Exophthalmos Reduction Research Articles

Quality of life in patients with Graves' orbitopathy submitted to orbital decompression: comparison between balanced and inferomedial techniques.

To compare inferomedial wall orbital decompression to balanced medial plus lateral wall orbital decompression in patients with Graves' orbitopathy in the inactive phase with regard to exophthalmos reduction and the effects on quality of life. Forty-two patients with inactive Graves' orbitopathy were randomly divided into two groups and submitted to one of two orbital decompression techniques: inferomedial wall orbital decompression or medial plus lateral wall orbital decompression. Preoperative and postoperative assessments included Hertel's exophthalmometry and a validated Graves' orbitopathy quality of life questionnaire. The results of the two groups were compared. Compared to preoperative measurement, exophthalmos reduction was statistically significant in both groups (p<0.001) but more so in patients undergoing medial plus lateral wall orbital decompression (p=0.010). Neither orbital decompression techniques increased the visual functioning subscale score on the Graves' orbitopathy quality of life questionnaire (inferomedial wall orbital decompression p=0.362 and medial plus lateral wall orbital decompression p=0.727), but a statistically significant difference was observed in the score of the appearance subscale in patients submitted to medial plus lateral wall orbital decompression (p=0.006). Inferomedial wall orbital decompression is a good alternative for patients who do not require large exophthalmos reduction. However, medial plus lateral wall orbital decompression offers greater exophthalmos reduction and greater improvement in appearance (higher Graves' orbitopathy quality of life questionnaire scores), making it a suitable option for esthetic-functional rehabilitation.

Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future?

Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.

Surgical management of dysthyroid optic neuropathy: A systematic review

ObjectiveThere is currently no recommendation on the optimal surgical management for dysthyroid optic neuropathy (DON). The aim of this study is to systematically review the surgical management of DON and its outcome on visual acuity (VA). Data sourcesMEDLINE, Cochrane Library, and clinicaltrials.gov Review MethodsA systematic review of studies about the surgical management of DON was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles were included if preoperative and postoperative VA in logMAR (Logarithm of the Minimum Angle of Resolution) were available. ResultsFifteen articles were included in the study accounting for 669 orbits. The mean VA improvement was of 0.44 logMAR overall, 0.41 logMAR for 1-wall, 0.41 logMAR for 2-wall, and 0.55 logMAR for 3-wall decompressions. The mean reduction in exophthalmos was 4.9 mm overall, 4.3 mm for 1-wall, 4.54 mm for 2-wall, and 6.02 for 3-wall decompressions. The mean new onset diplopia (NOD) rate was 19.84% overall, 19,12% for 1-wall, 20.75% for 2-wall, and 19.83% for 3-wall decompressions. ConclusionThe results are limited due to the high number of biases in the included studies. It seems that 3-wall decompression offers the best VA improvement and proptosis reduction although also the highest NOD and complications rate. Two-wall balanced decompression or 1-wall inferomedial decompression seems to be effective with less morbidity.

Associations between Orbital Morphology and Exophthalmos Changes after Endoscopic Orbital Decompression to Treat Thyroid-related Orbitopathy

Purpose: To investigate orbital morphology parameters associated with exophthalmos changes in patients undergoing endoscopic orbital decompression to treat thyroid-related orbitopathy.Methods: In total, 33 eyes of 18 patients with thyroid-related orbitopathy who underwent endoscopic orbital decompression were included in this retrospective study. Data were collected before and 6 months after surgery. We performed Hertel exophthalmometry and derived orbital morphology parameters from two-dimensional facial computed tomography records. Parameters associated with exophthalmos reduction on univariate linear regression analysis were subjected to multivariate linear regression analyses.Results: Univariate linear regression showed that the preoperative length of the medial orbital wall (β = 0.179, &lt;i&gt;p&lt;/i&gt; = 0.032) and the postoperative distance from the cone apex to the medial wall defect (β = -0.139, &lt;i&gt;p&lt;/i&gt; = 0.006) were associated with exophthalmos reduction after endoscopic orbital decompression surgery. Multivariate linear regression of these two parameters showed that the distance from the apex to the medial wall defect was associated with exophthalmos reduction (β = -0.118, &lt;i&gt;p&lt;/i&gt; = 0.019).Conclusions: The postoperative distance from the cone apex to the medial wall defect was associated with exophthalmos reduction. In patients with thyroid-related orbitopathy, this association should be considered when planning endoscopic orbital decompression.

Transnasal Endoscopic Orbital Decompression Combined with an Enhanced Recovery after Surgery Protocol in Graves Ophthalmopathy.

Objective Although enhanced recovery after surgery (ERAS) was shown to improve patients' recovery after surgery and transnasal endoscopic orbital decompression has been associated with lesser risks of postoperative complications compared to other surgical techniques in treating Graves ophthalmopathy (GO), there are currently no clinical studies on the application of ERAS in transnasal endoscopic orbital decompression. This study aimed to investigate the potential effects of combining transnasal endoscopic orbital decompression with ERAS in the treatment of GO. Methods A retrospective analysis was performed for 5 GO patients (10 eyes) treated with transnasal endoscopic orbital decompression from January 2021 to December 2021 at the Third Affiliated Hospital of Sun Yat-Sen University. All patients underwent ERAS, and the effects of ERAS on the postoperative complications and recovery of patients were evaluated. Results Ophthalmological examination showed that GO patients had good correction of exophthalmos after surgery combined with ERAS. Specifically, the exophthalmos reduction in subjects was 0.9–2.1 mm, with a mean reduction of 1.23 mm. In addition, a visual acuity improvement of 0.15–0.4, with an average improvement of 0.23, was also observed. Further, the Scale of Quality of Life for Diseases with Visual Impairment (SQOL-DVI) showed that, compared with before surgery, the patients' QOL was significantly improved 2 weeks after surgery. Before surgery, there were 2 patients with diplopia and blurred vision, and after postoperative adaptive exercise, the symptoms of these 2 patients disappeared after 6 months of follow-up. As for the other 3 patients, they had no diplopia or blurred vision after surgery. Conclusion This observational study found that transnasal endoscopic orbital decompression might be effective in treating GO, and ERAS might be considered an important adjunct to improving perioperative care and postoperative recovery.

РЕЗУЛЬТАТЫ КОМПЛЕКСНОГО КОНСЕРВАТИВНОГО ЛЕЧЕНИЯ ПАЦИЕНТОВ С ЭНДОКРИННОЙ ОФТАЛЬМОПАТИЕЙ СРЕДНЕЙ СТЕПЕНИ ТЯЖЕСТИ

Background. Pathogenetic therapy of the moderate severity endocrine ophthalmopathy (EOP) is performed by the administration of glucocorticoids (GC), which possess immunosuppressive, anti-inflammatory and anti-edematous effects. Currently, the application of selenium and pentoxifylline medications, as well as treatment with magnetic field over periorbital region are considered as a part of combined therapy for the disease. Purpose of the study. To evaluate the results of combined conservative treatment of patients with moderate severity EOP. Material and methods. The study included 25 patients (50 orbits) with the clinical signs of moderate severity EOP. Depending on the treatment regimen, patients were divided into group A (comparison) and group B (main). Group A (comparison) – 10 patients who received pulse therapy with methylprednisolone. Group B (main) – 15 patients who were prescribed a combination of pulse therapy with methylprednisalone and a new developed treatment regimen additionally: selenium 100 mgq 2 times a day for 6 months, pentoxifylline at a dose of 600 mg 2 times a day for 6 months, a low-frequency pulsed magnetic field generated by the "UniSPOK" apparatus, lasting for 10-20 minutes, up to 8-12 procedures performed daily. Methylprednisolone application in the form of intravenous pulse therapy was prescribed collegially by an endocrinologist and an ophthalmologist individually for each patient and in total did not exceed 4.5 g recommended for the present process intensity (on average, 4.5±0.5 g in both groups). Results. The sequence in decreasing of EOP clinical signs in patients receiving combination therapy was revealed: a decrease in tremor, eyelid edema and palpebral fissure width in comparison with the initial parameters were noted already by the 3rd month of treatment, after 6 months these indicators disappeared. Lacrimation in the studied groups was not recorded by the 6th month, which can be explained by the corticosteroids application. A significant reduction in exophthalmos under developed therapy was found after 6 months, while no reduction was observed in the standard treatment group. Conclusions. The method of EOP complex treatment, including pulse therapy with methylprednisolone in combination with selenium, pentoxifylline and magnetotherapy, was effective in the moderate severity of the disease and led to the reduction of the ophthalmopathy severity symptoms. The positive effect of the combined therapy indicates the necessity for a six-month treatment course.

Effect of orbital wall resection areas in the treatment of patients with endocrine orbitopathy

In patients treated by orbital wall decompression for endocrine orbitopathy (EO) there is limited evidence on the effect of orbital wall resections. Thus, the aim of this study was to evaluate the effect of one, two, and three-wall resections on orbital parameters to determine if any such correlations exist. Preoperative and postoperative data from all patients at a tertiary care centre who underwent decompression surgery from 2010 - 2020 were digitally analysed. The effect of the number and area of resected walls on orbital area, orbital volume, and Hertel value, and the effect of lateral rim advancement (LARA) were determined. A total of 131 orbital areas showed an increase from a mean (SD) preoperative area of 42.0 (4.6) cm2 to 47.3 (6.1) cm2 postoperatively (p<0.001). In total, the mean (SD) area of osseous wall removed in all patients was 6.2 (1.7) cm2 at the lateral orbit (n = 129), 6.7 (2.3) cm2 at the orbital floor (n = 123), and 5.8 (1.8) cm2 at the medial orbital wall (n =30). The mean (SD) orbital volume increased by 6.0 (3.0) cm3 after decompression. There was also a significant reduction in exophthalmos of 7.3 (3.2) mm (from 25.2 (3.9) to 17.9 (3.5), p<0.001). LARA was performed in 50 patients. Changes in volume and area, and reduction in exophthalmos were not significantly different with or without LARA. The postoperative effects of orbital wall resection are predictable and exhibit a relation with six units of change. Two-wall resection is the most common intervention.

Changes in Eyelid Parameters after Orbital Decompression according to the Surgical Approach in Thyroid Eye Disease.

PurposeTo evaluate the changes in eyelid parameters after the endonasal approach compared with transcaruncular medial wall decompression combined with the transconjunctival inferior wall decompression approach with inferomedial strut preservation.MethodsIn total, 71 patients with thyroid eye disease who underwent orbital decompression were retrospectively evaluated. The data collected included Hertel exophthalmometry, marginal reflex distance 1, marginal reflex distance 2, interpalpebral fissure, levator function test measures, and complications related to surgery.ResultsProptosis reduction produced a statistically significant improvement across all decompression groups. Lower eyelid retraction produced a statistically significant improvement in the two-wall decompression groups but not in the one-wall decompression groups. No statistical difference was observed in the upper eyelid retraction and levator function after surgery across all decompression groups. In the post-hoc analysis, statistical improvement was not observed in the lower eyelid retraction between the endonasal and transcaruncular approach in the one-wall and two-wall decompression groups, although statistically significant exophthalmos reduction and improvement in the lower eyelid retraction was noted in the two-wall decompression subgroups compared with one-wall decompression subgroups.ConclusionsOur study showed no differences in eyelid parameters between the endonasal and transcaruncular decompression approaches in one-wall and two-wall decompression. In the two-wall decompression group, proptosis reduction was greater with the endonasal approach than with the transcaruncular approach when the strut was preserved; however, it does not lead to a significant difference in the improvement of lower eyelid retraction.

A randomized comparative study of inferomedial vs. balanced orbital decompression. Analysis of changes in orbital volume, eyelid parameters, and eyeball position.

The objective of this study is to investigate and compare changes in orbital volume, eyelid parameters, and eyeball position after inferomedial and balanced (medial + deep lateral walls) orbital decompression (OD) in patients with Graves' orbitopathy (GO). Prospective interventional trial. Forty-two patients with inactive GO and clinical indication for OD were randomly assigned to inferomedial or balanced OD. Preoperative and postoperative Hertel exophthalmometry, standardized photography, and computed tomography were used to evaluate upper and lower eyelid margin reflex distances (MRD1 and MRD2), orbital expansion, and changes in eyeball position. Clinical and radiological exophthalmometry improved significantly after OD with both surgical techniques (p < 0.001), but more so with balanced OD (p = 0.02). Concurrent eyeball descent (p = 0.01) and orbital volume expansion (p < 0.001) were observed with both techniques. The mean decompression volume was similar for the medial wall and the lateral wall but significantly smaller for the inferior wall (p < 0.05). Significant correlation coefficients were found for Hertel reduction vs. total decompression volume (p < 0.05). In the multivariate linear analysis, lateral wall decompression volume (LWDV) was predictive of exophthalmos reduction (p < 0.05). The two techniques produced a similar reduction in MRD1 and MRD2. A significant correlation was also found between Hertel reduction and lower lid elevation (p < 0.05). Both inferomedial and balanced OD successfully expanded orbit capacity, but the latter was more efficient at reducing exophthalmos probably due to the inclusion of the lateral wall. Upper and lower eyelid retraction improved after OD, but only lower eyelid elevation was correlated with exophthalmos reduction.

Orbital wall decompression in the management of Graves' orbitopathy: a systematic review with meta-analysis.

To systematically review outcomes of orbital bony wall decompression for Grave's orbitopathy according to the surgical approach. A systematic search for studies published in "Ovid MEDLINE", "Web of Science" and "Embase" of patients with surgical treatment of Grave's orbitopathy was performed. The overall postoperative change in Hertel exophthalmometry was calculated by random-effect meta-analysis model with 95% confidence interval (CI). A total of 33 studies, including 1686 patients and 2946 procedures, were included. The weighted mean Hertel value overall reduction was - 4.56 mm (95% CI - 5.05 to - 4.07 mm). According to surgical techniques the reduction was - 4.36 mm (95% CI - 5.22 to - 3.50) for infero-medial technique, - 4.88 mm (- 5.68 to - 4.08) for medial-lateral technique, - 4.32 mm (- 4.80to - 3.84) for lateral technique, - 5.45 mm (- 6.16 to - 4.74) for three-wall technique and - 3.47 mm (- 5.81 to - 1.12) for medial technique. The overall rate of new-onset of primary gaze diplopia was reported in 23 studies. The included procedures were 653 and results were heterogeneous (heterogeneity: Q = 78.8 df = 22, I2 = 72.09%, p<0.01). The pooled proportion (95% CI) rate of new-onset of primary gaze diplopia was 12% (7-16). Our metanalysis highlights that orbital bony wall decompression represents an effective surgical procedure. The three wall approach was associated with the best results in terms of exophthalmos reduction. Data suggest that an exclusive lateral approach may help to avoid the new-onset of primary gaze diplopia during the postoperative period.

Risk Factors for New Onset Diplopia After Graduated Orbital Decompression.

The aim of the study was to identify possible risk factors for new onset diplopia in 20° of primary position (NOD PP) after orbital decompression. A predisposition for NOD has been established for patients with pre-existing diplopia in secondary gaze; therefore, the authors focused on patients without preoperative diplopia. Retrospective chart review of patients who underwent balanced orbital decompression between 2012 and 2019 due to Graves orbitopathy at the authors' institution. Exclusion criteria were incomplete clinical data set, revision surgery, and medial or lateral decompression only. The following clinical parameters were evaluated preoperatively and postoperatively: Hertel exophthalmometry, objective measurement of misalignment using the prism-cover-test, assessment of the field of binocular single vision, and measurement of monocular excursions. In addition, the diameter of the extraocular eye muscles was measured in all preoperative CT scans. We included 327 patients (612 orbits), 126 patients (242 orbits) had no preoperative diplopia. In patients with NOD PP (34%, n = 43/126), enlargement of the medial rectus muscle and restriction of abduction and elevation were significantly more frequent than in patients with no NOD PP. The degree of exophthalmos decrease positively correlated with postoperative squint angle. We were able to identify the diameter of the medial rectus muscle, restriction of abduction, and elevation as well as an extensive reduction of exophthalmos as risk factors for NOD PP in patients with no preoperative diplopia.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES:To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves’ orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.METHODS:Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.RESULTS:Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).CONCLUSIONS:IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Ендокринна орбітопатія: персоналізований підхід до лікування пацієнта

Background. This article highlights the main approaches to the treatment of patients with endocrine orbitopathy (EO) and current opportunities for planning and conducting personalized orbital decompression, including the use of Computer-Aided Design (CAD) / Computer-Aided Manufacturing (CAM) technologies. Optimization of treatment of this pathology which can lead to changes in appearance, inability to perform usual work, social isolation, and in the most difficult cases to vision loss is a topical issue of ophthalmology and maxillofacial surgery. The aim. To analyze current information on basic approaches to the treatment of patients with endocrine orbitopathy and the possibility of using computer technologies for planning and performing personalized orbital decompression. Results. The use of corticosteroids, radiation therapy, surgical treatment are the key methods used to manage patients with EO. The use of CAD/CAM technologies allows to plan surgery according to the morphological features of the orbit of each patient. This can potentially affect the outcome of decompression and reduction of exophthalmos, as well as intraoperative complications. When using standard approaches, the results of decompression may vary significantly due to the differences in morphological parameters of the orbits. This dictates the need for a personalized approach to the management of patients with EO. Due to the significant variability of morphological parameters of the orbits in the case of standard approaches, the results in different patients can differ significantly, which dictates the need for a personalized approach to the management of patients with EA. Conclusions. EUGOGO 2016 recommends a multidisciplinary step-by-step approach to the management of patients with EO, depending on its activity and severity and the impact on the patient’s quality of life. A personalized approach using computer simulations and the development of surgical navigation templates for surgical decompression of the orbit will ensure optimal functional and aesthetic treatment results. Keywords: endocrine orbitopathy, treatment, orbital decompression, ComputerAided Design (CAD) / Computer-Aided Manufacturing (CAM) technologies, personalized approach.

The use of computer‐aided design/ computer‐aided manufacturing technologies in the treatment of Graves' orbitopathy

AbstractPurposeTo study the advantages of using Computer‐Aided Design (CAD)/Computer‐Aided Manufacturing (CAM) technologies in the treatment of Graves Orbitopathy (GO).MethodsResearch analysis of contemporary scientific medical publications on the subject, The 2018 European Group on Graves ‘Orbitopathy Guidelines for the Management of Graves’ Orbitopathy (EUGOGO), Philips Diamond Select Brilliance CT64, software environment Sim Plant 13.02 and Geomagic Freeform Plus.ResultsGraves Orbitopathy (GO) is an autoimmune disease that results in dysteroid optic neuropathy (DON) in 3–5% of patients and progressive vision loss. According to the recommendations of EUGOGO 2018, orbital decompression is performed at the first stage of surgical treatment as scheduled with moderate inactive GO or immediately in patients with DON and/or rupture of the cornea with the involvement of a multidisciplinary team of radiodiagnosis, endocrinologist, ophthalmologist and maxillofacial surgeon. To increase the volume of bone orbit, surgeons extend the medial, lateral walls of the orbit, or the floor of the orbit, and remove a certain amount of infraorbital fat, but the only correct approach to date has not been determined (EUGOGO 2016). Given the need for an individual approach to the patient, the use of CAD/CAM technology to obtain three‐dimensional models of the skull expands the ability to study the features of the anatomy of the walls of the orbit, its volume, planning of surgery.ConclusionsThe result of a carefully planned orbit decompression using CAD/CAM technology is not only the reduction of intraocular pressure and exophthalmos for optimal treatment, but also the reduction of intraoperative complications (traumatization of the neurovascular bundles, muscles, etc.), shortening the duration of surgery.

Orbitadekompression bei endokriner Orbitopathie – Erfahrungen und Ergebnisse

HintergrundDie endokrine Orbitopathie ist die häufigste extrathyreoidale Manifestation des Morbus Basedow und tritt bei schätzungsweise 25–50 % der betroffenen Patienten auf. Krankheitsbedingt kommt es zu einer entzündlichen Schwellung der Orbitaweichteile. Die Behandlung erfolgt meist konservativ. Bei schweren Fällen mit beeinträchtigendem Exophthalmus oder akuter, steroidrefraktärer Visusbedrohung kann eine chirurgische Orbitadekompression die Beschwerden der Patienten lindern oder das Sehvermögen erhalten. Ein wesentlicher Aspekt der Versorgungsqualität besteht in der Vermeidung postoperativer Doppelbilder.Ziel der ArbeitErfahrungs- und Ergebnisbericht von 100 chirurgischen Orbitadekompressionen bei 62 Patienten an einem interdisziplinären Orbitazentrum. Patienten mit Kompression der Orbitaspitze wurden mittels pterionaler Dekompression behandelt. Patienten ohne Hinweise auf Orbitaspitzenbeteiligung wurden mittels tiefer lateraler Wandresektion oder pterionaler Dekompression behandelt.MethodikRetrospektive Datenanalyse.ErgebnisseDie mittlere Exophthalmusreduktion betrug 2,9 mm. Augen mit visusbedrohendem Schweregrad gewannen im Mittel 2,2 Zeilen an Sehschärfe, der Visus bei rehabilitativer Indikation blieb stabil. Die Komplikationsrate betrug 4 %. Neue Doppelbilder wurden nach 2 Eingriffen beobachtet. Bei einem Patienten kam es zu einer Visusminderung von 0,8 auf 0,1. In 9 Fällen führte die Operation zu einem vollständigen Rückgang zuvor beklagter Doppelbilder.DiskussionVisusgewinn, Exophthalmusreduktion und Komplikationsrate sind in diesem Kollektiv vergleichbar mit zuvor publizierten Arbeiten. Diese Studie bestätigt die Rolle der Orbitadekompression bei visusbedrohender und schwer beeinträchtigender endokriner Orbitopathie.

Neurofibromatosis – diagnostic challenges

Neurofibromatosis is a rare disease and in its classical presentation is not difficult to diagnose, but when the clinical finding is not typical it becomes a diagnostic problem. Aim: to present a clinical case of neurofibromatosis that was a diagnostic problem because of its atypical manifestation. Clinical case description: one-year follow-up and treatment of a patient with neurofibromatosis at the UMHB Pleven Eye Clinic. The patient was treated initially for keratitis according to the clinical presentation and patient’s complaints. During the second visit complaints of double images and exophthalmos were reported. CAT showed tumor formation in the orbit. Trifold biopsy was made due to inconsistency of the clinical picture with the finding. Steroid therapy was applied at the first visit showing good response, and of course clouded the diagnosis. Partial resection of tumor masses was made during the 2nd visit and 2nd biopsy. Results showed some response to anti-inflammatory therapy and yet unclear diagnosis. A larger biopsy contributed to the reduction of double images without significant reduction in exophthalmos. The diagnosis was made after the 3rd skin biopsy. Conclusion: a rare disease requiring a multidisciplinary approach. Further monitoring of the progression of orbital fibromas and/or subsequent orbital surgery and/or radiation or chemotherapy is required.

Computed Tomography-Based Prediction of Exophthalmos Reduction After Deep Lateral Orbital Wall Decompression for Graves' Orbitopathy.

To examine the predictability of exophthalmos reduction using preoperative computed tomography (CT) in deep lateral orbital wall decompression for Graves' orbitopathy. This was a retrospective, observational, case-control study conducted at a single institution. Forty-three patients (43 orbits) who were treated with deep lateral decompression with (27 patients) and without (16 patients) fat removal. Multivariate linear regression analyses were used to identify factors influencing exophthalmos reduction 3 months postoperatively. Variables investigated included age; smoking history; history of corticosteroid therapy and/or radiotherapy; preoperative diplopia; width, depth, and height of the greater wing of the sphenoid bone (trigone); and volume of fat removed. The influence of these parameters on the area of the orbital opening was also analyzed. Trigone width and amount of fat removed were positively correlated with exophthalmos reduction (both, P < .050); none of the other variables exhibited significant correlations. The predictive equation for postoperative reduction in Hertel exophthalmometric values was 0.57 + 0.15 × trigone width (mm) + 1.1 × fat removed (cm3). Depth and height were positively correlated (both, P < .050) and width was negatively correlated (P = .0045) with orbital opening area. Trigone width and amount of fat removed were positive predictors of exophthalmos reduction after deep lateral decompression. Trigone width was inversely associated with orbital width, and results showed that larger exophthalmos reductions could be achieved in narrower orbits. This CT-based prediction method will assist preoperative decision-making regarding additional fat removal and/or removal of another orbital wall.

Effect of orbital radiotherapy on the outcome of surgical orbital decompression for thyroid-associated orbitopathy (TAO): a retrospective study in 136 patients.

In patients with moderate to severe thyroid-associated orbitopathy (TAO), orbital radiation therapy (ORT) can prevent disease progression. In the sequelae stage, orbital decompression surgery can be useful in case of functional discomfort. The aim of this study was to evaluate the effect of orbital ORT on the outcomes of decompression surgery. In this retrospective study, we included 136 patients who had had bilateral orbital decompression between 1995 and 2016. Before surgery, 38 patients received Radiation Therapy (RT+) while 98 did not (RT-). All RT+ patients and 20 RT- patients had systemic corticosteroid treatment. In both groups surgical outcome was evaluated by exophthalmos reduction (mm), palpebral fissure (mm), distance between the lid margin and the corneo-scleral limbus (mm), existence of conjunctival hyperemia and diplopia. In both RT+ and RT- groups, surgery improved the proptosis, significantly greater in RT+(3.66 ± 1.79 mm) than in RT- group (2.85 ± 1.80 mm) (p < 0.019). No significant differences were noted in the palpebral fissure, the distance from the lid margin to the corneo-scleral limbus. After surgery, only one patient (5%) in the RT+ group presented with new-onset diplopia, whereas in the RT- group there were 14 (36%) patients (p < 0.007). After orbital decompression, the number of conjunctival hyperemia decreased by 6 (21%) in the RT+ group versus 21 (60%) in the RT- group (p < 0.006). Orbital radiotherapy during the inflammatory phase enhances the outcomes after orbital decompression in TAO. After surgery we observed a greater improvement in proptosis and in diplopia for RT+ versus RT- patients.

Quantitative analysis of extraocular muscle volume and exophthalmos reduction after radiation therapy to treat Graves' ophthalmopathy: A pilot study.

The aim of this study was to provide radiological information on the inherent response of Graves' ophthalmopathy after radiation therapy. Quantitative analysis of extraocular muscle volume was performed on 96 involved extraocular muscles in a total of 16 patients. A total of 48 computed tomography images were analyzed. Exophthalmos was also measured. The percentage reductions in extraocular muscle volume and exophthalmos length were determined and compared to the pre-radiation therapy values at 6-, 12-, and 24-month follow-up. The median follow-up time was 21.5 months (range: 7.2-29.4 months). The mean reduction in relative tumor volume compared to the pre-radiation therapy extraocular muscle volume was 46.1% (range: 33.3%-58.8%). The mean relative extraocular muscle volumes were 71.5% at 6 months, 59.2% at 12 months, and 54.3% at 24 months after radiation therapy. The volume of the involved extraocular muscles decreased rapidly within the first 12 months of follow-up. The mean pre-radiation therapy length of exophthalmos was 21.7 mm (range: 17.6-26.1 mm). The mean percentages of exophthalmos length by comparison with the pre-radiation therapy length were 96.7% at 6 months, 92.3% at 12 months, and 88.5% at 24 months after radiation therapy. Exophthalmos decreased slowly and steadily during the follow-up period. Quantitative volumetric analysis of the pattern of extraocular muscle volume reduction and exophthalmos length reduction in response to radiation therapy will allow clinicians to better understand the effect of radiotherapy on Graves' ophthalmopathy.

Efficacy and Side Effects of Lateral Orbital Wall Decompression Including the Orbital Rim in Patients with Graves' Orbitopathy

Graves' orbitopathy is the most common extrathyroidal manifestation of Graves' disease. In the burnt out fibrotic phase exophthalmos, diplopia and lid retraction may remain, which can require multiple rehabilitative surgical interventions. Orbital decompression is an established surgical procedure for the treatment of exophthalmos in Graves' orbitopathy. The aim of the study was to evaluate the efficacy and side effects of the deep lateral orbital wall decompression including the orbital rim. In this retrospective, non-comparative case series, all patients with Graves' orbitopathy, who underwent lateral orbital wall decompression at the Eye Clinic of the University of Göttingen between 2008 and 2015, were analysed in terms of exophthalmos reduction, diplopia (Gorman score) and complications. The surgical technique involved the removal of the lateral orbital wall including the orbital rim combined with additional orbital fat resection via swinging eyelid approach. 127 patients who underwent 195 orbital decompressions were included. Mean exophthalmos reduction was 4.0 ± 1.2 mm (range 1.5 - 7.5 mm). Preoperatively, 47 patients/77 orbits (37.0/39.5%) presented without diplopia. Postoperatively, 3 patients/3 orbits (6.4/3.9%) showed new-onset diplopia (2.4% of all patients, 1.5% of all orbits). Diplopia in primary gaze was noted in one of the 3 patients (0.8% of all patients, 2.1% of patients without preoperative diplopia), and inconstant diplopia was seen in the other 2 patients. Postoperative improvement of diplopia was noted in 19 patients/19 orbits (15.0% of all patients, 23.8% of patients with preoperative diplopia/9.7% of all 195 interventions), and 16.1% of cases with preexisting diplopia. No severe complications were seen, except for one case of postoperative bleeding, which was successfully managed surgically without any functional deficits. A visible scar formation was noted in 6 cases (3.1%), temporal hollowing in 3 cases (1.5%), oscillopsia when chewing in 3 cases (1.5%) and a de-insertion of the lateral canthal region in 2 cases (1%). Deep lateral orbital wall decompression, including the orbital rim, is an effective surgical technique to reduce exophthalmos in patients with Graves' orbitopathy with a low risk of functional and aesthetic complications.