Endocrine Exophthalmos Research Articles

Эндокринная офтальмопатия: споры о методах декомпрессии орбиты

Эндокринная офтальмопатия: споры о методах декомпрессии орбиты

An Oculist Looks at Endocrine Exophthalmos

Based on a talk delivered before the Royal Medical Society on Friday. 12th December 1958.When it was suggested to me that I should talk around some subject that held interest beyond the strictly ophthalmological one I saw a chance to present the ophthalmologist as someoneother than a man confined within the bony boundaries of his orbit, often fighting stern actions to defeat the invasive tactics of his neighbours, the neuro surgeons and the nose and throat doctors. Here was an opportunity to demonstrate the many connections of our subject and the many other branches of medical practice with which we are at times associated, ranging from neurology and rheumatology, through paediatrics, midwifery, and dermatology, to metabolic disease and endocrinology--to mention but a few of the pies in which anophthalmological finger may be found.

The role of episcleral venous pressure in the development of secondary glaucomas

Between 1983 and 1987 the authors studied 64 patients with dilated episcleral vessels and open-angle glaucoma. Elevated episcleral venous pressure was found to be the cause of the increased intraocular pressure. Clinically, the cause of elevation of venous pressure included spontaneous carotid cavernous fistulas, Sturge-Weber syndrome, orbital tumors, endocrine exophthalmos, anterior scleritis and idiopathic cases. A variety of pathophysiological mechanisms causing elevated episcleral venous pressure were found. The clinical course and complications associated with elevated episcleral venous pressure are discussed.

Surgical treatment of endocrine exophthalmos by removal of orbital fat: clinical experience.

To report a series of 73 patients with endocrine exophthalmos treated by removal of orbital fat using the transpalpebral approach during the period 1989 to 1999. The operation was performed according to the technique described by Olivari. Aesthetic analysis was done preoperatively and postoperatively (more than 6 months after surgery). The number of complications was also observed. The average volume of resected fat was approximately 7.6 mL per orbit. No major complication was observed. In 9 patients with epiphora, all improved. One patient developed postoperative diplopia and 5 complained of temporary diplopia. Appearance improved in 62 patients (85%). Surgical removal of orbital fat associated with endocrine exophthalmos provides consistent improvement in appearance with a low rate of complications. Additional procedures may be indicated to improve the cosmetic outcome.

Decompression of the orbit using a lateral rhinotomy approach in patients with malignant endocrine exophthalmos

Malignant endocrine exophthalmos is a complication seen in 1-2% of patients treated for thyrotoxicosis. A variety of surgical techniques have been used to prevent loss of vision due to compression of the optic nerve. In this study, nine patients with rapidly diminishing vision were operated upon using a lateral rhinotomy technique creating the largest possible space for expansion into the nose and decompressing the optic nerve far back in the orbit. In all patients the vision was improved 1 year after surgery and the proptosis was decreased.

Eye muscle antibodies in endocrine exophthalmos. Clinical and serological observations.

Serum samples were obtained from 65 patients with endocrine exophthalmos class I-V. In 33/65 patients who were treated either with prednisone or with ciclosporin, blood was sampled before, during and after therapy. Antibodies against eye muscle were determined during the course of immunosuppressive therapy in order to have an objective parameter of the therapeutic effect. To ascertain the specificity of the reaction both eye and abdominal muscles were used as antigens in an ELISA system. Both IgG and IgM antibodies were detected. In 45/65 patients (71%) eye muscle antibodies were positive before starting therapy. Antibodies were mostly detected in patients with active disease. Patients with exophthalmos of recent onset always had IgM antibodies whereas patients with chronic exophthalmos were mostly IgG positive. Patients with relapse showed mostly IgG but also IgG and IgM positivity in 2 cases. In 58% of cases only IgG antibodies were found whereas in 34% both IgG and IgM were detected and in 8% only IgM antibodies. There was no association between antibodies directed against eye muscle and thyroid microsomal and thyroglobulin antibodies or with the state of thyroid function. Furthermore there was no correlation between exophthalmos classes and eye muscle antibody binding activity. The antibody level declined during therapy with prednisone or with ciclosporin but rose again 8-12 weeks after stopping the drug in patients with progressive disease.

Tear crystallography in the differential diagnostics of eye and orbital diseases

For the differential diagnosis of orbital diseases a new method of tear fluid thesiography is worked out. This technique had never before been used in ophthalmology. The crystallographic picture, of normal tear fluid from the control group of patients as well as from patients with inflammatory eye or orbital neoplasms and endocrine ophthalmopathies were studied.Fifty-one patients were examined. The control group consisted of 15 healthy subjects of about the same age. With the help of our method crystallograms of tear fluid, taken from patients with endocrine exophthalmos, orbital phlegmon and neoplasm were made. Essential differences in the crystallograms of healthy subjects' tear fluid and tear fluid from patients with inflammatory or tumorous orbital disorders are singled out.The method of tear crystallography is informative enough. It may be used in the complex examination of patients with orbital diseases.

Enhanced prednisolone elimination: a possible cause for failure of glucocorticoid therapy in Graves' ophthalmopathy.

This study was undertaken to determine the pharmacokinetics of intravenous prednisolone in patients with Graves' eye disease. 6 women with Graves' ophthalmopathy treated with prednisolone for severe endocrine exophthalmos were compared with 6 healthy female volunteers. All subjects with Graves' disease had been taking carbimazole and I-thyroxine as concurrent drugs for at least 4 months prior to study day. All subjects were euthyroid. Each subject received .54 mg/kg prednisolone as an i.v. bolus. Plasma concentrations for total and unbound prednisolone were determined by HPLC and equilibrium dialysis. Significant increase (p less than .01) in clearance values and significant decreases in half-life times (p less than .01) were found for both total and unbound prednisolone in women with Graves' disease compared with the control subjects. Volumes of distribution at steady-state were unchanged in both groups. The data suggest that patients with Graves' ophthalmopathy show an enhanced elimination for prednisolone and that is why they may need higher doses of corticoid although the function of the thyroid gland is euthyroid.

Evaluation of extraocular muscles in patients with endocrine exophthalmos before and after treatment

The authors discuss the behaviour of the eyeball motility and the thickness of the external eye muscles in patients with infiltrative ophthalmopathy. the observations covered 22 patients with Graves' disease, being in the state of euthyroidism. Prior to the beginning of therapy and directly after its termination, all patients were subjected to full clinical evaluation, computerized tomography as well as to examination of the range of eyeball movements. A restriction of all movements of the eyeballs was disclosed, the most serious handicap being recorded in the upward movement (6.5 mm), upward and external movement (8.2 mm), upward and internal (8.5 mm). the tomographic estimation revealed restriction of the straight muscles, inferior and superior, on the average by 3.5 mm, medial by 2.5 mm, and of the lateral straight muscles by 0.5 to 1 mm. Glucocorticoids and glucocorticoids together with imuran were used during the treatment. the therapy lasted from four to nine months. Just after the end of the therap...

Utility of ultrasound in unilateral endocrine exophthalmos

Sometimes thyroid diseases cause exophthalmos in both eyes and in these cases the diagnosis is easy. the diagnosis becomes more difficult in case of unilateral exophthalmos and especially when the patient is not known to have a thyroid disease. In these cases more serious pathologies are suspected, like orbital tumours, etc. the authors show the value of echography in these patients and also in those where exophthalmos is not so evident and a thyroid disease has not yet been diagnosed. With echography they have established Graves' disease. By performing some simple thyroid tests they avoided expensive and invasive investigations like CT. In 14 years they have studied 2684 cases of orbital pathology, in particular the 365 cases in whom Graves' disease was suspected and in whom in 11.6% of these a unilateral exophthalmos was present.

Autoimmune Thyroid Disease

The concept of thyroid autoimmune disease now includes the following clinical entities: 1 degree thyrotoxicosis and goitrous thyroiditis (Hashimoto) with their variants, and 1 degree myxedema (atrophic thyroiditis); some cases of sporadic nontoxic goiters; most cases of neonatal hyperthyroidism; and a proportion of congenital athyreotic cretinism. Endocrine exophthalmos, though clinically associated with Graves' disease, is now considered a separate immunological entity.

Functional results in Graves' disease following ophthalmo-rhinosurgical orbital decompression

The results of the first consecutive series of 36 orbital decompression operations (technique of Buschmann and Richter) were analyzed. Compression optic neuropathy with visual impairment and field defects improved postoperatively fast and to a remarkable extent. Lagophthalmos and lid retractions disappeared in most patients, but additional lid surgery was necessary in some cases. In severe motility disturbances, combined decompression and squint surgery resulted in good motility and normal binocular vision, at least in all important directions of gaze. Pseudoglaucoma itself needs no treatment, but primary glaucoma became uncontrollable during the development of an endocrine exophthalmos. It was controlled again by topical drug application after surgical orbital decompression. The operation is also indicated if severe grade III orbitopathy causes personal or professional problems for the patient.

Transantral orbital decompression in the treatment of Graves' disease.

A series of twenty patients operated on for severe endocrine exophthalmos is presented. All the operations were performed by removing the orbital floor, making a total ethmoidectomy and removing part of the inferior orbital margin; in some cases, a section of the lateral orbital wall was also removed. No serious complications were detected. In all but one patient there was an immediate, marked decrease in exophthalmometry. A marked decrease of the inflammatory signs of the conjunctivae was also observed within a week following surgery.

Orbital decompression in endocrine exophthalmos of Graves' disease.

Transantral decompression was performed bilaterally in 27 and unilaterally in 3 patients with endocrine exophthalmos of Graves' disease. In 28 patients there was an immediate reduction of proptosis and in about half of the patients in addition a marked decrease in chemosis and conjunctival injection indicating that these signs were mostly due to orbital vascular congestion. In one patient with exophthalmos of more than 2 years duration and progressive swelling of the eye muscles no response was observed. In another patient decompression did not reduce proptosis which, however, 4 months later responded to retrobulbar irradiation. In one further patient much more marked reduction of proptosis and disappearance of persistent periorbital swellings were obtained after glucocorticoid treatment given half a year after decompression. Postoperatively diplopia occurred in about half of the patients but corrective operations were required only in a quarter of the patients. Transantral decompression is an effective method for rapid treatment of progressive exophthalmos of Graves' disease. In patients with unilateral exophthalmos the asymmetry may be reversed after unilateral operation. The authors use decompression not only in the most severe cases (categories 5 and 6a-c according to the classification of the American Thyroid Association) but also in less severe cases (categories 2b-c and 3b-c) when there is a steady progression as a primary treatment possibly combined with other forms of therapy.

Surgical treatment for malignant exophthalmos of endocrine origin.

Endocrine exophthalmos is a poorly understood disease process thought to be related to a dysfunction of the thyroid-pituitary axis. Initial therapy for symptomatic endocrine exophthalmos is medical. Failure to respond to medical management is heralded by progressive exophthalmos, exposure keratitis, and decreasing visual acuity. The pathophysiologic processes involved and an historical review of the various surgical procedures used are discussed. The results of 28 patients surgically decompressed by a transantral transethmoid approach are presented. Preservation or improvement in visual acuities were observed in all but one patient. Diplopia was generally not improved and may be worsened in some patients.

Ethmoidektomie und Orbitadekompression bei endokriner Ophthalmopathie

23 orbita decompression operations were performed in patients suffering from endocrine exophthalmos (Grave's disease) after normalization of thyroid metabolism and systemic corticoid therapy remained unsuccessful. We developed a modification of an external ethmoidectomy. The lamina of the middle nasal concha is carefully preserved, any opening to the nasal cavity is closed. Flap door incisions of the periorbita complete this procedure. Results are good and were followed up for a period of 30 months. The operation resulted in prompt restitution of normal eye position with fast normalization of visual acuity and field. Squint surgery was done in addition.

Ophthalmo-rhinosurgical decompression operation in malignant endocrine exophthalmus

The thyroid metabolism has to be treated first. If this is not followed by regression of the exophthalmos, treatment with prednisone over a period of several weeks is indicated. If this does not result in permanent improvement, surgical decompression of the orbit is indicated, especially if the exposition of the cornea or compression of the optic nerve represent an imminent danger. In such cases surgical decompression is preferable to multiple series of prednisone or radiation treatment (Wright 1981, Trokel 1982). Both the Krönlein-Berke operation for resection of the lateral orbital wall as well as neurosurgical resection of the orbital roof have proved to be excellent for removal of correspondingly located orbital tumors; effective decompression of the orbit in malignant endocrine exophthalmos, however, cannot be achieved this way, as the temporal muscle and the brain, respectively, prevent protrusion of the swollen orbital tissues through these apertures. Resection of the orbital floor is somewhat more effective. The mucosa of the maxillary sinus can easily be moved by the protruding orbital tissues, resulting in a reduction in the size of the maxillary sinus. This decompression, however, is effective only in the anterior two-thirds of the orbit, while the optic nerve must be relieved from the pressure of the swollen muscles in particular in the posterior one-third of the orbit. The only effective way is to remove the medical orbital wall up to the tip of the orbit. Surgical techniques for this purpose have already been recommended, but appeared unsatisfactory from a rhinological point of view.(ABSTRACT TRUNCATED AT 250 WORDS)

Cosmetic correction of eyelid deformities associated with exophthalmos.

Several procedures are detailed for correction of endocrine exophthalmos, including lateral tarsorrhaphy, levator marginal myotomy, excision of Muller’s muscle and levator recession, scleral implantation, scleral grafting, and tarsal grafting. The most predictable results were found with ear cartilage grafts to lengthen the posterior lamella.

The Effect of Anterior Orbital Decompression on Motility in Thyroid Exophthalmos

Nineteen orbits from 13 patients with endocrine exophthalmos were effectively decompressed into the maxillary and ethmoid antra through an anterior orbitotomy. Six patients with preoperative diplopia had improved ocular ductions and return of binocular single vision in functional positions. Diplopia was not induced in five patients with normal pre-op motility. In one patient with active orbitopathy, a large postoperative esotropia was caused by worsening of medial rectus inflammation. This approach appears to lessen the incidence of postoperative diplopia and may make subsequent extraocular muscle procedures unnecessary.

Cosmetic Correction of Eyelid Deformities Associated with Exophthalmos

Several procedures are detailed for correction of endocrine exophthalmos, including lateral tarsorrhaphy, levator marginal myotomy, excision of Muller’s muscle and levator recession, scleral implantation, scleral grafting, and tarsal grafting. The most predictable results were found with ear cartilage grafts to lengthen the posterior lamella.