[Reoperation after orbital decompression for Graves' ophthalmopathy]

Teprotumumab in advanced reactivated thyroid eye disease

Purpose

To report the case of a patient with reactivated, refractory thyroid eye disease (TED) treated with teprotumumab.

Observations

A 51-year-old female with a 16-year history of thyroid eye disease previously treated with orbital decompression and multiple eyelid surgeries presented in a recurrent flare of the disease. The disease recurrence was refractory to intravenous steroid therapy and only partially responsive to oral steroid therapy, and the patient developed dysthyroid optic neuropathy in the right eye with decreased visual acuity and color vision. Clinical activity score was 8/10 and proptosis measurements were 27 mm OD and 26 mm OS. The patient underwent treatment with eight infusions of teprotumumab coinciding with a low taper of oral prednisone and experienced resolution of dysthyroid optic neuropathy, decrease of clinical activity score to 1, and dramatic improvement in proptosis (17 mm OD, 17 mm OS) and extraocular muscle size on imaging. Thirty weeks after completion of teprotumumab and 2 weeks after the second dose of the COVID vaccine, she experienced another flare and subsequently underwent bilateral orbital decompressions.

Conclusion

This case report suggests teprotumumab may be used in patients with reactivation of longstanding thyroid eye disease. Reduction of extraocular muscle size and improvement in proptosis suggest teprotumumab may be disease-modifying even in advanced cases.

Modified endoscopic transnasal orbital apex decompression in dysthyroid optic neuropathy

BACKGROUND

To describe the surgical technique and assess the clinical efficacy and safety of modified endoscopic transnasal orbital apex decompression in the treatment of dysthyroid optic neuropathy.

METHODS

In this retrospective research, forty-two subjects (74 orbits) who underwent modified endoscopic transnasal orbital apex decompression for the treatment of dysthyroid optic neuropathy were enrolled. Preoperative and postoperative best-corrected visual acuity (BCVA), visual field mean deviation (MD), Hertel exophthalmometry, and new onset diplopia were assessed before and after the intervention. The Wilcoxon test was used for differential analysis. Linear mixed-models' analyses were conducted to assess the potential predictors for BCVA change.

RESULTS

Postoperatively, the mean BCVA improved from 0.70 ± 0.62 logMAR to 0.22 ± 0.33 logMAR. BCVA significantly improved in 69 eyes (93%), remained stable in 4 eyes (5%) and deteriorated in 1 eye (1%). MD of visual fields improved from -13.73 ± 9.22 dB to -7.23 ± 7.04 dB. Proptosis decreased from 19.57 ± 3.38 mm to 16.35 ± 3.01 mm. Preoperative BCVA, MD of visual fields and medical rectus diameter were independent factors associated with improvements in BCVA (P < 0.05) by linear mixed-models' analyses. Eighteen patients (42.9%) developed new diplopia postoperatively.

CONCLUSION

Modified endoscopic transnasal orbital apex decompression effectively restores vision in dysthyroid optic neuropathy.

Radiotherapy for Active Thyroid Eye Disease

PURPOSE

To critically review the published literature on orbital radiotherapy as a treatment modality for thyroid eye disease (TED).

METHODS

A systematic review and analysis of the relevant published literature was performed.

RESULTS

Thyroid eye disease is an autoimmune condition that is amenable to treatments that modulate the immune response, including orbital radiotherapy (ORT). Ideal candidates for ORT are patients in the early, active phase of TED with moderate to severe, or rapidly progressive, disease, including patients with significant motility deficits and compressive optic neuropathy. Patients with progressive strabismus may also benefit. Patients with mild or inactive disease will not benefit from ORT when compared with the natural history of the disease. Orbital radiotherapy should generally be used in conjunction with corticosteroid therapy, with response to corticosteroids demonstrating the immunomodulatory therapeutic potential of ORT. When treating TED-compressive optic neuropathy, ORT may help obviate the need for urgent surgical decompression, or postpone it until the stable, inactive phase of the disease. Orbital radiotherapy treatment doses should approach 20 Gy in most cases, but lower doses may be considered in younger patients without significant dysmotility. The safety profile of ORT is well established, and side effects are minimal in appropriately selected patients.

CONCLUSIONS

Radiotherapy is a safe and effective treatment for active TED in appropriately selected patients.

Orbital Radiotherapy Combined With Corticosteroid Treatment for Thyroid Eye Disease-Compressive Optic Neuropathy

PURPOSE

To evaluate the effectiveness of orbital radiotherapy (ORT) in the treatment of thyroid eye disease (TED)-compressive optic neuropathy.

METHODS

A retrospective review of patients with corticosteroid-responsive compressive optic neuropathy due to TED treated with ORT. Study was conducted in compliance with Health Insurance Portability and Accountability Act. One hundred four patients (163 orbits) with a mean age of 61.7 years met inclusion criteria. Seventy-four percent (77/104) were female, and 32.7% (34/104) were current or previous smokers. A total absorbed dose of 2000 cGy fractionated in 10 treatment doses over the course of 2 weeks was administered to the retroocular tissues according to a standard protocol. The primary end point was failure of ORT, defined as persistent optic neuropathy following completion of radiotherapy that mandated urgent orbital decompression surgery.

RESULTS

Ninety-eight of 104 (94%) patients or 152 of 163 (93.3%) orbits did not require orbital decompression surgery during the acute phase. Patients who responded successfully to ORT had similar improvements in visual acuity, color vision, Humphrey threshold visual field testing, and afferent pupillary defects compared with patients who failed ORT and underwent urgent decompression surgery. Only 36.7% of successfully treated patients ultimately underwent elective surgery, including orbital decompression, strabismus, or eyelid surgery, during the inactive phase of TED.

CONCLUSIONS

The data from this study, the largest retrospective review reported to date, supports the use of ORT in eyes with corticosteroid-responsive TED-compressive optic neuropathy. ORT may favorably alter the natural history of active-phase TED by preventing recurrent compressive optic neuropathy after withdrawal of corticosteroids.

Post-operative orbital haematomas over a 12-year period. A description of three cases among 280 orbital procedures

PURPOSE

To evaluate the incidence of orbital haematoma requiring surgical treatment following procedures including fracture repairs and orbital osteotomies over a 12-year period and to discuss their management.

METHODS

The records of all the patients who underwent a procedure involving the orbits from 1998 to 2011 were reviewed for evidence of post-operative haematomas. Medical data including clinical presentation, time between diagnosis and treatment, management and subsequent outcome were collected.

RESULTS

280 patients were included, 257 procedures for orbital or zygomato orbital fractures and 23 osteotomies for dysthyroid orbitopathy or malunited orbital fractures. Three cases (1.07%) of post-operative haematomas were observed as follows: 2/257 orbital fractures (0.77%) and 1/23 osteotomies (4.34%). All cases occurred in the early post-operative period of less than 6 h. No spontaneous loss of vision or pain was described by patients. All could be operated on as soon as the diagnosis was established; no CT-scans were required. Orbital drainage was successfully performed in all cases.

CONCLUSION

Post-operative orbital haematomas are uncommon complications. Diagnosis is based on a clinical examination, including pain, proptosis and alteration in visual acuity. Surgical treatment should be undertaken immediately following diagnosis.