Treatment Options for Thyroid Eye Disease

Correction of lower eyelid retraction combined with entropion in thyroid eye disease patients of East Asian ancestry

PURPOSE

This study evaluates causes and treatment of lower eyelid retraction with co-existing entropion in Thyroid Eye Disease (TED) patients of East Asian ancestry.

METHODS

The medical records for 25 eyelids from 15 TED patients with lower eyelid retraction and entropion who had undergone combined orbital decompression and lower eyelid retraction correction surgery at the Second Hospital of Dalian Medical University from January 2017 to December 2018 were prospectively reviewed. We build a numerical model of biomechanics to analyze von Mises stress and displacement at the lower eyelid.

RESULTS

The mean follow-up duration was 6 ± 2 months. The difference of mean exophthalmos was 5.16 ± 1.21 mm (t = 21.26, p = 4.479E-17 < 0.05). The difference of mean MRD2 was 1.9 ± 0.14 mm (t = 67.57, p = 6.751E-29 < 0.05). About 2 of 25 eyelids entropion recurred postoperatively; the overall success rate was 92%. The biomechanical analysis results reveal that the eyelid margin is given more stress and caused more displacement in East Asian ancestry under the same force of pressure.

CONCLUSIONS

This study shows that the lower eyelid retraction with coexistent entropion is attributable to the unique anatomical features of patients of East Asians ancestry. We corrected the lower eyelid retraction and entropion during the orbital decompression operation. The results show that this method is safe and effective. It can simultaneously improve the symptoms of TED patients such as exophthalmos, lower eyelid retraction, and entropion, with minimal complications.

Virtual Surgical Planning for Orbital Reconstruction

The advent of computer-assisted technology has revolutionized planning for complex craniofacial operations, including orbital reconstruction. Orbital reconstruction is ideally suited for virtual planning, as it allows the surgeon to assess the bony anatomy and critical neurovascular structures within the orbit, and plan osteotomies, fracture reductions, and orbital implant placement with efficiency and predictability. In this article, we review the use of virtual surgical planning for orbital decompression, posttraumatic midface reconstruction, reconstruction of a two-wall orbital defect, and reconstruction of a large orbital floor defect with a custom implant. The surgeon managing orbital pathology and posttraumatic orbital deformities can benefit immensely from utilizing virtual planning for various types of orbital pathology.

Treatment of ocular motor palsies

OPINION STATEMENT

The management of ocular motor palsies first requires careful determination of the etiology. Possibilities include ischemia, inflammation, infection, trauma, compression, or congenital. Prognosis for recovery varies greatly between etiologies; hence, determination of the underlying process is crucial in the short- and long-term management of these patients. Naturally, our ultimate goal is to improve visual function as much as possible. A guiding principle in the initial management of ocular motor palsies is to improve patient comfort and visual function by eliminating diplopia in primary position while clinically observing the patient for improvement or stability. Offering a definitive treatment which creates the largest possible zone of binocular single vision in primary and reading positions can be undertaken once stability has been demonstrated. In the initial phase after an acute ocular motor palsy has occurred, occlusion of an eye can be used to eliminate diplopia. Options include a patch or applying translucent or satin tape to one of the lenses which prevents diplopia but still lets light through. Alternatively, prismatic correction placed on or ground into spectacles may improve function and restore binocularity in patients with temporary or permanent ocular deviations. This is generally effective for patients with up to 20 to 25 prism diopters (PD) of horizontal misalignment and 10 to 15 PD of vertical. Once a stable misalignment has been demonstrated (several months), a variety of surgical options exist. Use of adjustable sutures, improved suture materials, and surgical techniques has expanded the role and scope of surgery for these patients. Planning the surgical approach is based on residual extraocular muscle function, careful measurements, and assessment of patient expectations.