Objective: To describe a rare cause of acute isolated sphenoid sinusitis in an adult, immunocompetent, female, complicated by meningitis due to a clival abscess and subsequent development of orbital apex syndrome, originating from an infected pneumatized anterior clinoid process (ACP) Methods: We present a case report of a 61-year-old, healthy, female, who presented with a one-week history of fever, upper respiratory tract infection symptoms, and severe headache. Initial computed tomography (CT) of the head revealed isolated sphenoid sinusitis with posterior wall dehiscence communicating with the prepontine subarachnoid space. She underwent an endoscopic transseptal repair of the clival defect with a nasoseptal flap, followed by a three-week intravenous antibiotic regimen. Apart from consistent headaches, her postoperative course was unremarkable. Four months later, she presented with orbital apex syndrome. Magnetic resonance imaging (MRI) revealed mucosal disease in a pneumatized ACP. She underwent a second surgical intervention including a left-sided sphenoidectomy, orbital and optic canal decompression. Results: Initial surgical management successfully addressed the intracranial infection. However, persistent headaches and delayed onset of orbital apex syndrome occurred despite unremarkable interim imaging and endoscopy. A gadolinium-enhanced MRI ultimately identified inflammation within the pneumatized ACP, when the patient presented with orbital apex syndrome. Intraoperative cultures during the second surgery grew Pseudomonas, for which she underwent prolonged intravenous antibiotic therapy. There has been marked improvement in her symptoms, with a remaining mild sixth cranial nerve palsy and postnasal drip at her most recent follow-up. Conclusion: Isolated sphenoid sinusitis, especially involving a pneumatized ACP, can present insidiously and lead to serious intracranial and orbital complications despite early intervention. High clinical suspicion and early use of MRI are essential in patients with persistent symptoms and subtle imaging findings. Multidisciplinary management and long-term follow-up are crucial for optimal outcomes.

We report a case of a phenotypic shift of thyroid eye disease following treatment with teprotumumab. A 35-year-old female nonsmoker with Graves disease developed mild type I thyroid eye disease featuring unilateral lid retraction and was treated with teprotumumab. Following completion of treatment, a reactivation was associated with progression to severe type II phenotype, with marked extraocular muscle enlargement, bilateral proptosis, and nonsteroid-responsive compressive optic neuropathy requiring orbital decompression. This case raises important questions regarding the potential influence of Insulin-like growth factor 1 (IGF-1) suppression on the phenotype of thyroid eye disease.

Comparison of transconjunctival and transnasal approaches for orbital decompression: a randomized controlled trial.

BackgroundThis study aimed to describe and compare eyelid contours before and after orbital fat decompression in patients with Graves’ ophthalmopathy (GO) by measuring their midpupil lid distances (MPLDs).MethodsA retrospective comparative study of patients with GO who underwent orbital fat decompression was performed. Standard digital images of primary gaze were analyzed using a self-designed software. Radial MPLDs of the upper and lower eyelids were measured from 0° (nasal) to 180° (temporal) with 15° spacing. Pre- and postoperative MPLDs were compared and the relationship between MPLD changes and Hertel exophthalmometric value changes were analyzed. Eyelid contour symmetries were assessed using the nasal-to-temporal MPLD ratios.ResultsA total of 31 eyes from 17 patients and 25 eyes from 17 normal participants (control) were included. The mean postoperative Hertel value change was 3.8 ± 1.1 mm. After orbital fat decompression, MPLDs in the lower eyelids decreased, more significantly on the nasal sectors (nasal 30°, 45°, 60°, 75°, and 90°, p = 0.030, 0.024, 0.036, 0.040, and 0.042, respectively). Conversely, MPLDs slightly increased in the upper eyelids but was not statistically significant. Changes in MPLDs did not correlate with the extent of proptosis reduction.ConclusionsOrbital fat decompression effectively improves lower eyelid retraction in patients with GO, especially on the nasal sectors. This effect is independent from the amount of proptosis reduction. Upper eyelid contour remains unchanged after the surgery.

This study was conducted to develop a technique for endoscopic assistance during deep lateral orbital bone decompression. The study included 349 patients (603 orbits) with thyroid-associated ophthalmopathy (225 women and 124 men, mean age 42.6±11.3 years) who underwent endoscopic-assisted deep lateral wall decompression (DLWD) at the M.M. Krasnov Research Institute of Eye Diseases. Near-maximum depth of osteodestruction in the deep portion of the lateral wall (LW) of the orbit in the projection of the lateral rectus muscle was achieved in 256 patients (442 orbits). In 290 of these orbits, slight prominence of semi-transparent thinned cortical plates under the influence of the underlying dura mater (DM) was observed. In 19 cases, reaching the cortical layer of the greater wing of the sphenoid bone adjacent to the DM was indicated by the appearance of thin cortical fragments in the projection of the middle cranial fossa oriented at an acute angle to the bone defect; in 5 of these cases, cortical fragments occupied almost the entire orbital surface of the sphenoid trigone (ST). Additionally, exposure of the DM occurred in 49 cases during deep DLWD. One of the anatomical variants of the orbital vascular system found in 75 orbits was a vascular branch within the ST, which topographically corresponded to the course of the anastomosis between a. meningea media and a. lacrimalis. The obtained results indicate the high importance of endoscopic assistance during critical stages of DLWD, particularly in hard-to-reach areas of the LW, which helps minimize the incidence of intraoperative complications.

Background:This study sought to assess the safety, efficacy, and cosmetic outcomes of aesthetic deep orbital fat decompression for nonthyroidal proptosis.Methods:A retrospective review was conducted on 23 patients who underwent bilateral aesthetic deep orbital fat decompression at the Oculofacial Clinic Tokyo between 2022 and 2024. Preoperative and postoperative assessments included Hertel measurements, interpupillary distance, intraocular pressure, best corrected visual acuity, and fusion image area. Procedures were performed by senior attending surgeons, with outpatient follow-up conducted by attending physicians and clinical fellows.Results:The mean volume of resected fat was 3.0 ± 1.0 mL. Hertel measurements significantly decreased from 19.0 ± 2.7 to 16.7 ± 2.8 mm (P < 0.001), interpupillary distance narrowed from 66.2 ± 3.5 to 63.9 ± 3.1 mm (P < 0.001), and intraocular pressure reduced from 16.2 ± 2.9 to 14.0 ± 2.4 mm Hg (P < 0.001). Best corrected visual acuity and fusion image area remained stable. No permanent visual loss or diplopia was observed during the follow-up period. Minor complications, including transient diplopia and mild ocular discomfort, resolved spontaneously without the need for intervention.Conclusions:Aesthetic deep orbital fat decompression appeared to be a safe and effective procedure for congenital proptosis, achieving significant cosmetic and functional improvements. However, future prospective investigations are warranted to establish its long-term safety and efficacy.

Disclosure: Z. Roe-Zurz: None. L. Madrigal: None.Graves’ ophthalmopathy (GO) is a serious complication of autoimmune hyperthyroidism, affecting approximately 30% of patients. It is characterized by immune-mediated inflammation of retro-orbital tissues, which can lead to sight-threatening complications. Recent evidence suggests that obesity and related metabolic factors—including hyperinsulinemia, insulin resistance (HOMA-IR), and elevated high-sensitivity C-reactive protein (hs-CRP)—are associated with both the presence and severity of GO. Here, we present a case of chronic GO that significantly improved following BMI reduction after sleeve gastrectomy. A 49-year-old woman with class III obesity and a complex thyroid disease history—including Graves’ ophthalmopathy (GO) previously managed with orbital decompression and lid surgery in 2012, as well as papillary thyroid carcinoma status post-thyroidectomy with post-ablative hypothyroidism—presented in the Fall of 2023 with progressive frontal headaches, orbital pain, and upward gaze diplopia. Examination revealed proptosis, lateral lid fullness, and 1+ scleral show. Hertel ophthalmometry, which measures the distance between the corneal apex and lateral orbital rim, showed slight, but objective, progression to 25/25 mm at a 105 mm base. Orbital CT demonstrated asymmetric enlargement of the medial and inferior rectus muscles with bilateral proptosis. Her TSH and free T4 were within normal limits, and thyroglobulin antibodies were undetectable.Despite multiple obesity therapies, including daily liraglutide, her ocular symptoms worsened over several months. She was referred for bariatric surgery, and following a postoperative BMI reduction from 35 to 30, her ocular symptoms rapidly improved. Hertel measurements returned to baseline at 23/23 mm and later improved further to 17/17 mm at a 105 mm base.Understanding how obesity and its associated factors—particularly its pro-inflammatory state—influence the pathophysiology and progression of GO may help define metabolic and weight-loss management for Graves’ disease and other autoimmune disorders. While we hypothesize that a reduction in systemic inflammation, rather than direct orbital fat loss, contributed to our patient’s improvement in her thyroid orbitopathy, this case presents an intriguing possibility that warrants further investigation.Presentation: Monday, July 14, 2025

This study assesses intersurgeon variability in proptosis reduction after orbital decompression for thyroid eye disease. This multicenter retrospective study included patients with thyroid eye disease who underwent orbital decompression from 1 of 7 surgeons at 7 different institutions between January 2002 and December 2018. Data were included if a single decompression technique was performed on ≥10 patients by ≥2 surgeons. The primary outcome was postoperative change in proptosis with emphasis on comparison among surgeons utilizing similar surgical techniques. Statistical analysis was performed with χ2 and ANOVA testing, and a multivariable logistic regression model was generated. Six hundred thirty-three orbits that underwent orbital decompression were included. Five different decompression techniques were analyzed: medial wall (n = 29), fat + lateral wall (n = 113), medial wall + floor (n = 123), fat + lateral wall + medial wall (n = 140), and fat + lateral wall + medial wall + floor (n = 228), without significant difference in proptosis reduction among surgeons. Surgeons did not demonstrate significant differences in outcomes at different time points compared with each other or themselves. Outcomes when comparing endoscopic versus open medial wall decompression varied among surgery types. Multivariate modeling revealed a statistically significant association between postoperative change in proptosis with preoperative proptosis (p < 0.001). Postoperative change in proptosis did not differ significantly between surgeons utilizing similar orbital decompression techniques for patients with thyroid eye disease. This study may strengthen the statistical validity of multicenter clinical trials assessing orbital decompression outcomes performed by surgeons employing uniform surgical techniques, thereby advancing our understanding of optimal surgical management strategies for thyroid eye disease.

Alemtuzumab is a monoclonal antibody that targets CD52 and is commonly used to treat multiple sclerosis. Thyroid dysfunction occurs in 20% to 30% of patients treated with alemtuzumab. This may lead to thyroid-associated orbitopathy (TAO), which can cause debilitating dry eye, diplopia, proptosis, ocular pain, and vision loss. This meta-analysis aims to quantify the incidence of alemtuzumab-induced TAO (AI-TAO) and to characterize its clinical features. Studies were extracted from Cochrane, Embase (Ovid), Medline (Ovid), and additional gray literature. Using R version 4.4.1 on RStudio, the meta-analysis was conducted using the meta package. Depending on the level of heterogeneity, either a fixed-effects or random-effects model was used to pool the data. Funnel plots were used to assess publication bias. Meta-analysis of 1545 patients across 12 studies revealed that the incidence of alemtuzumab-induced Graves' disease was 25% (95% confidence interval [CI]: 11-46%) and AI-TAO was 6% (95% CI: 3-10%). Of the patients with established alemtuzumab-induced Graves' disease, 20% (95% CI: 12-30%) developed TAO. Pooled analysis of 8 studies (n = 556), revealed that the mean onset of AI-TAO was 37.38 months (95% CI: 28.90-46.76). In summary, 51/65 (78.5%) of TAO patients were managed conservatively, and 22/65 (33.9%) were managed surgically. Orbital decompression was required in only 5/65 (7.7%) patients. The incidence of AI-TAO is 6% which is less common than the estimated incidence of 20% to 30% of alemtuzumab-induced thyroid dysfunction. This finding emphasizes the need for patient counseling, baseline ophthalmic examination, and interdisciplinary follow-up for early detection and management of AI-TAO.

Thyroid Eye Disease: Management, Advances, and Future Opportunities.

Thyroid eye disease (TED), the leading adult orbital disease, is an autoimmune disorder characterized by fibrosis. Effective anti-fibrotic treatments are scarce, except for orbital decompression surgery involving orbital adipose tissue (OAT) removal, due to high rates of drug resistance following hyperthyroidism treatment and the lack of suitable mouse models. Understanding the mechanisms behind fibrotic remodeling of OAT could aid mouse model development and identify novel therapies. In the present study, stromal vascular fraction cells of OAT from patients with inactive-stage TED, characterized by pronounced fibrosis, are analyzed at single-cell resolution. platelet-derived growth factor receptor (PDGFR)α+dipeptidyl peptidase (DPP)4+ fibroblasts exhibiting progenitor characteristics and fibrotic potential at the transcriptional level are identified. PDGFRα+DPP4+ fibroblasts showed the strongest interactions with macrophages, particularly M2 macrophages, which are enriched and topographically localized within the fibrotic area. Moreover, M2 macrophages promoted extracellular matrix production in PDGFRα+DPP4+ cells via the Growth arrest specific (GAS)6-AXL Receptor Tyrosine Kinase (AXL) signaling pathway. Using a specific AXL inhibitor or AXL knockdown, fibrosis is substantially reduced in PDGFRα+DPP4+ fibroblasts in vitro, and in patient cell-derived orthotopic xenograft models established via GAS6. By identifying pro-fibrotic intercellular networks in OAT, these findings establish a rapid and repeatable mouse model of TED fibrosis and propose the GAS6-AXL axis as a potential therapeutic target for TED.

Thyroid eye disease (TED) during pregnancy is a rare but potentially sight-threatening complication of Graves' disease (GD), which may be worsened by pregnancy. Severe TED may require urgent intervention, including surgical orbital decompression to prevent irreversible vision loss. We report a case of a woman in her 30s with severe TED secondary to GD, first presenting with GD at 20 weeks of gestation and then undergoing preterm elective delivery at 35+2 weeks to enable prompt surgical decompression. This case presents the unique challenges of managing severe sight-threatening TED during pregnancy and the multidisciplinary approach needed to carefully balance risks and optimise maternal and fetal outcomes.

This study presents a comparative analysis of outcomes of lateral orbital wall decompression performed using ultrasonic bone removal with standard and modified techniques. The study included 78 patients (109 orbits) with exophthalmos without visual impairment (subgroups 1A and 1B) and with optic neuropathy (ON) due to thyroid eye disease (TED) (subgroups 2A and 2B). Lateral wall decompression (LWD) was performed using ultrasonic bone removal with a modified (n=58, patient subgroups 1A and 2A) or standard (n=51, subgroups 1B and 2B) technique. Postoperative evaluation included visual function, degree of exophthalmos, and palpebral fissure parameters. In subgroup 1A, exophthalmos regression averaged 3.8±0.9 mm, while in subgroup 1B it amounted to 2.9±0.8 mm. Comparable improvement in visual acuity was observed in subgroups 2A and 2B, with a median gain of 0.4, along with positive changes in perimetry and color vision. The modified LWD technique using ultrasonic bone removal achieved a mean exophthalmos reduction of approximately 4 mm. In cases complicated by ON, improvement in visual function was observed for up to 4 years.

A prospective study evaluating the necessity of compression eye patches in orbital surgery based on bilateral simultaneous orbital decompression surgery.

Background: Dysthyroid optic neuropathy (DON) is a rare but serious complication of Graves' orbitopathy (GO) that can lead to permanent vision loss. In a previous study, medical and surgical treatment of DON according to EUGOGO guidelines resulted in partial or no recovery in 30% of patients. Insulin growth factor-1 receptor inhibitor teprotumumab has shown significant improvement of GO symptoms, but little is known about its effect on DON. The aim of this study was to evaluate the efficacy of teprotumumab in treating steroid- and surgery-resistant DON. Methods: This retrospective case series included 6 patients (8 eyes; median age 58 years) with confirmed DON resistant to steroids and orbital decompression (median duration of DON 2 months, interquartile range [IQR 2.0-6.5]) treated at the Hospices Civils de Lyon. Median time from the end of first-line treatment was 34.5 days (IQR: 8.0-61.7). The treatment protocol was 8 intravenous infusions of teprotumumab administered every 3 weeks. Definition of DON recovery was based on changes in best-corrected visual acuity (BCVA) and visual field mean deviation (VF-MD). Results: At the end of teprotumumab treatment, DON recovered in 7/8 (87.5%) of affected eyes, with BCVA improvement in all patients (median 0.30 logMAR [0.24-0.42], p = 0.004) and a median VF-MD improvement of 66% (46-90) (p = 0.024). In 3/6 patients, DON improved after one infusion. All patients showed improvements in clinical activity score and proptosis. Improvements persisted over the follow-up (median from first infusion, 73.8 weeks), with no DON relapse but inflammatory relapse in two patients. Due to adverse events, two patients did not complete all infusions. Conclusions: The data suggest teprotumumab as a promising treatment for steroid- and surgery-resistant DON with rapid symptom improvement and long-lasting recovery. However, these only preliminary results need to be better evaluated by specific clinical trials.

Ethmoidal foramina are located in the medial wall of the orbit along frontoethmoidal suture. These foramina transmitting ethmoidal neurovascular bundles vary in number and topography in various ethnic groups. The precise location and number of these foramina are important while dealing with various surgeries involving medial orbital wall. Aim of study is to highlight the incidence, number, topography of ethmoidal foramen and correlate with clinical implications. The study was conducted in the Department of Anatomy using 105 right-sided and 105 left-sided orbits. The number of foramina were counted by visual inspection, and distance between these foramina along with distances of these foramina from optic canal were measured, and statistical analysis was carried out using Microsoft Excel 2019. The ethmoidal foramina with range of 0 to 5 were observed. The ethmoidal foramina were absent in 10% of orbits with 12.5% on right-sided orbits and 7.6% on left-sided orbits. Maximum number of 5 ethmoidal foramina were detected in 2.4%, 4 ethmoidal foramina in 6.7%, 3 ethmoidal foramina in 20.95%, 2 ethmoidal foramina in 54.3% and single ethmoidal foramina in 5.7% of orbits. The mean distances between anterior-middle, middle-posterior, anterior-posterior EF and posterior ethmoidal foramina-optic canal were 5.8 ± 0.8mm, 5.2 ± 0.9mm, 10.5 ± 0.9mm and 5.1 ± 0.8mm, respectively. The number and precise location of ethmoidal foramina are essential during various interventions involving orbit such as medial orbital wall fractures, the orbital decompression, to prevent complications.

Thyroid eye disease (TED) is the most common extrathyroidal manifestation of Graves' disease (GD), driven by stimulatory thyrotropin receptor autoantibodies (TRAbs). Intravenous glucocorticoid pulse therapy (ivGC) is the first-line treatment for active moderate-to-severe TED. This retrospective cohort study aimed to identify predictive factors associated with treatment response in TED patients receiving ivGC therapy. We analyzed data from 146 TED patients treated with ivGC at our endocrine outpatient center between 2014 and 2021. The median treatment duration was 11 weeks (IQR: 1), with a median cumulative dose of 4.25g (IQR: 0.25). The primary outcome was defined as the absence of the need for additional orbital decompression or strabismus surgery. Secondary outcomes included changes in ophthalmological and thyroid-related parameters. Predictive factors were identified using binary logistic regression. The primary outcome was achieved in 20.54% of the patients. Predictors of surgery following ivGC treatment included current smoking (OR = 4.854, 95% CI: 1.522-15.482), age (OR = 1.051, 95% CI: 1.002-1.101), baseline diplopia (OR = 4.987, 95% CI: 1.218-20.417), and impaired visual acuity (OR = 0.274, 95% CI: 0.078-0.965). IvGC treatment improved diplopia (risk ratio = 0.87), and clinical activity score (Cohen's d = 1.30), with a trend toward reduced TRAb levels (Cohen's d = 0.71). Smoking, diplopia, and age were unfavorable for avoiding surgery, while impaired visual acuity was favorable. IvGC was associated with significant ophthalmological improvements. These findings support more personalized approaches to TED treatment.

Innovations in artificial intelligence (AI) have paved the way for automated analysis and detection of various anterior and posterior segment diseases in ophthalmology. The goal of this study is to review the literature surrounding the utilization of AI for oculoplastic diseases or conditions. A literature search was conducted on Pubmed and Embase using a combination of terms including AI and oculoplastics, blepharoptosis, eyelid ptosis, brow lift, blepharoplasty, eyelid aesthetics, entropion, eyelid reconstruction, eyelid malposition, periocular cancer, periorbital melanoma, eyelid tumor, eyelid cancer, mohs reconstruction, orbital inflammation, orbital decompression, thyroid eye disease, thyroid ophthalmopathy, giant cell arteritis, lacrimal gland or lacrimal duct, dacryoadenitis, orbital fracture, orbital infections. AI large language models were excluded. This review included 19 studies on eyelid and brow ptosis, 16 on periocular and intraocular cancer, 9 on orbital trauma and tumors, 17 on autoimmune, infectious, and inflammatory conditions of the orbit and malformations, and 30 on thyroid eye disease, with focus on clinical diagnosis, severity, and prediction of therapeutic outcomes. Oculoplastics has seen an expansion of potential uses for AI, focusing on diagnosis of ptosis and brow ptosis, detection of eyelid cancer from pathology slides and clinical photographs, detection and diagnosis of orbital tumors and orbital processes, evaluation of radiographic images, and detection and monitoring of thyroid eye disease. Across applications, results may be promising, however, there are significant challenges such as data privacy, ethical considerations, acquisition and analysis of nonstandardized imaging data, and the need for continuous validation of AI algorithms in real-world clinical settings.

A 55-year-old woman with uncontrolled diabetes presented with acute right eyelid swelling, mucoid nasal discharge for 20 days, and headache for 7 days. Examination showed lid edema and ethmoidal sinus tenderness, with normal visual acuity and extraocular movements (EOM). Computed Tomography (CT) confirmed preseptal cellulitis with ethmoidal sinusitis. Initial treatment was with IV meropenem and vancomycin. Worsening on the second day led to emergency functional endoscopic sinus surgery and orbital decompression. Cultures revealed Staphylococcus pseudintermedius, a zoonotic pathogen linked to pets. The patient had history of pet exposure. Antibiotic therapy was continued, and 2 ml of pus was drained on anterior orbitotomy. The patient recovered with improved EOM and reduced edema. This case highlights a rare zoonotic infection presenting as an orbital abscess.

BackgroundPatients with thyroid eye disease may develop dysthyroid optic neuropathy (DON), which is commonly treated via orbital decompression surgery. This study aims to identify preoperative factors that can predict postoperative best corrected visual acuity (BCVA) in patients with DON and to classify recovery rates based on these prognostic factors.MethodsWe retrospectively assessed thirty-two patients (51 orbits) diagnosed with DON who underwent orbital decompression.ResultsUnivariate and multivariate mixed effects analysis revealed that preoperative BCVA was the strongest predictor of postoperative BCVA (p < 0.0001). Other significant prognostic factors were extraocular muscle hypertrophy (p = 0.01), visual field mean deviation (p = 0.009), retinal nerve fiber layer thickness (p = 0.01), and afferent pupillary defect (p < 0.0001). We then stratified outcomes by the strongest prognostic factor, preoperative BCVA, which demonstrated that 17 of 19 (89.5%) orbits with preoperative BCVA < logMAR 0.20 (20/32 Snellen) achieved acceptable final vision (defined as better than logMAR 0.40 or 20/50 Snellen), compared to 16 of 20 (80%) orbits with preoperative BCVA logMAR 0.20–0.60 (20/32–20/80 Snellen), and only 3 of 11 (27.3%) orbits with preoperative BCVA > logMAR 0.60 (20/80 Snellen). Patients with preoperative BCVA of logMAR 0.60 (20/80 Snellen) or better had > 80% chance of recovering with acceptable final vision after surgery, compared to a < 30% chance for patients with preoperative BCVA worse than logMAR 0.60 (20/80 Snellen).ConclusionsThese results highlight preoperative BCVA as the strongest predictor of DON outcome and suggest that earlier intervention prior to substantial BCVA deterioration may yield better results.Level of evidence: 3Retrospectively Registered.