sont basées sur les critères d'activité et de sévérité de l'Eugogo ainsi que l'évaluation des facteurs de mauvais pronostic visuel. L'âge moyen de nos patients était de 40 ans avec une légère prédominance masculine (54.5%). 68.2% des patients étaient en euthyroidie, 18.2% étaient tabagique. Le facteur le plus associé significativement à la neuropathie est la compression au niveau de l'apex orbitaire (P = 0.03). Le traitement était basé sur la corticothérapie intraveineuse et/ou la décompression orbitaire en fonction de l'activité et la sévérité de la maladie. L'évolution globale après traitement a été marquée par une amélioration des signes inflammatoires, réduction de l'exophtalmie. Le pronostic visuel était plus mauvais chez les patients plus âgés (P = 0.0001), de sexe masculin (P = 0.03) et traités par irathérapie (P = 0.04). Dans les limites d'une étude rétrospective, nos résultats étaient globalement concordants avec la littérature. L'orbitopathie dysthyroidienne reste une maladie dont l'évaluation et la prise en charge thérapeutique sont non encore bien élucidées. Des études de cohortes, probablement multicentriques, sont à envisager pour améliorer la prise en charge.

甲状腺眼症に対して鼻内内視鏡下眼窩減圧術を施行した3症例

甲状腺眼症はバセドウ病などの甲状腺疾患に合併し，眼球突出や眼瞼腫脹，重症例では複視や視力障害をきたす。活動期にはステロイドや放射線外照射による治療が行われるが，無効例は眼窩減圧術の適応となる。また非活動期には視機能回復と整容性を目的に，眼窩減圧術や眼瞼手術が行われる。今回我々は，バセドウ病に伴う甲状腺眼症に対して鼻内内視鏡下眼窩減圧術を施行した3症例を経験した。眼窩減圧術は鼻内内視鏡下に行い，眼窩内側壁および下壁内側を除去した。内直筋の上方と下方に2本の平行な眼窩骨膜切開を行い，眼窩内容物を篩骨洞内と上顎洞内に脱出させた。症例1は圧迫性視神経症による視力低下を認め，ステロイド治療により視力は一時的に改善したが再増悪を繰り返し，眼窩減圧術を施行した。術後視力は改善した。症例2と症例3は眼球突出・複視などの症状を認めステロイド治療および放射線外照射を行ったが症状改善が乏しく，眼窩減圧術を施行した。鼻内内視鏡下眼窩減圧術は1990年以降多くの報告を認め，一般的な手術方法の一つとなっている。しかし国内での報告は少数である。外切開を加える必要がなく整容面で優れ，安全に行うことができる手術と考える。

Optical coherence tomography measurements in compressive optic neuropathy associated with dysthyroid orbitopathy.

The purpose of the study was to assess the influence of optic nerve compression on the peripapillary retinal nerve fiber layer (RNFL) thickness in eyes with acute and chronic dysthyroid optic neuropathy (DON). Patients with DON and healthy control subjects underwent peripapillary optical coherence tomography (OCT) scanning with the Cirrus HD-OCT. Patients were classified as acute (within 6months from the onset of DON) versus chronic (6months or more from the onset of DON) DON. The thickness of peripapillary RNFL was compared between eyes with acute and chronic DON and control eyes. Baseline factors associated with visual acuity at the last visit were also analyzed. The mean temporal peripapillary RNFL thickness was thinnest in chronic DON at 66 ± 12μm compared to 76 ± 8μm in eyes with acute DON and 73 ± 12μm in control eyes (p = 0.014). In a multivariable analysis, patients with greater inferior peripapillary RNFL thickness and younger age tended to have better visual acuity at the last visit (p = 0.034, odds ratio [OR] = 1.038 and p = 0.007, OR = 0.912, respectively). Our data revealed a notable difference in temporal peripapillary RNFL thickness in eyes with chronic DON compared to eyes with acute DON and control eyes. We also found a significant association between inferior peripapillary RNFL thickness and visual acuity at the last visit. Thicker inferior peripapillary RNFL thickness was associated with better visual outcome. Further studies with large sample sizes using a prospective design should more clearly reveal the time aspect of the association between the onset of DON and the changes in peripapillary RNFL, and their clinical significance.

Endoscopic orbital floor decompression with preservation of the inferomedial strut

Medial and inferior orbital decompression is most commonly performed in the setting of dysthyroid orbitopathy. Diplopia represents the most common complication and may be minimized through the preservation of a bony inferomedial strut (IMS). Historically, this has required a transconjunctival approach due to the technical demands of performing an isolated orbital floor decompression using endoscopic instrumentation. Here we describe a novel technique of a purely endoscopic orbital floor decompression with reliable preservation of the IMS. Description of a novel surgical technique for endoscopic orbital floor decompression with IMS preservation using frontal sinus instrumentation visualized by a 70-degree endoscope. We have successfully used this technique in 12 orbits with 100% preservation of the bony inferomedial strut and no complications. The extent of decompression and width of the residual strut may be fine tuned as needed to optimize results. Orbital floor decompression with IMS preservation may be reliably performed using purely endoscopic techniques. Successful completion of this procedure requires the adaptation of standard frontal sinus instrumentation to the maxillary sinus roof and thus may be readily mastered by any endoscopic surgeon comfortable with frontal sinus techniques.

Post-operative orbital haematomas over a 12-year period. A description of three cases among 280 orbital procedures

PurposeTo evaluate the incidence of orbital haematoma requiring surgical treatment following procedures including fracture repairs and orbital osteotomies over a 12-year period and to discuss their management. MethodsThe records of all the patients who underwent a procedure involving the orbits from 1998 to 2011 were reviewed for evidence of post-operative haematomas. Medical data including clinical presentation, time between diagnosis and treatment, management and subsequent outcome were collected. Results280 patients were included, 257 procedures for orbital or zygomato orbital fractures and 23 osteotomies for dysthyroid orbitopathy or malunited orbital fractures. Three cases (1.07%) of post-operative haematomas were observed as follows: 2/257 orbital fractures (0.77%) and 1/23 osteotomies (4.34%).All cases occurred in the early post-operative period of less than 6 h. No spontaneous loss of vision or pain was described by patients. All could be operated on as soon as the diagnosis was established; no CT-scans were required. Orbital drainage was successfully performed in all cases. ConclusionPost-operative orbital haematomas are uncommon complications. Diagnosis is based on a clinical examination, including pain, proptosis and alteration in visual acuity. Surgical treatment should be undertaken immediately following diagnosis.

Mucocèle ethmoïdale après décompression orbitaire osseuse transpalpébrale

We report a case of a late ethmoidal mucocele occurring after transpalpebral bony orbital decompression. A 39-year-old man presented with a recurrence of a right-sided proptosis without signs of orbital inflammation. The patient had undergone bilateral transpalpebral bony orbital decompression for dysthyroid orbitopathy 2 years prior. Orbital CT scan showed a large mucocele in the supero-lateral right ethmoidal sinus with lateral extension to the medial rectus. The patient was therefore referred to an ear, nose and throat (ENT) surgeon, who performed an anterior ethmoidectomy with marsupialization and drainage of the mucocele via an endoscopic approach. A complete postoperative resolution of proptosis was observed without recurrence of the mucocele to date, approximately 6 months postoperative. Sinus complications occurring after orbital decompression may include sinusitis, hematoma, imploding antrum syndrome and mucoceles. Recurrent proptosis secondary to an ethmoidal mucocele is a rare event after bony orbital decompression surgery, with only two cases reported in the international literature. Management requires ophthalmologic diagnosis and collaboration between the ophthalmologist and otorhinolaryngologist.

Transnasal endoscopic orbital decompression: 15-year clinical experience in Southern Taiwan

To present the results and evaluate the efficacy of endoscopic transnasal orbital decompression for dysthyroid orbitopathy. Retrospective chart review of patients who underwent endoscopic transnasal orbital decompression from 1996 to 2010 in one institution. We included 42 orbits of 25 patients. Preoperative and postoperative examinations included visual acuity, Hertel exophthalmometry, tonometry, exposure keratitis, and diplopia. The measurements of outcome depend on proptosis reduction, intraocular pressure reduction, and visual acuity improvement of 42 orbits of 25 patients. There were no surgical complications for the 42 orbital decompressions except one patient experienced cerebrospinal fluid leak during the operation. Mean proptosis reduction in all orbits was 1.93 ± 0.25 (mean ± standard deviation, p < 0.01) after 1 month postoperatively and 2.07 ± 0.29 (p < 0.01) after 3 months postoperatively. An average reduction of intraocular pressure was 4.40 ± 0.72 (p < 0.01) and 4.38 ± 0.80 (p < 0.01) respectively after 1 and 3 months postoperatively. Visual acuity increased from a preoperative average of 0.45 ± 0.34 to 0.66 ± 0.36 and 0.70 ± 0.35 after 1 and 3 months postoperatively. In addition, postoperative relief of exposure keratitis is also noted. The transnasal orbital decompression procedure has statistically significant improvements in proptosis, intraocular pressure, and visual acuity. The procedure has obvious benefit in relieving exposure keratitis. Furthermore, there are favorable cosmetic results and rare complications.

Dysthyroid optic neuropathy: diagnosis and treatment

AbstractOptic neuropathy is a rare complication of dysthyroid orbitopathy (incidence &lt; 5%). Its onset is often insidious and progression is frequently slow. However it is mandatory to recognize it early as it is a potentially blinding but treatable condition. At the end of the presentation, participants will be able to recognize the various clinical features of dysthyroid optic neuropathy, decide which diagnostic procedures is necessary to establish the diagnosis, understand the underlying physiopathologic mechanisms, and choose amongst the therapeutic options.

High-resolution, three-dimensional, and contrast-enhanced ultrasonographic findings in diseases of the eye

Objectives To review the contrast-enhanced ultrasound (CEUS) and 3D ultrasound findings (3D-US) in various pathologies involving the eye and orbit and to compare them with high-resolution US (HRUS) findings. Background CEUS is a valid diagnostic tool for study several districts. There are numerous pathological conditions of the eye in which CEUS can be very helpful or detrimental. Image Findings We review a wide range of ocular lesions, traumatic (retinal and choroidal detachments) and malignant (choroidal melanoma, tumors inside and outside the muscle cone) evaluated alternatively with CEUS and 3D and compare these findings with those obtained with HRUS. Dysthyroid orbitopathy is not included in this review. Conclusion CEUS plays a central role in the differentiation of detached retina (vascular) and vitreous membranes (avascular). It is also helpful in the assessment of tumor of the eye, in planning treatment for choroidal melanoma, and in assessing orbital masses for neovascularization. HRUS is highly effective in the detection of traumatic and non-traumatic lesions of the eye, but it is less effective for the assessment of orbital lesions. The 3D module has increased the diagnostic value of CEUS. CEUS is cost-effective and can be used when CT and MR cannot be performed.

Outcomes following surgical decompression for dysthyroid orbitopathy (Graves' disease)

Graves' disease is a multiorgan autoimmune disease of complex pathophysiology that primarily affects the thyroid gland and orbit. The ophthalmic manifestations of Graves' disease may vary from mild proptosis which causes minimal cosmetic embarrassment to subluxation of the globe, exposure keratitis, corneal abrasion and even blindness. This article focuses on outcomes following orbital decompression. Surgical techniques have evolved with improved understanding of sinonasal anatomy and being technology-driven with the use of the fiberoptic endoscope and image guidance. The most common surgical outcome reported in the literature is reduction in proptosis, followed by visual acuity and intraocular pressure. Quality-of-life assessments are not routinely measured. There are a myriad of surgical techniques currently in practice which underscores the fact that no single technique is clearly superior to another. Endoscopic decompression results in a mean reduction of 3.50 mm and is associated with a low complication rate. Nevertheless, the literature suggests that the best techniques are likely to be multiwall approaches such as combined medial and lateral wall decompression. Management of dysthyroid ophthalmopathy is clearly multidisciplinary. Future studies should consider a minimum data set for reporting outcome measures which should include a quality of life tool.

L’exophtalmie basedowienne

Dysthyroid orbitopathy is a disease that is edematous and inflammatory, generally chronic, sometimes subacute or acute, and is characterized by exophthalmos in the majority of cases, retraction of the lid, restrictive strabismus with diplopia, corneal ulceration, ocular hypertension, and compressive optic neuropathy. Proptosis is the cardinal sign. Exophthalmos is frequently axial and is bilateral in 85%–90% of cases. Displacement of the globe in the vertical and horizontal axes is not rare, particularly when intense enlargement of an extraocular muscle produces a mass effect. Proptosis stems from a conflict for the space in the orbital cavity. The infiltration of the fat, muscles, and lacrimal gland by lymphocytes, plasma cells, and mucopolysaccharides, which are very hydrophilic, all contribute to the orbitopathy. The majority of patients with minimal exophthalmos do not require special treatment since they tend to improve spontaneously. In severe forms, it is important to evaluate the activity for steroid use to eliminate the inflammation in the soft tissues and to make rehabilitative surgery possible under better conditions. When a good response is not obtained, radiotherapy is evaluated. The surgical treatment by bone orbital decompression and sometimes lipectomy is indicated in inactive forms, disfiguring exophthalmos, certain particular cases such as dysthyroid optic neuropathy, ocular hypertension, corneal exposition.

Surgical treatment of dysthyroid orbitopathy

Objectives Orbital decompression for dysthyroid orbitopathy may be performed by open or transnasal endoscopic approaches; however, criteria for the selection of the appropriate surgical technique have not been well-defined. Our goal was to compare the surgical outcomes of orbital decompression techniques employed by the otolaryngology and ophthalmology services at a single institution, so as to clarify the indications and develop a rationale for optimal management. Study Design Case series with chart review. Setting Tertiary care academic medical center. Subjects and Methods Orbital decompressions on 112 orbits of 69 patients from 2001 to 2008 at a tertiary care academic medical center. Results The majority (83%) of orbital decompressions were performed primarily for proptosis, whereas the remainder was indicated for dysthyroid optic neuropathy. Maximum reduction of proptosis was achieved with an endoscopic medial and inferior orbital wall decompression combined with a lateral orbitotomy with fat removal. The average reduction in proptosis was 7.4 mm ± 2.3 mm (primary surgery for proptosis). The endoscopic approach alone provided the least average proptosis reduction but was highly successful in the treatment of dysthyroid optic neuropathy. Conclusions A three-wall decompression using a combined endoscopic and external approach provides the greatest amount of decompression. The endoscopic approach as a single modality is best suited for patients with mild proptosis and for patients with dysthyroid optic neuropathy. Cooperation between otolaryngology and ophthalmology achieves the best care for patients with thyroid eye disease who require surgical treatment.

A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy

To systematically review and compare the surgical outcomes of orbital decompression for dysthyroid orbitopathy. Data sources used were PubMed, EMBASE, and Cochrane search for English-language literature from January 1990 to April 2008, combined with manual review of citations within article bibliographies. Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. Articles were then assigned level-of-evidence grades as defined by the Oxford Centre for Evidence-Based Medicine. A total of 516 citations were generated from which 135 abstracts were regarded as potentially relevant. After other relevant articles identified from the bibliography and duplicate articles excluded, 56 studies were available for analysis. Fifty studies were identified as level 4 and six as level 3 evidence. A total of 2,315 patients were pooled, from which 4,176 orbits were decompressed. Fifteen different surgical techniques were broadly identified. The most common surgical indication was cosmesis. Decompression by combined transpalpebral-endoscopic technique resulted in the highest average reduction in postoperative proptosis. The largest improvement in visual acuity was after coronal approach orbital decompression. The overall complication rate was 9.3%. The most significant complications were vision loss and cerebral vascular accident. The highest complication rate was associated with combined endoscopic and transpalpebral decompression. There are myriad techniques in practice for decompressing the orbit, but no one technique has yet to achieve consistently good outcome and low complication rates. The reporting of outcomes should conform to a minimum dataset. Laryngoscope, 2009.

O.339 Orbital decompression for endocrine orbitopathy

A procedure has been developed for maximizing decompression in patients with nonspecific orbital inflammatory disease or dysthyroid orbitopathy that involves removal of parts of all four orbital walls through a lateral orbitotomy using a 30-mm incision combined with a canthotomy and an inferior cul-de-sac incision. The procedure has been performed on seven orbits of four patients who had greater than 30 mm of forward placement of the eyes as measured by Hertel exophthalmometry and/or a 10-mm difference in the forward placement of the two eyes, indications considered for this procedure. The procedure has resulted in 10-17 mm of reduction in proptosis in these patients, which is consistently greater than that obtained by any other procedure. A complication of spinal fluid leak resulted in the recommendation that the procedure not be performed in patients over 65 whose dura is considered too thin to prevent spontaneous leakage and minimal surgical trauma. In all circumstances, this procedure must be performed by an experienced neuro-ophthalmic orbital surgical team.

Das freie autologe Tarsustransplantat als Spacer zur Behandlung der Unterlidretraktion bei Endokriner Orbitopathie

Lower lid retraction in dysthyroid orbitopathy is of less functional concern than optic neuropathy or diplopia in central positions of gaze. However, it may lead to incomplete lid closure resulting in corneal exposure. Patients often suffer from aesthetic impairment. A retrospective analysis of 13 consecutive patients treated for lower lid retraction due to Grave's Disease between 2005 and 2007 was undertaken. In spite of regular ophthalmological examinations, specific attention was directed to measurement of the lid fissure width and scleral show for quantification of lower lid retraction. OPERATION: The lower lid is everted and the conjunctiva is opened horizontally underneath the tarsal edge. Lower lid retractors are disinserted and dissected until the lower lid might be elevated in symmetry to the fellow eye. This procedure is continued until 1 mm overcorrection is gained. A free tarsal transplant is harvested from the ipsilateral upper lid tarsus. At least 4 mm vertical tarsus have to be left. Tarsus is sutured with absorbable material. In the 13 patients operated upon (9 women, 4 men) aged 23 - 67 years, scleral show was preoperative 2.7 mm (mean) and postoperative 0.1 mm. Lid fissure width was preoperative 13 mm (10 - 16 mm) and immediately postoperative 10.3 mm (7 - 13). 6 months postoperative the lid-elevating effect was reduced by 0.5 mm in maximum in the 9 patients available for control. The lid closure deficit, which was present in 7 patients before, could be corrected completely in 5 and diminished to 1 mm in 2 patients. Using this particular technique, functional and aesthetical satisfying results are obtained. The main advantages are renunciation of allogen, xenogeny or synthetic material with its possible risks of slow-virus infection and/or extrusion. Further studies are necessary to evaluate long-term results.

Análise morfométrica da fenda palpebral de pacientes com retração palpebral na fase aguda da orbitopatia distireoidiana submetidos à injeção palpebral de toxina botulínica tipo A

To compare morphometric data of eyelid fissure using computerized image analysis before and after application of botulinum toxin type A in patients with eyelid retraction caused by dysthyroid orbitopathy in acute stage. This was a prospective study with 12 individuals that received transcutaneous 5 UI/0.1 ml injection of botulinum toxin in the upper eyelid. They were examined periodically for 6 months. Clinical eyelid examination was performed and recorded using a video camera connected to a microcomputer. Vertical eyelid fissure, upper eyelid margin to reflex distance and the eyelid area showed reduction in the treated eye. A decrease in the levator function of the upper eyelid was observed, and also, a reduction in the difference between the lateral and medial areas. The lower eyelid margin reflex distance did not show any significant differences after the application. Measurements of the contralateral eye increased up to 2 weeks after the application. These results showed a reduction in eyelid retraction and improving the upper eyelid contour, without changes in the lower eyelid position.