Intraocular Pressure Change With Eye Positions Before and After Orbital Decompression for Thyroid Eye Disease

A meta-analysis of the efficacy of two-wall orbital decompression operations for thyroid-associated ophthalmopathy

BACKGROUND

The main treatment for the symptoms of proptosis and optic nerve compression caused by thyroid-associated ophthalmopathy is orbital decompression surgery. Medial inferior wall decompression and balanced decompression are two frequently used surgical procedures. However, there is no unified consensus on how to choose different surgical options for orbital decompression in clinical practice.

AIMS

To compare the effects of medial inferior wall decompression and balanced decompression surgery through meta-analysis and to provide reference for clinical optimal decision making.

METHODS

Databases, including PubMed, Web of Science, Ovid, Cochrane Library, and ClinicalTrials.gov, were searched for randomized controlled trials and cohort studies on decompression surgery for thyroid-associated ophthalmopathy published from inception to March 21, 2023. Using RevMan 5.3 software, a meta-analysis was conducted based on the following outcome indicators: proptosis, diplopia rate, intraocular pressure, visual acuity, and complication rate.

RESULTS

Two randomized controlled trials and five cohort studies with a total of 377 patients were included in this analysis. After balanced decompression surgery, patients with thyroid-associated ophthalmopathy experienced a significant decrease in proptosis [MD = 4.92, 95% CI (4.26, 5.58), P < 0.0001]. Balanced decompression can improve postoperative visual acuity [MD = - 0.35, 95% CI (- 0.56, - 0.13), P = 0.001] and intraocular pressure [MD = 5.33, 95% CI (3.34, 7.32), P < 0.0001]. The rates of proptosis [MD = 0.33, 95% CI (- 1.80, 2.46), P = 0.76] and diplopia [OR = 1.20, 95% CI (0.38, 3.76), P = 0.76] did not differ between patients who underwent medial inferior wall decompression and those who underwent balanced decompression.

CONCLUSION

Balanced decompression and medial inferior wall decompression are both effective options for surgical treatment of thyroid-associated ophthalmopathy in clinical practice.

Secondary Effects of Orbital Decompression in Thyroid Eye Disease: A Review

PURPOSE

Orbital decompression is mainly performed in thyroid eye disease to reduce proptosis and retrobulbar pressure, to improve venous congestion, and to relieve optic nerve compression. Secondary effects of orbital decompression are also occasionally encountered. The aim of this study was to review the secondary effects of orbital decompression.

METHODS

This is a comprehensive literature review that summarizes the secondary effects of orbital decompression.

RESULTS

Decreased intraocular pressure, inter-pupillary distance, and eyelid pressure, and improvement of eyelid retraction, lateral flare, orbital discomfort, and psychosocial condition after orbital decompression are favorable changes for patients. In contrast, refractive changes in some patients and decreased Bell's phenomenon and nasal function worsen patients' condition.

CONCLUSION

These favorable changes may reduce the patients' burden for treatment of thyroid eye disease. In contrast, as some of the adverse effects significantly worsen the patients' disease condition, we should carefully monitor these changes.

Correlation Analysis between Intraocular Pressure and Extraocular Muscles Based on Orbital Magnetic Resonance T2 Mapping in Thyroid-Associated Ophthalmopathy Patients

Background: The correlation between intraocular pressure (IOP) and the magnetic resonance imaging (MRI) parameters in thyroid-associated ophthalmopathy (TAO) patients was explored. Methods: This study included 82 eyes in 41 TAO patients who had a large difference in the IOP between each eye. We measured the T2 relaxation time (T2RT) of the extraocular muscles (EOMs), the orbital fat, and the area of the EOMs. Results: There was a positive correlation between IOP and exophthalmos, the clinical activity score (CAS), the T2RT (of the medial rectus (MR)), the area of the MR, inferior rectus (IR) and lateral rectus, and the mean area. We established a regression model with IOP as the dependent variable, and the area of the IR was statistically significant. Conclusions: High IOP in TAO patients was positively correlated with the degree of exophthalmos and EOM inflammation (especially the inferior rectus). The state of the EOMs in an orbital MRI may partially explain high IOP and provide the necessary clinical information for subsequent high IOP treatment.

Effect of teprotumumab on intraocular pressure in thyroid-associated ophthalmopathy

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Intraocular Pressure and Glaucoma in Thyroid Eye Disease

PURPOSE

Current literature lacks a summary of knowledge on intraocular pressure (IOP) elevation and glaucoma in thyroid eye disease (TED). This review aims to augment existing literature by providing such a summary. It qualitatively evaluates current knowledge on the pathogenesis, prevalence, and management of concomitant ocular hypertension or glaucoma in TED patients.

METHODS

In this narrative review, relevant publications were identified through a computerized database search. Search results were screened for relevance. Correspondence, Editorials, and Letters to the Editors were excluded. References cited within the identified articles were used to further augment the search. Information extracted for qualitative analysis included epidemiologic data, methods of IOP assessment, management protocols, and response to treatment.

RESULTS

Studies in current literature are relatively heterogenous, differing in country of origin, TED cohort sizes, and IOP measurement techniques. Further studies are required to elucidate the true epidemiologic relationship between TED and ocular hypertension or glaucoma. Proposed models of IOP elevation include elevation of episcleral venous pressure, mucopolysaccharide deposition within the trabecular meshwork, restrictive myopathy, steroid-induced glaucoma, and secondary glaucoma. IOP-reducing effects of TED treatment options are discussed.

CONCLUSIONS

While raised IOP in TED is a common phenomenon, the diagnosis of glaucoma in TED requires a high index of suspicion before any intervention.

[Ocular hypertension and optic neuropathies secondary to dysthyroid orbitopathy: Review of the literature]

Dysthyroidism, especially Graves' disease, causes potentially severe orbital disease. This is frequently accompanied by ocular hypertension stemming from multiple pathophysiological mechanisms. Adaptations in the technique of intraocular pressure measurement must occur, using portable equipment if necessary. Glaucomatous optic neuropathy secondary to dysthyroid orbitopathy is rare, and screening for signs of compressive optic neuropathy is essential in the case of visual field loss. In cases of secondary glaucomatous optic neuropathy, treatment of the intraocular pressure is based mainly on systemic corticosteroid therapy and topical medications as necessary.

Swinging Eyelid Approach to Zygomaticomaxillary Complex Fracture

A surgical approach to zygomaticomaxillary complex (ZMC) fracture has not been standardized. The authors reviewed 15 cases of ZMC fractures treated with the swinging eyelid approach and evaluated the effectiveness of the technique by an observational study of Japanese patients. Results were assessed from authentic and functional perspectives: the presence of entropion/ectropion, external canthal malposition and chemosis of the conjunctiva. After a minimum follow-up of 10 months, no patients had lower eyelid ectropion, entropion or retraction. Wounds appeared inconspicuous, and a lateral canthal shape was preserved. No post-operative chemosis of the conjunctiva was observed. Each case was evaluated based on patient satisfaction about their aesthetic outcomes. Patient self-assessment is classified into 4 groups (excellent, good, fair, and unsatisfactory). Thirteen patients were assessed to have an "excellent" outcome, and 2 patients were assessed to have a "good" outcome. No patients had "fair" or "unsatisfactory" outcomes. Avoidance of scarring is a goal of every craniofacial surgeon. The swinging eyelid approach to ZMC fractures offers a simple alternative to the conventional technique. It is versatile and provides sufficient exposure to surgical fields with less visible scar because skin incision is made along the natural crease line, "the crow's feet."

Medial and mediolateral orbital decompression in intractable Graves' Orbitopathy

OBJECTIVE

Graves' Orbitopathy (GO) has well established treatment guidelines; however, its management is still controversial. The aim was to evaluate the results of medial and mediolateral orbital decompression (OD) in intractable GO.

METHODS

Retrospective chart review of all patients with advanced stages of GO, who underwent medial (1-wall) or mediolateral (2-wall) OD between May 2012 and November 2014 in our institution. Ophthalmologic examinations included visual acuity, Hertel exophthalmometry (proptosis), intraocular pressure (IOP), visual field (30:2) and diplopia. Follow-up was performed 1 week, 3 months and 1 year postoperatively. Additionally, a questionnaire was used to investigate subjective benefits.

RESULTS

The study included 34 eyes of 20 patients. In our study, GO patients who underwent mediolateral OD had significantly higher IOP preoperatively (p<0.05) and lower visual acuity, proptosis and visual field compared with patients who underwent medial OD. After 1- and 2-wall OD, visual acuity, proptosis, visual field and IOP in upgaze improved significantly. Using a questionnaire, the patients reported significant improvements in impaired vision, eye pain and pressure, vitality and social life. 94% of all patients reported they would repeat the operation. After 2-wall OD, the surgical scar had little effect.

CONCLUSION

With GO patients in advanced stages, both medial (1-wall) and mediolateral (2-wall) OD procedures are convincing therapeutic options. In more advanced GO stages with high IOP, 2-wall OD should be prioritized, as mediolateral OD had superior long-term functional outcomes.

Clinical factors affecting intraocular pressure change after orbital decompression surgery in thyroid-associated ophthalmopathy

OBJECTIVE

To report the physiological monitoring of intraocular pressure (IOP) during the postoperative periods after orbital decompression surgery and ascertain the correlation between the clinical factors and IOP changes.

METHODS

The medical records of 113 orbits from 60 patients who underwent orbital decompression surgery were reviewed retrospectively. IOP measurement during the postoperative periods was classified based on the postoperative day: week 1 (1-7 days), month 1 (8-41 days), month 2 (42-70 days), month 3 (71-97 days), month 4 (98-126 days), and final (after 127 days). The mean postoperative follow-up was 286.5 days for orbits with at least 6 months of follow-up. Univariate and multivariate linear regression analyses were performed to assess the correlation between the IOP reduction percentage and clinical factors.

RESULTS

The mean IOP increased from 16.9 to 18.6 mmHg (10.1%) at postoperative week 1 and decreased to 14.4 mmHg (14.5%) after 2 months. Minimal little changes were observed postoperatively in the IOP after 2 months. Preoperative IOP had a significant positive effect on the reduction percentage both at postoperative week 1 (β=2.51, P=0.001) and after 2 months (β=1.07, P=0.029), and the spherical equivalent showed a positive correlation with the reduction level at postoperative week 1 (β=1.71, P=0.021).

CONCLUSION

Surgical decompression caused a significant reduction in the IOP in thyroid-associated orbitopathy, and the amount of reduction was closely related to preoperative IOP; however, it may also cause a transient elevation in the IOP during the early postoperative phase in highly myopic eyes.

Delayed Correction of Hypotony Maculopathy in a Patient with Glaucoma and Thyroid-Related Orbitopathy

Hypotony maculopathy is a condition that may result in visual deterioration from choroidal folds or optic disc edema. Optic disc edema can result from altered translaminar pressure gradients (lowered intraocular pressure, increased cerebrospinal fluid pressure, or increased orbital pressure). We report a case of bilateral optic disc edema in a patient with glaucoma and thyroid-related orbitopathy. The patient's disc edema was initially presumed to be secondary to her orbitopathy, but persisted after bilateral orbital decompression. Ultimately, disc edema and choroidal folds in the right eye resolved after trabeculectomy revision and an increase in intraocular pressure. This case serves as a reminder of the causes of optic disc edema and demonstrates delayed reversal of hypotony maculopathy.