Exophthalmometry Measurement Research Articles

Clinical Manifestations of Thyroid-associated Ophthalmopathy Accompanied by Thyroid Cancer

Purpose: To analyze the clinical manifestations of thyroid-associated ophthalmopathy accompanied by thyroid cancer.Methods: We performed a retrospective chart review of 33 patients diagnosed at our ophthalmology department with both thyroid- associated ophthalmopathy and thyroid cancer. We performed thyroid function tests at the first visit and at diagnosis of the thyroid cancer, and recorded the type of thyroid cancer, thyroidectomy history, clinical activity score (CAS), exophthalmometry, margin reflex distance (MRD) 1, diplopia, follow-up duration of ophthalmopathy, and ocular treatments. We divided patients into two groups according to the time of diagnosis of thyroid ophthalmopathy and thyroid cancer.Results: The average age of the 33 patients was 45.55 years, and eight and 25 were males and females, respectively. The average CAS score, exophthalmometry measurement, and MRD1 were 2.00 ± 1.67, 19.28 ± 3.24 mm, and 4.52 ± 1.58 mm, respectively. Patients whose ocular symptoms preceded the diagnosis of thyroid cancer tended to have a higher thyroid hormone level, CAS score, and exophthalmometry measurement, and required more ocular treatments, compared to the other patients. The average thyroid auto-antibody levels were increased in both groups. In patients whose ophthalmopathy preceded the thyroid cancer, exophthalmometry measurements were significantly decreased after thyroidectomy.Conclusions: It is crucial to identify ophthalmopathy in association with thyroid cancer. Patients whose ocular symptoms started before the diagnosis of thyroid cancer may present with hyperthyroidism and severe ocular symptoms, and may need ocular treatments. Patients should be informed that thyroid-associated ophthalmopathy may develop after thyroidectomy or radioiodine therapy, and their ocular symptoms should be closely monitored.

Endoscopic repair of combined orbital floor and medial wall fractures involving the inferomedial strut.

To evaluate the safety, efficacy, and feasibility of an endoscopic transconjunctival inferior fornix and precaruncular approach for repair of combined orbital medial wall and floor fractures involving the inferomedial strut. A retrospective study was performed in 84 patients with combined orbital medial wall and floor fractures involving the inferomedial strut. All patients underwent surgery by endoscopic transconjunctival inferior fornix and precaruncular approach. A large polyester mesh plate was implanted to cover the fracture defect. The enophthalmos, diplopia, and surgical complications were evaluated pre- and postoperatively. Patients were followed for at least 6 months. A total of 84 patients (55 men and 29 women) with a mean age of 36.88 ± 12.95 years were included in this study. Preoperatively, all 84 patients had an enophthalmos >2 mm, and the mean exophthalmometry measurement was 11.6 ± 2.14 mm. Diplopia was presented in 33 patients. Postoperatively, good symmetry was acquired in 81 of 84 patients, with a mean improvement of 3.02 ± 0.99 mm in the enophthalmos (P < 0.05). Recovery from diplopia occurred in 32 of 33 patients. A new onset of diplopia occurred postoperatively in 13 of the remaining 51 patients, only to recover spontaneously after 1 month. One patient suffered retrobulbar hemorrhage after surgery and was cured by conservative therapy. No other serious complications occurred. The endoscopic transconjunctival inferior fornix and precaruncular approach is a promising management technique for combined orbital medial wall and floor fractures involving the inferomedial strut.

A Comparative Study of Clinical vs. Digital Exophthalmometry Measurement Methods.

Background A number of orbital diseases may be evaluated based on the degree of exophthalmos, but there is still no gold standard method for the measurement of this parameter. In this study we compare two exophthalmometry measurement methods (digital photography and clinical) with regard to reproducibility and the level of correlation and agreement with measurements obtained with Computerized Tomography (CT) measurements. Methods Seventeen patients with bilateral proptosis and 15 patients with normal orbits diseases were enrolled. Patients underwent orbital CT, Hertel exophthalmometry (HE) and standardized frontal and side facial photographs by a single trained photographer. Exophthalmometry measurements with HE, the digital photographs and axial CT scans were obtained twice by the same examiner and once by another examiner. Pearson correlation coefficient (PCC) was used to assess correlations between methods. Validity between methods was assessed by mean differences, interintraclass correlation coefficients (ICC's), and Bland–Altman plots. Results Mean values were significantly higher in the proptosis group (34 orbits) than in the normal group (30 orbits), regardless of the method. Within each group, mean digital exophthalmometry measurements (24.32 ± 5.17 mm and 18.62 ± 3.87 mm) were significantly greater than HE measurements (20.87 ± 2.53 mm and 17.52 ± 2.67 mm) with broader range of standard deviation. Inter-/intraclass correlation coefficients were 0.95/0.93 for clinical, 0.92/0.74 for digital, and 0.91/0.95 for CT measurements. Correlation coefficients between HE and CT scan measurements in both groups of subjects (r = 0.84 and r = 0.91, p < 0.05) were greater than those between digital and CT scan measurements (r = 0.61 and r = 0.75, p < 0.05). On the Bland–Altman plots, HE showed better agreement to CT measurements compared to the digital photograph method in both groups studied. Conclusions Although photographic digital exophthalmometry showed strong correlation and agreement with CT scan measurements, it still performs worse than and is not as accurate as clinical Hertel exophthalmometry. This trail is registered with NCT01999790.

Orbital fat expansion in thyroid eye disease is related to age.

To objectively measure the differential expansion of orbital fat and muscle volume in patients with thyroid eye disease. In this retrospective study, eligible participants were adults with clinical evidence of thyroid eye disease and high-resolution computed tomography scans of their orbits. Patients with a history of decompression surgery and/or medical or other conditions that could alter the orbital anatomy were excluded. Three dimensional reconstructions of the orbits allowed the calculation of the fat volume, muscle volume and bony orbital volume using the MIMICS imaging analysis tool. Both orbits from each patient were included without bias through the use of the generalized estimating equation. The primary outcome was the measurement of fat volume. Secondary outcome measures included the correlation of the muscle volume, bony orbital volume and exophthalmometry with age. Fifty patients with thyroid eye disease who were included contributed 100 orbits. The sample included 29 females (age 57, standard deviation = 14.8) and 21 males (age 52, standard deviation = 18.14). Mean (standard deviation) exophthalmometry measurement was 21.58 (4.01). Fat volume and exophthalmometry were negatively correlated with age (p = 0.00001 and p = 0.00001, respectively). Muscle volume (p = 0.985) and bony orbital volume (p = 0.484) did not correlate with age. Older patients with thyroid eye disease have less expansion of fat volume compared with younger patients. There are no associations between age and the bony orbital volume or muscle volume. These results support the growing body of evidence which suggests that the pathophysiology of TED is different in older patient.

Orbital fat volume in the inferolateral quadrant in Japanese: a guide for orbital fat decompression without injury to the oculomotor nerve.

The inferior oblique muscle branch of the oculomotor nerve is susceptible to injury during orbital fat removal from the inferolateral quadrant of the orbit. Understanding the amount of removable orbital fat volume in this quadrant may be helpful in achieving maximum fat decompression without causing nerve injury. The aim of this study was to calculate the orbital fat volume in the inferolateral quadrant using computed tomographic (CT) images. In this retrospective, observational study, contiguous 1-mm coronal CT images were obtained from 53 sides (30 patients). The cross-sectional areas of the orbital fat in the inferolateral quadrant were measured from the level just behind the inferior oblique muscle to the orbital apex. The cross-sectional areas reached the inferior oblique muscle branch medially, the lateral orbital wall laterally, the inferior edge of the lateral rectus muscle superiorly, and the orbital floor inferiorly. An integrated value between the cross-sectional areas and the CT slice thickness was calculated. The mean orbital fat volume in the inferolateral quadrant was 3.9±1.4mL (range: 1.3-7.0mL). Multiple regression analysis demonstrated a significant relationship between orbital fat volume and Hertel exophthalmometry measurement (adjusted r 2=0.101; P=0.012), although the thickness of the lateral and inferior recti muscles was deleted from the regression equation by stepwise process. The orbital fat volume in the inferolateral quadrant can serve as a guide for orbital fat removal without causing injury to the inferior oblique muscle nerve branch.

Lower lid retraction in thyroid orbitopathy: lamellar shortening or proptosis?

To investigate any correlation between lower lid retraction and proptosis and also between lower lid retraction and lamellar length, as measured by fornix depth, in patients with thyroid eye disease (TED). One hundred and sixty-six eyes of 83 patients with TED were enrolled. The inferior fornix depth, Hertel exophthalmometry measurement, clinical activity score, and lower lid position were the main outcome variables. The correlation between lower lid position measurement and Hertel measurements and also between the lower lid position measurement and inferior fornix depth were evaluated using ANOVA and Pearson's tests. The mean age of subjects in patients with and without lid retraction was 42.8 ± 1.5 and 47.7 ± 1.6 years, respectively (P = 0.4). The inferior fornix depth in patients with and without lower lid retraction was 11.8 ± 1.5 and 11.8 ± 1.3 mm, respectively (P = 0.960). Pearson's analysis showed a significant correlation between the degree of proptosis and lower lid retraction in TED patients (P = 0.01). However, no significant correlation was found between the level of lower lid retraction and the fornix depth (P = 0.87). The main cause of lower lid retraction in TED is proptosis. The beneficial effect of orbital decompression on improvement of lower lid retraction must be considered during a stepwise surgical approach in TED patients.

Measurement of Fracture Size Using the Picture Archiving Communication System in an Outpatient Clinic for Factors that Influence Postoperative Enophthalmos in Adult Inferior Orbital Wall Fractures

This study aims to determine the relationships between postoperative enophthalmos, preoperative enophthalmos, and fracture sizes in adults with inferior orbital wall fractures. The records of 31 patients who had operations for pure orbital floor blowout fractures from March 2003 to February 2004 were retrospectively reviewed. Using the Picture Archiving Communication System, we measured fracture sizes according to the orbital computed tomography results. We calculated fracture sizes according to the supposition that the fracture was a 2-dimensional figure. Hertel exophthalmometry was performed on preoperative day 1 and 3 months postoperatively. Mean changes of enophthalmos were 2.80 mm (P < 0.05, paired t test). The mean fracture size was 6.11 cm(2) (range, 3.56-11.73 cm(2)). Fracture size was a more accurate predictor of postoperative enophthalmos than the degree of preoperative enophthalmos (Pearson correlation; with preoperative enophthalmos = 0.513, with fracture size = 0.743, P < 0.05). In linear regression analysis, preoperative exophthalmometry measurements contributed approximately 27.1% to postoperative enophthalmos, whereas fracture size contributed approximately 54.3% (P < 0.05). In multiple regression analysis, the equation was Y = 0.313X + 0.464X' - 0.684 (X is the size of fracture; X', preoperative exophthalmometry measurement). The above 2 factors explained 82.3% of the total postoperative enophthalmos variance. Other factors, which contribute approximately 18%, might include time between insult and corrective surgery. In our study, fracture size was a better predictive factor for postoperative enophthalmos than preoperative exophthalmometric measurement. With our method, postoperative enophthalmos can be predicted more conveniently in a clinical setting, and decisions regarding the timing of early surgical reduction were made easier.

Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system.

The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.

Human leukocyte antigens associated with hyperthyroid graves ophthalmopathy in japanese patients

PURPOSE: To evaluate the association of human leukocyte antigen (HLA) types in Japanese patients with Graves ophthalmopathy. METHODS: Japanese patients with severe ophthalmopathy (48 patients) and patients without ophthalmopathy (46 patients) were selected prospectively from 234 consecutive patients with hyperthyroid Graves disease. The criteria for severe ophthalmopathy were proptosis of 19 mm or more, or a 3-mm difference in exophthalmometry measurement between the two eyes, or diplopia at the primary eye position. The criteria for the absence of ophthalmopathy were proptosis of 16 mm or less, no diplopia, no lid retraction, and no thickening of extraocular muscles. Serologic HLA typing of class I and II antigens was performed in the two patient groups. The frequency of each HLA antigen in the two patient groups was compared to that in 767 unrelated normal healthy Japanese controls. RESULTS: The frequencies of HLA-DR14 and DQ1 were significantly higher in the patient group with severe ophthalmopathy (35% and 75%, respectively) than in healthy controls (4% and 43%, respectively; corrected P < .05), and also greater than in the patient group without ophthalmopathy (13% and 55%, respectively; P < .01). On the other hand, the frequencies of HLA-B35, B54, DR4, and DQ4 were significantly higher in the patient group without ophthalmopathy (23%, 23%, 43%, and 30%, respectively) than in the patient group with severe ophthalmopathy (13%, 15%, 25%, and 19%, respectively; P < .01). CONCLUSIONS: HLA-DR14 and DQ1 antigens may be genetic markers of predisposition to the development of severe ophthalmopathy. In addition, HLA-B35, B54, DR4, and DQ4 may be genetic markers of resistance to severe ophthalmopathy. Variation in the severity of ophthalmopathy associated with Graves disease may depend, in part, on the presence or absence of particular HLA antigens.

Orbital Venous Anomalies Demonstrated by Spiral Computed Tomography

To describe the radiographic appearance of acute hemorrhage in orbital venous malformations and how spiral computed tomography (CT) can aid in the diagnosis of these lesions in patients with atypical presentations. Case series from the Eye Plastics and Orbital Service of Massachusetts Eye and Ear Infirmary. PARTICIPANTS/INTERVENTION/MAIN OUTCOME MEASURES: Three patients who initially presented with signs and symptoms of orbital hemorrhage are presented. Their initial clinical and radiologic imaging, follow-up examination, and results of the spiral CT are summarized. The initial CT in each case showed a well-localized homogeneous mass in the posterior/inferior orbit. In the two cases without antecedent trauma, it was difficult to distinguish these localized hemorrhages from possible intraorbital neoplasm. On resolution of the hemorrhage, these three patients had different presentations. The first patient had intermittent proptosis that was documented by increase in exophthalmometry measurement before and after Valsalva maneuver (symptomatic and with clinical signs). The second patient had a subjective orbital pressure sensation, but no visible change by examination (symptomatic but without clinical signs). The third patient was not symptomatic and had no significant clinical findings (asymptomatic and without clinical signs). Spiral CT showed the presence of an enlarging inferior orbital mass during Valsalva maneuver, which was not apparent pre-Valsalva in all these patients. Localized hemorrhages easily may be mistaken for solid intraorbital masses: therefore, accurate determination can avoid unnecessary surgical intervention. Patients with orbital venous malformation may or may not have symptoms and clinical signs of intermittent proptosis. After the resolution of the initial hemorrhage, spiral CT during Valsalva maneuver using a single breath hold technique is useful in showing the presence of this venous anomaly when suspicious of this entity, even in patients who are asymptomatic.

Epidemiological data of 100 recent myasthenic patients

PURPOSE: To evaluate the association of human leukocyte antigen (HLA) types in Japanese patients with Graves ophthalmopathy.METHODS: Japanese patients with severe ophthalmopathy (48 patients) and patients without ophthalmopathy (46 patients) were selected prospectively from 234 consecutive patients with hyperthyroid Graves disease. The criteria for severe ophthalmopathy were proptosis of 19 mm or more, or a 3-mm difference in exophthalmometry measurement between the two eyes, or diplopia at the primary eye position. The criteria for the absence of ophthalmopathy were proptosis of 16 mm or less, no diplopia, no lid retraction, and no thickening of extraocular muscles. Serologic HLA typing of class I and II antigens was performed in the two patient groups. The frequency of each HLA antigen in the two patient groups was compared to that in 767 unrelated normal healthy Japanese controls.RESULTS: The frequencies of HLA-DR14 and DQ1 were significantly higher in the patient group with severe ophthalmopathy (35% and 75%, respectively) than in healthy controls (4% and 43%, respectively; corrected P < .05), and also greater than in the patient group without ophthalmopathy (13% and 55%, respectively; P < .01). On the other hand, the frequencies of HLA-B35, B54, DR4, and DQ4 were significantly higher in the patient group without ophthalmopathy (23%, 23%, 43%, and 30%, respectively) than in the patient group with severe ophthalmopathy (13%, 15%, 25%, and 19%, respectively; P < .01).CONCLUSIONS: HLA-DR14 and DQ1 antigens may be genetic markers of predisposition to the development of severe ophthalmopathy. In addition, HLA-B35, B54, DR4, and DQ4 may be genetic markers of resistance to severe ophthalmopathy. Variation in the severity of ophthalmopathy associated with Graves disease may depend, in part, on the presence or absence of particular HLA antigens.