Teprotumumab and Orbital Decompression for the Management of Proptosis in Patients With Thyroid Eye Disease

PURPOSE

To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence.

METHODS

Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects.

RESULTS

One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up ( p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone.

CONCLUSIONS

Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone.

Efficacy and safety of tripterygium glycosides for active moderate to severe Graves' ophthalmopathy: a randomised, observer-masked, single-centre trial

BACKGROUND

Tripterygium glycosides (TG) has been used to treat a spectrum of inflammatory and autoimmune diseases. Our preliminary studies have shown that TG is effective in the treatment of active Graves' ophthalmopathy (GO).

OBJECTIVE

We aimed to compare the efficacy and tolerability of TG with intravenous methylprednisolone (iv.MP) in patients with active moderate-to-severe GO.

METHODS

This study was an observer-masked, single-centre, block-randomised trial. Patients with active moderate-to-severe GO were randomly assigned to receive iv.MP (500 mg once per week for 6 weeks followed by 250 mg per week for 6 weeks) or with TG (20 mg tablet three times per day for 24 weeks). The primary endpoints were the overall response rate and the patients' quality of life at 12 and 24 weeks.

RESULTS

In this study, 161 patients were enrolled and randomised from 2015 to 2019. A total of 79 were randomly assigned to receive iv.MP and 82 to receive TG. A greater overall response rate was found in the TG group compared with the iv.MP group at week 24 (90.2% vs 68.4%, P = 0.000). Similarly, the patients' quality of life of the TG group showed a significantly higher response than the iv.MP group at week 24 (89.02% vs 72.15%, P = 0.001). The TG therapy showed a better CAS response than the iv.MP (91.5% vs 70.9% improved, P < 0.05), and up to 91.2% of patients were inactive. Also, the TG group showed a significantly higher improved rate of diplopia, proptosis, visual acuity, soft tissue involved and the decrease of eye muscle motility than the iv.MP group at week 24. Significantly more patients in the iv.MP group than the TG group experienced adverse events.

CONCLUSION

Compared with iv.MP treatment, TG therapy is more effective and safer for patients with active moderate to severe GO.

Invasive fungal disease misdiagnosed as tumour in association with orbital apex syndrome

Invasive sino-orbital aspergillosis is a rare cause of orbital apex syndrome (OAS) in immunocompetent patients and often misdiagnosed as tumour because of its aggressive nature and invasive patterns. We report a 23-year-old immunocompetent man presenting with painful progressive loss of vision, ophthalmoplegia and proptosis of the right eye suggestive of OAS. MRI with gadolinium contrast showed an enhancing heterogeneous mass filling the paranasal sinuses, extraconal space and extending up to the right orbital apex. A functional endoscopic biopsy reported as invasive sino-orbital aspergillosis. He was started on intravenous voriconazole and maximal surgical debridement was done. He gradually regained his vision to 20/30 in the right eye. A review of literature reported several such cases which were managed medically or surgically but with poor visual recovery. This case highlights the need for awareness among clinicians for early diagnosis and treatment to prevent vision loss and better survival.

A Prospective, Randomized, Double-blind, Placebo-controlled Study of Orbital Radiotherapy for Graves' Ophthalmopathy

CONTEXT

Although widely used for more than 85 years, the efficacy of radiotherapy for Graves' ophthalmopathy (GO) has not been established convincingly.

OBJECTIVE

To evaluate the efficacy of radiotherapy for GO.

DESIGN

Prospective, randomized, internally controlled, double-blind clinical trial in a tertiary care academic medical center.

PARTICIPANTS

The patients were ethnically diverse males and females over age 30 seen in a referral practice. The patients had moderate, symptomatic Graves' ophthalmopathy (mean clinical activity score, 6.2) but no optic neuropathy, diabetes, recent steroid treatment, previous decompression, or muscle surgery. Forty-two of 53 consecutive patients were enrolled after giving informed consent and fulfilling study entry criteria. Eleven eligible patients declined to participate because of inconvenience, desire for alternative therapy, or concern about radiation.

INTERVENTION

One randomly selected orbit was treated with 20 Gy of external beam therapy; sham therapy was given to the other side. Six months later, the therapies were reversed.

MAIN OUTCOME MEASURES

Every 3 months for 1 year, we measured the volume of extraocular muscle and fat, proptosis, range of extraocular muscle motion, area of diplopia fields, and lid fissure width. Effective treatment for GO will modify one or more of these parameters.

RESULTS

No clinically or statistically significant difference between the treated and untreated orbit was observed in any of the main outcome measures at 6 months. At 12 months, muscle volume and proptosis improved slightly more in the orbit that was treated first.

CONCLUSIONS

In this group of patients, representative of those for whom radiotherapy is frequently recommended, we were unable to demonstrate any beneficial therapeutic effect. The slight improvement noted in both orbits at 12 months may be the result of natural remission or of radiotherapy, but the changes are of marginal clinical significance.

A New Era in the Treatment of Thyroid Eye Disease

PURPOSE

Improved understanding of thyroid eye disease (TED) pathogenesis has facilitated identification of a targeted molecular approach for TED treatment offering the potential to halt or slow disease progression in a nonsurgical manner. Herein, we provide a summary of the current knowledge of TED management, followed by discussion of a novel insulin-like growth factor-1 receptor (IGF-1R) antagonist antibody and its potential to change the course of the disease.

DESIGN

Perspective.

METHODS

Review of the literature and authors' experience.

RESULTS

Many publications demonstrate IGF-1R overexpression in TED, and its activation as an autoantigen as a critical factor in TED pathogenesis. Several in vitro studies demonstrate that IGF-1R inhibition attenuates downstream molecular events including cytokine and hyaluronan production, and cellular differentiation. These observations led to the hypothesis that blocking IGF-1R may abrogate the clinical progression of TED. The recent completion of phase 2 and 3 randomized, placebo-controlled trials demonstrate the efficacy and safety of teprotumumab, a fully human monoclonal IGF-1R antagonist antibody, in patients with moderate-to-severe, active TED. Both the phase 2 and the recent phase 3 study results demonstrate that more patients with active TED receiving teprotumumab experienced a meaningful improvement in proptosis.

CONCLUSIONS

Current TED treatment strategies target inflammation and symptoms, but do not modify the disease course. Therefore, proptosis as well as strabismus and its resulting diplopia often remain, impacting patient well-being and quality of life over the long term. Targeted molecular therapy using teprotumumab demonstrates disease-modifying benefits with the potential to shift the paradigm for TED treatment.

A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression

Introduction: Different minimally invasive surgical approaches to the orbit allow individualized bone resection to reduce proptosis and decompress the optic nerve in patients with Graves' orbitopathy (GO). This study aims to compare piezosurgery to an oscillating saw used to resect bone from the lateral orbital wall. Methods: In a retrospective study, we analyzed balanced orbital decompressions performed on 174 patients (318 cases) with GO. An oscillating saw was used in 165 cases (saw group) and piezosurgery in 153 cases (piezo group). Peri- and postoperative complications, reduction of proptosis, new onset of diplopia and improvement of visual acuity in cases of pre-operative optic nerve compression were analyzed. Results: We observed no significant differences in the surgical outcome between the two groups. Proptosis reduction was 4.6 mm in the saw group (p < 0.01) and 5.3 mm in the piezo group (p < 0.01). Intraoperative handling of the piezosurgery device was judged superior to the oscillating saw, due to soft tissue conservation and favourable cutting properties. Duration of the surgery did not differ between the groups. No serious adverse events were recorded in both groups. Conclusion: The application of piezosurgery in orbital decompression is more suitable than an oscillation saw due to superior cutting properties such as less damage to surrounding soft tissue or a thinner cutting grove.

A novel FAM20C mutation causing hypophosphatemic osteomalacia with osteosclerosis (mild Raine syndrome) in an elderly man with spontaneous osteonecrosis of the knee

Raine syndrome is characterized by FGF23-mediated hypophosphatemic osteomalacia with osteosclerosis caused by mutations in the FAM20C gene. We report a case of a 72-year-old man who presented with rapid progressive spontaneous osteonecrosis of the knee (SONK). A full osteologic assessment including dual energy X-ray absorptiometry (DXA), high-resolution peripheral quantitative computed tomography (HR-pQCT), and serum analyses revealed a high bone mass in the lumbar spine and hip (DXA T-score + 7.5 and + 4.7/+4.2) with increased bone microstructural parameters in the distal radius and tibia (BV/TV 127%, 140% of the age-matched mean, respectively), as well as a low bone turnover state. Phosphate levels were low due to renal phosphate wasting and high FGF23 levels (126.5 pg/ml, reference range 23.2-95.4 pg/ml). Using gene panel sequencing, we identified a novel FAM20C heterozygous missense mutation in combination with a homozygous duplication that potentially alters splicing. Taken together, this is the first case of mild Raine syndrome with spontaneous osteonecrosis of the knee, phosphate wasting, and a pronounced trabecular high bone mass phenotype.

The Effect of Pulsed Electromagnetic Field on Patients with Endocrine Ophthalmopathy

Purpose

To evaluate eye signs, proptosis and ocular movements in patients with endocrine ophthalmopathy under the influence of pulsed electromagnetic field therapy.

Methods

We examined 14 patients (9 women, 5 men) with endocrine ophthalmopathy and evaluated eye signs, proptosis and ocular movements before and after the course of pulsed electromagnetic field therapy, and 12 controls. Their age ranged from 29 to 57 years. Visual sensitivity was investigated with a static automatic perimeter (Allergan Humphrey Field Analyzer). The score was calculated by rating the severity of involvement of soft tissue, proptosis, extraocular movements, corneal state and optic nerve function on a scale from 0 to 3. The pulsed electromagnetic field procedures were carried out with the help of electromagnetic spectacles.

Results

Pulsed electromagnetic field therapy reduced the score for soft tissue and proptosis in patients who suffered from endocrine ophthalmopathy. There was fall in the mean score for ocular movements, corneal and optic nerve function but it did not reach significance after treatment. Electromagnetic field therapy has no useful effect on visual signs and eye movements in two patients who had had the illness more than two years.

Conclusions

Localised pulsed electromagnetic field procedures can be recommended, together with other methods of conservative treatment of endocrine ophthalmopathy.

Non lethal Raine syndrome and differential diagnosis

Raine syndrome is a rare autosomal recessive bone dysplasia characterized by characteristic facial features with exophthalmos and generalized osteosclerosis. Amelogenesis imperfecta, hearing loss, seizures, and intracerebral calcification are apparent in some affected individuals. Originally, Raine syndrome was originally reported as a lethal syndrome. However, recently a milder phenotype, compatible with life, has been described. Biallelic variants inFAM20C, encoding aGolgi casein kinase involved in biomineralisation, have been identified in affected individuals. We report here a consanguineous Moroccan family with two affected siblingsa girl aged 18 and a boy of 15years. Clinical features, including learning disability, seizures and amelogenesis imperfecta, initially suggested a diagnosis of Kohlschutter-Tonz syndrome. However,a novel homozygous FAM20Cvariantc.676T > A, p.(Trp226Arg) was identified in the affected siblings. Our report reinforces that Raine syndrome is compatible with life, and that mild hypophosphatemia and amelogenesis imperfecta are key features of the attenuated form.

[COEXISTENCE OF ORBITAL VARICOSE VEIN AND THYROID ORBITOPATHY]

PURPOSE

To describe a thyroid orbitopathy patient who had asymmetric progression of exophthalmos due to orbital varicose vein.

PATIENT

A 55-year-old patient with thyroid orbitopathy had asymmetric progression of exophthalmos without complaints over 4 years of follow-up.

RESULTS

In repeated computerized tomography (CT) of the orbit, a dilation of the superior ophthalmic vein was noted on the more proptotic eye, in addition to bilateral excessive orbital fat. This finding was also confirmed on color Doppler imaging in valsalva manoeuver.

CONCLUSIONS

In patients with thyroid orbitopathy who have atypical progression course of their exophthalmos, repeated orbital CT scan is advocated to rule out other concurrent orbital disorders such as varicose veins.

Unusual Presentation of Lacrimal Gland Pleomorphic Adenoma

The pleomorphic adenoma of lacrimal gland presents as a painless, progressive, slowly growing supero-temporal swelling with variable proptosis. This tumor is usually found in adults and extremely rare in teenage. We report a case of a 15-year-old boy with pleomorphic adenoma of lacrimal gland which mimicked pseudotumor of orbit due to its presentation as an orbital inflammatory disease and the age distribution. Neuroimaging also suggested pseudotumor and oral steroid was started. But, there was no improvement on steroids and ultrasound guided Fine Needle Aspiration Cytology (FNAC) was performed which suggested Pleomorphic adenoma of the lacrimal gland. En-bloc excision of the mass through antero-lateral orbitotomy was done with satisfactory final outcome The histopathological evaluation was consistent with pleomorphic adenoma of the lacrimal gland.

[Rationale for distinguishing the lipogenic form of thyroid orbitopathy]

Pathogenesis of lipogenic form of thyroid orbitopathy (TO) is presented. 172 patients with TO are presented, among them 47 males (93 orbits) and 125 females (250 orbits). Features of clinical manifestations of lipogenic form of TO are described. The results of CT of extraocular muscles (EOM) and orbital fat volume are studied in these patients and the density of EOM is assessed.

A case report of orbital haemorrhage associated with endoscopic sinus surgery and reversible sight loss: a multidisciplinary approach to management

We report a case of intraoperative orbital haemorrhage as a complication of endoscopic sinus surgery performed under general anaesthesia. Initial unilateral complete visual loss occurred, but recovered due to accurate and early diagnosis combined with urgent surgical intervention. This patient's case is reported to illustrate the importance of early recognition of clinical signs and how a stepwise approach to management can result in a favourable visual outcome. Moreover, the mechanisms and pathophysiology of visual loss due to orbital haemorrhage following endoscopic sinus surgery are discussed.

[Soft oculopression]

BACKGROUND

The method of so-called oculopression is used to reduce the intraocular tension before intraocular operations. For outpatient cataract operations we tested a gentle and, especially for the patient, pleasant alternative which combines an easy and safe treatment with good results for tension reduction.

PATIENTS AND METHOD

For a total of 100 patients a routine examination glove was filled with 350 ml of warm tap water and after injection placed for 10 min on the eye scheduled for surgery.

RESULTS

With this method, an excellent and self-calibrating reduction of the intraocular pressure could be shown (average intraocular pressure before injection: 18.94 mmHg, after injection: 31.34 mmHg and after soft oculopression: 20.31 mmHg).

CONCLUSION

The method of soft oculopression can be recommended because of its excellent self-calibrating tension reducing effect combined with a pleasant and easy application.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus

PURPOSE

Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

METHODS

A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus.

RESULTS

The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms.

CONCLUSION

A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Results and predictability of fat-removal orbital decompression for disfiguring graves exophthalmos in an Asian patient population

PURPOSE

To evaluate proptosis reduction by fat-removal orbital decompression (FROD), to determine the incidence of postoperative diplopia, and to assess predictability of proptosis reduction per volume of resected orbital fat.

DESIGN

Cross-sectional study.

METHODS

One hundred and twenty patients (31 men; 89 women) with Graves ophthalmopathy were treated with FROD via the transforniceal approach on 222 orbits between April 2003 and April 2006. Fifteen (12.5%) patients exhibited preoperative diplopia; 105 (87.5%) were without diplopia; mean follow-up +/- standard deviation (SD) was 10.9 +/- 5.1 months (range, six to 37 months). Univariate and multivariate analyses were used to evaluate Hertel change with FROD by linear regression. The setting was thyroid eye disease special clinics at National Taiwan University Hospital.

RESULTS

Mean Hertel values +/- SD decreased from 20.3 +/- 1.8 mm (range, 16.5 to 26.0 mm) to 16.8 +/- 1.4 mm (range, 13.5 to 21.0). Mean proptosis reduction +/- SD was 3.6 +/- 1.0 mm (range, 1.5 to 7.5 mm). Mean volume of resected orbital fat +/- SD was 3.6 +/- 1.0 ml (range, 1.2 to 6.5 ml). New-onset diplopia was noted for 2.8% of patients after FROD. The final predictive equation for Hertel change is shown as: 0.72 x removal of intraconal fat (ml) - 0.001 x age (yrs) - 0.22 x gender (male, 1; female, 0) - 0.19 x preoperative diplopia (yes, 1; no, 0) + 1.02.

CONCLUSIONS

FROD can achieve reasonable proptosis reduction and can reduce incidence of new-onset diplopia for patients with disfiguring Graves exophthalmos. The volume of resected orbital fat correlates with mean Hertel value change. The amount of resected orbital fat may predict proptosis reduction.

Change in proptosis following extraocular muscle surgery: effects of muscle recession in thyroid-associated orbitopathy

PURPOSE

To evaluate the effect of strabismus surgery on proptosis in patients with thyroid-associated orbitopathy.

METHODS

The medical records of 22 consecutive patients with thyroid-associated orbitopathy undergoing strabismus surgery were reviewed. Data pertaining to the number of muscles operated on, amount of muscle recession, prior orbital decompression, and exophthalmometry were evaluated.

RESULTS

Thirty-eight eyes in 22 patients with thyroid-associated orbitopathy were studied before and after strabismus surgery. The mean change in exophthalmometry following strabismus surgery in all eyes was +0.6 mm (p < 0.01). Eyes with prior decompression averaged a 0.9 mm increase following strabismus surgery (p < 0.01); those without decompression averaged a 0.2 mm decrease (p = 0.658). In eyes that underwent two rectus muscle recessions the increase in Hertel measurements averaged 1.2 mm; when only one muscle was recessed, the average increase was 0.2 mm. In the eyes with muscle recession < or =5 mm, the mean exophthalmometric increase was 0.7 mm. When a muscle recession of more than 5 mm was performed, the exophthalmometry showed a mean increase of 0.5 mm.

CONCLUSIONS

Strabismus surgery on patients with thyroid-associated orbitopathy can worsen proptosis, especially in those with prior decompression. When planning for orbital decompression, the surgeon should consider this effect. Moreover, patients should be made aware of the possible changes to their appearance.

Intra-operative quantification of the surgical gesture in orbital surgery: application to the proptosis reduction

BACKGROUND

Proptosis is characterized by a protrusion of the eyeball due to an increase of the orbital tissue volume. To recover a normal eyeball positioning, the most frequent surgical technique consists in the osteotomy of orbital walls combined with a loading on the eyeball to initiate tissue decompression. The first biomechanical models dealing with proptosis reduction, validated in one patient, have been previously proposed by the authors.

METHODS

This paper proposed an experimental method to quantify the intra-operative clinical gesture in proptosis reduction, and the pilot study concerned one clinical case. The eyeball's backward displacement was measured by an optical 3D localizer and the load applied by the surgeon was simultaneously measured by a custom-made force gauge. Quasi-static stiffness of the intra-orbital content was evaluated.

FINDINGS

The average values for the whole experiment was 16 N (SD: 3N) for the force exerted by the surgeon and 9 mm (SD: 4mm) for the eyeball backward displacement. The averaged quasi-static stiffness of the orbital content was evaluated to 2.4N/mm (SD: 1.2) and showed a global decrease of 45% post-operatively.

INTERPRETATION

The protocol and the associated custom-designed devices allowed loads, induced displacements and macroscopic stiffness of the orbital content to be measured intra-operatively. The clinical relevance has been demonstrated in a pilot study. To our knowledge, no study has been published allowing the clinical gesture in proptosis reduction to be quantified intra-operatively. Associating an enlarged database and validated patient-related predictive models will reinforce the surgical efficiency and patient comfort contributing to diagnosis and intra-operative guidance.

MRI findings in isolated spontaneous thrombosis of the superior ophthalmic vein

We report the case of a 40-year-old woman with systemic lupus erythematosus who presented with spontaneous thrombosis of the superior ophthalmic vein resulting in permanent vision loss. The diagnosis was established by noncontrast CT scanning, gadolinium-enhanced MRI, and conventional catheter angiography.

Periocular Inflammation After Retrobulbar Chlorpromazine (Thorazine) Injection

PURPOSE

Retrobulbar chlorpromazine injection is a relatively recently described method of pain control in nonseeing eyes. This report illustrates severe sterile inflammation as a potential complication.

METHODS

In this university-based, retrospective, small case series, we reviewed the records of 2 female patients and 1 male patient (ages, 13 to 89 years) who developed severe inflammation after retrobulbar chlorpromazine injection.

RESULTS

Three patients had development of severe periocular edema after retrobulbar chlorpromazine injection. Two had development of chemosis, limited extraocular motility, proptosis, and incomplete eyelid closure, necessitating temporary tarsorrhaphy. The third patient had development of facial edema involving the ipsilateral eyelids, forehead, and cheek. Strikingly, it extended to the contralateral face. All 3 patients denied discomfort. In each case, swelling was first noted the day after injection and progressed for 1 week. All were treated with topical lubrication and two with temporary tarsorrhaphy. Resolution occurred within 3 weeks in each case.

CONCLUSIONS

Severe periocular inflammation can result from retrobulbar chlorpromazine injection and may manifest as chemosis, proptosis, limited ocular motility, and facial swelling that may extend well beyond the eyelids. Awareness of this potential adverse reaction is important both for patient counseling before injection and subsequent treatment. Specifically, a sterile inflammatory response should be differentiated from infection to avoid inappropriate therapy.

Prospective evaluation of fundus changes in patients with orbital mass lesions

PURPOSE

To study fundus changes associated with orbital mass lesions.

METHODS

In a prospective, interventional case series, 28 patients undergoing surgery for discrete orbital masses had detailed fundus examination under dilation using direct and indirect ophthalmoscopy. Preoperative visual acuity and the amount and duration of proptosis were noted. Fundus photographs were taken, and postoperative changes were documented. The main outcome measures were the frequency of various fundus changes and their correlation with other clinical features.

RESULTS

Nineteen (68%) of 28 patients had fundus changes; the commonest change was optic disk edema, seen in 14 patients (50%). The mean amount of proptosis +/- SD was 7.7 +/- 7.1 mm for patients with fundus changes and 4.22 +/- 2.1 mm for patients with normal fundus. Of 19 patients with fundus changes, 12 (63%) had an intraconal mass, and 11 (58%) had globe indentation. Twenty patients (71%) had diminished visual acuity preoperatively; of these patients, 8 (40%) had improvement in vision after surgery, 10 (50%) did not have any change in vision, and 2 (10%) had a postoperative decrease in visual acuity. Five (62%) of 8 patients with postoperative improvement in visual acuity had proptosis for < 2 years before surgery was undertaken, while only 1 (10%) of 10 patients retaining their preoperative vision had a duration of proptosis of < 2 years.

CONCLUSION

Fundus changes are frequently seen with orbital masses. An increased amount of proptosis, intraconal location, and globe indentation are associated with fundus changes. Postoperative improvement in visual acuity is less likely in patients with a longer duration of symptoms.

Sclerosing therapy as first line treatment for low flow vascular lesions of the orbit

PURPOSE

To evaluate the outcome of sodium morrhuate 5% injections in patients with low flow vascular lesions, which consist of orbital lymphangiomas, and in one patient with intraosseous cavernous hemangioma.

DESIGN

Prospective, interventional consecutive case series.

METHODS

Intralesional sodium morrhuate 5% was injected under direct visualization or under radiographic guidance to six patients with orbital lymphangiomas and one patient with intraosseous cavernous hemangioma. Comprehensive eye examination and follow-up imaging studies were performed. main outcome measures: Lesion size was evaluated by orbital imaging and clinical examination, visual acuity, exophthalmos, and posttreatment complications.

RESULTS

Seven patients (four female, three male; average age, 33 years) were included. Six patients were diagnosed with orbital lymphangioma, and one patient was diagnosed with intraosseous cavernous hemangioma. Patients received an average of 2.6+/-2 intralesional injections of sodium morrhuate, with a range of one to six injections and a mean volume of 0.9+/-0.8 ml (range, 0.2 to 2.1 ml). Lesions showed a decrease in size an average of 50% (33%) and ranged from minimal (10%) to near total resolution (85%). Visual acuity and intraocular pressure remained unchanged; exophthalmos decreased an average of 1.5+/-1.8 mm. Complications included one case of orbital hemorrhage that resolved spontaneously and transient keratopathy in all patients with anterior orbital lesions.

CONCLUSION

Intralesional sclerosing therapy with sodium morrhuate 5% is effective in tumor debulking in patients with orbital lymphangioma and is not associated with vision-threatening complications. It may be a better alternative to surgery for low flow orbital tumors, which includes lymphangioma.

The removal of the deep lateral wall in orbital decompression: its contribution to exophthalmos reduction and influence on consecutive diplopia

PURPOSE

To evaluate the contribution of maximal removal of the deep lateral wall of the orbit to exophthalmos reduction in Graves' orbitopathy and its influence on the onset of consecutive diplopia.

DESIGN

Case-control study.

METHODS

The medical records of two cohorts of patients affected by Graves' orbitopathy with exophthalmos > or = 23 mm, without preoperative diplopia, were retrieved at random from the pool of patients decompressed for rehabilitative reasons at our institution (01/1990 to 12/2003), and retrospectively reviewed. They had been treated with an extended (cases, group 1, n = 15) or conservative (controls, group 2, n = 15) 3-wall orbital decompression performed through a coronal approach. The deep portion of the lateral wall had been removed in the extended decompression group while preserved in the conservative decompression group. Demographics, preoperative characteristics, and surgical outcome were compared. The difference in mean exophthalmos reduction between groups 1 and 2 was considered to be the contribution of the deep lateral wall to reduction of exophthalmos.

RESULTS

Groups 1 and 2 were drawn from a pool of 37 and 335 patients, respectively. Demographics and preoperative characteristics of the two groups were not significantly different. The mean contribution of the deep lateral wall to exophthalmos reduction was 2.3 mm. The onset of consecutive diplopia was not significantly different between the two groups (case n = 2/15, controls n = 5/15; P = .203). Diplopia resolved spontaneously in all the patients of group 1, while all the patients of group 2 required surgery.

CONCLUSIONS

Removal of the deep lateral orbital wall as part of a coronal-approach, 3-wall decompression, enhances the degree of exophthalmos reduction without increasing the risk of consecutive diplopia.

Coronal or swinging eyelid decompression for patients with disfiguring proptosis in Graves' orbitopathy? Comparison of results in one center

PURPOSE

To compare 2 different approaches for 3-wall orbital decompression in patients with disfiguring proptosis due to Graves' orbitopathy, and to determine which technique is preferable.

DESIGN

Retrospective nonrandomized study with a concurrent comparison group.

PARTICIPANTS

Charts of 74 consecutive patients with disfiguring proptosis due to Graves' orbitopathy who underwent coronal (46) or swinging eyelid (28) decompression between January 1, 2000 and January 1, 2004 were studied retrospectively. Patients with dysthyroid optic neuropathy were excluded.

METHODS

We analyzed the following parameters: proptosis reduction, ocular motility, number of additional operations, number and kind of complications, patients' satisfaction, patients' estimation of numbness or abnormal sensations in the field of operation and surgical scars, and duration of hospitalization time.

MAIN OUTCOME MEASURES

Reduction of proptosis, changes in eye motility, and duration of hospitalization.

RESULTS

Mean proptosis reductions were 4.8 mm (range, 1-11) after coronal decompression and 5.6 mm (range, 0-8) after swinging eyelid decompression (P = 0.025). Patients who were operated by the swinging eyelid approach had no more deteriorated motility and a shorter hospitalization time. Complications were seen rarely. Both groups of patients showed high satisfaction scores.

CONCLUSION

Relative to the coronal approach, swinging eyelid decompression results in at least the same proptosis reduction, no greater motility disturbance, and a shorter hospitalization time.

Evaluation of extraocular muscles using dynamic contrast enhanced MRI in patients with chronic thyroid orbitopathy

OBJECTIVE

The purpose of the current study is to investigate the underlying pathophysiological changes of extraocular muscle (EOM) in Graves orbitopathy using dynamic contrast MR imaging and to correlate these MR functional changes with the anatomic abnormalities.

METHODS

EOMs of 16 patients with Graves disease and 12 normal volunteers were examined by dynamic enhanced MRI. We quantified the peak enhancement ratio of EOMs and calculated the ratio versus temporalis muscle and the ratio of maximum upslope versus temporalis muscle. We compared the ratios between normal volunteers and patient groups.

RESULTS

Mean of peak enhancement ratio values for the EOMs in patients with Graves disease tends to decrease according to the severity of the anatomic and clinical changes. The mean maximum upslope also decreased according to the severity of the disease for EOMs.

CONCLUSION

Hemodynamic information obtained by dynamic contrast enhanced MRI is useful in evaluating the clinical course of thyroid orbitopathy.

Horizontal Eyelid Movement on Eyelid Closure

PURPOSE

When performing ptosis surgery, a suture is placed between the levator and the tarsal plate at the point of the desired peak. This placement is done while the patient's eye is closed, but its effects are observed with the patient's eye open. Unaccounted-for horizontal eyelid movement on eyelid closing may therefore adversely affect the desired outcome. The purpose of this study was to characterize the horizontal translation of the eyelid on closing the eyes.

METHODS

In this experimental case series study, a randomly selected upper eyelid of normal subjects, subjects with ptosis, and subjects with exophthalmos, ages 21 through 70, was studied to determine the horizontal eyelid movement on closing the eyes by videotape analysis of the movement of dots placed above the eyelid margin and on the eyelid crease above the center of the pupil.

RESULTS

The eyelid translation on closing the eye is medial and varies among subjects from 0.1 mm to 3.5 mm. The movement is usually greater at the eyelid margin than at the eyelid crease.

CONCLUSIONS

The amount of horizontal eyelid translation on closing the eyes is clinically significant in many people. The clinical impact of this finding should affect how ptosis surgery is performed. The desired point of peaking of the eyelid should be marked at the beginning of the case with the eyes open and the mark used as a guideline for placing the suture that will determine the peak.

Customized, Single-Incision, Three-Wall Orbital Decompression

PURPOSE

To present the clinical outcome in 55 consecutive patients by using a customized, single-incision, 3-wall orbital decompression.

METHODS

A retrospective chart review was performed of 97 customized, single-incision, 3-wall decompressions in 55 consecutive patients within one surgeon's practice. A standardized surgical technique featuring lateral small-incision, 3-wall decompression with specific "strut" preservation was used in all patients. Success of the procedure was assessed on the basis of the amount of proptosis reduction achieved, as measured by the difference in Hertel exophthalmometry measurements, and by improvement in or preservation of preoperative visual acuity and color vision in the setting of compressive optic neuropathy. Subjective diplopia was recorded before and after surgery, as was the presence of extraocular muscle restriction.

RESULTS

A total of 97 orbital decompressions in 55 consecutive patients were reviewed. The majority of surgeries were performed for disfiguring proptosis with some degree of exposure-related symptoms (81%), with other indications including compressive optic neuropathy (17%), and pain (2%). The average amount of proptosis reduction achieved at 3 months was 5 mm (range, 1 to 11 mm). Visual acuity in patients with compressive optic neuropathy improved an average of 2 lines on the standard Snellen chart testing (range, 1 to 5). Color vision improved an average of 5 Ishihara plates (range, 0 to 13). Seventy-one percent of patients had subjective diplopia before surgery; 21% of these patients reported improvement or complete resolution of diplopia after surgery. Of the 29% of patients without preoperative subjective diplopia, all but one (1.8 of total patients) remained symptom free.

CONCLUSIONS

We find that a customized, single-incision, 3-wall orbital decompression provides adequate decompression and proptosis reduction while minimizing postoperative strabismus and providing an aesthetically desirable result.

Pentoxifylline (PTX)--an alternative treatment in Graves' ophthalmopathy (inactive phase): assessment by a disease specific quality of life questionnaire and by exophthalmometry in a prospective randomized trial

PURPOSE

To investigate the effect of pentoxifylline (PTX) in subjects with inactive Graves' ophthalmopathy (GO) through a specific quality of life (QOL) questionnaire and exophthalmometry readings.

METHODS

Eighteen females were randomly divided in two groups. Group A (n=9) was treated with PTX 1200 mg orally/day for 6 months. Group B (n=9) received placebo during the initial 6 months and then PTX for another 6 months. Proptosis measurements were carried out every 3 months and a questionnaire graded from 0 to 10 according to the severity of the symptoms was performed at baseline and after placebo and PTX administration.

RESULTS

At baseline, Group A questionnaire score values were 5.5 (median; range 3.5 to 8.0), and 5.0 after 6 months (3.0 to 6.0; p=0.01). In Group B, baseline values were not significantly different after 6 months of placebo: 6.0 (4.5 to 7.0) and 5.5 (4.5 to 7.0), respectively. However, a significant change was observed 6 months after PTX: 4.0 (2.0 to 5.0; p<0.001). Patients in Group A had a progressive improvement of proptosis during PTX: at baseline, 23 mm (median; range 20 to 32); after 3 months, 23 mm (18 to 30; p=0.02); and after 6 months, 23 mm (18 to 30; p=0.005). In Group B, proptosis remained stable during placebo: at baseline, 23 mm (21 to 25); after 3 months, 23 mm (20 to 25); and after 6 months, 23.5 mm (20 to 25). A significant change was observed after 3 and 6 months of PTX: 22 mm (19 to 24; p=0.0006) and 20.8 mm (17 to 25; p=0.0003), respectively.

CONCLUSIONS

Pentoxifylline seems to improve the QOL of patients in the inactive phase of GO. The objective findings of the proptosis readings corroborate to suggest that PTX may be an effective and promising drug in the inactive phase of GO.

Primary-gaze diplopia in patients with thyroid-related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome

Our goal was to investigate the incidence of postoperative primary gaze diplopia in patients with thyroid-related orbitopathy (TRO) undergoing deep lateral wall orbital decompression surgery with intraconal fat debulking in the Jules Stein Eye Institute over a period of 4(1/4) years. Overall 201 orbital decompression surgeries were performed in 116 patients (23 males, 93 females). All surgeries were performed by two of the authors (R.A.G. and J.D.M.) and in the noninflammatory phase of the disease. Exophthalmos decreased by an average of 3.4 +/- 2.7 mm from 23.8 +/- 3.2 mm (17-31) to 20.4 +/- 2.5 mm (14-29), p < 0.001, 95% confidence interval (CI) (3.0:3.8). 31% of patients had preoperative primary gaze diplopia and 28.4% had postoperative primary gaze diplopia. Thirty (83%) of the 36 patients with preoperative diplopia had also postoperative diplopia; 6 (16.7%) of the 36 patients had improvement in diplopia following deep lateral wall decompression. Of the 80 (69%) of patients without preoperative double vision 3 developed postoperative double vision in primary gaze (2.6% of all patients). These 3 patients were older (56 versus 46 years, p = 0.047), had more limitation in ocular movements (p = 0.017) and achieved more decrease in proptosis with surgery (6 versus 3.1 mm, p = 0.024). No complications were associated with orbital decompression. In conclusion deep lateral wall orbital decompression surgery with intraconal fat debulking is associated with a low rate (2.6%) of new-onset primary gaze diplopia. Some patients (5.2%) with preoperative diplopia actually had improvement in diplopia postoperatively. This surgery is effective in reduction of congestion and exophthalmos, and is not associated with detrimental effects on visual acuity.

Late reactivation of thyroid orbitopathy

BACKGROUND

Thyroid orbitopathy is characterized by spontaneous remissions and exacerbations. Although data on the natural history are scarce, the active phase is usually self-limited, encompassing an average period of 18-36 months. Late reactivation, defined as active orbitopathy occurring after more than 5 years of quiescent disease, appears to be an uncommon and poorly documented event. The aim of the present study was to assess the incidence and characteristics of late reactivation of thyroid orbitopathy within a tertiary referral orbital clinic.

METHODS

A retrospective case review was conducted of patients with thyroid orbitopathy seen at the Royal Adelaide Hospital Orbital Clinic between 1996 and 2001.

RESULTS

From 193 cases of thyroid orbitopathy, eight cases (5%) of late reactivation were identified. The mean age of patients was 51 years (range 32-76 years) with a female to male ratio of 3:1. All cases presented with proptosis and seven demonstrated increased diplopia and gaze restriction. Signs of soft tissue inflammation were seen in three cases. All were euthyroid at presentation with a past history of thyroid orbitopathy and hyperthyroidism. One patient had an association of smoking with reactivation but the remainder had no discernible precipitants. The average interval between the initial orbitopathy and reactivation was 12 years (range 6-30 years). Computed tomography revealed enlarged extraocular muscles in seven cases and two showed partial response to treatment with low dose radiotherapy and steroids. The average length of disease activity was 14 months (range 9-18 months).

CONCLUSION

Late reactivation of thyroid orbitopathy appears to be an uncommon phenomenon. It may occur under euthyroid conditions with no obvious precipitants and often presents as a reactivation of myopathy.

[Concentrations of soluble vascular cell adhesion molecule-1 (sVCAM-1) in patients witt Graves' disease and thyroid associated orbitopathy]

The aim of this study is to evaluate serum concentrations of sVCAM-1 in patients with Graves' disease (GD) and thyroid associated orbitopathy (TAO). We measured serum sVCAM-1 levels in initially hyperthyroid GD patients without TAO, in patients with progressive and stable orbitopathy in euthyroid stage of GD and healthy controls. The highest serum concentrations of sVCAM-1 were observed in patients with hyperthyroid GD. In patients with euthyroid GD and progressive TAO, sVCAM-1 levels were slightly decreased than those in the group of patients with hyperthyroid GD and markedly elevated in comparison to the group of patients with stable TAO. In patients with hyperthyroid GD, sVCAM-1 concentrations dropped significantly after they had become euthyroid , but were still higher than those observed in group of patients with stable TAO and healthy people. Serum levels of sVCAM-1 in early stage of the progressive TAO (<6 m-ths) were higher than those in late stage of the disease (>6 m-ths), despite lower orbitopathy index (OI) found in early stage of the orbitopathy (<6 m-ths). In conclusion, both hyperhyroidism and TAO may contribute to elevated levels of sVCAM-1. A significant decrease in sVCAM-1 levels in initially hyperthyroid GD patients is associated with euthyroid stage of the disease. Concentrations of sVCAM-1 seem to correlate with the activity, not severity of progressive TAO.

[Assessment of soluble E selectin levels in patients with Graves' disease and thyroid orbitopathy]

The aim of this study is to evaluate serum concentrations of sELAM-1 in patients with Graves' orbitopathy (GO). We studied levels of soluble form of E selectin -1 in patients with euthyroid progressive GO (group I) and euthyroid stable GO (group II), hyperthyroid Graves' disease (GD) without GO (group III) and in healthy controls (group IV). sELAM-1 levels were measured by ELISA method. The highest serum levels of sELAM-1 were found in group III. Mean sELAM-1 concentrations in patients with progressive and stable GO were slightly lower than those in group III patients. The sELAM-1 serum concentrations in group I and II were comparable, nearly the same despite the different clinical picture of the disease in both groups. Mean serum concentrations of sELAM-1 decreased significantly during treatment of progressive GO, parallel to the improvement of the eye changes. In conclusion, sELAM-1 concentrations do not reflect the degree of GO activity. A significant decrease in sELAM-1 concentrations are associated with the efficient outcome of treatment. Increased sELAM-1 levels seem to result form both GO and GD.

[Thyroid orbitopathy (pathogenesis, diagnosis and treatment)]

PURPOSE

To review and to update the current diagnostic and therapeutic approaches and the pathogenesis of thyroid orbitopathy. To propose a practical, basic and precocious approach based in the knowledge of the disorder.

METHODS

Literature review and exposition of our experience in the management of thyroid orbitopathy.

RESULTS

Thyroid orbitopathy is an inflammatory orbital disease that probably has an autoimmune origin and most of the time is related to systemic disorders of the thyroid gland. The disease has a variable clinical presentation and it may cause severe damage in vision and orbital architecture, therefore, producing a decrease in the patient's quality of life and may also alter significantly the personal behavior. Pathogenesis of the disease is not yet fully understood, but it is widely held that there is a common autoantigen shared between the thyroid gland and the orbital adipogenic fibroblasts. Women are more likely to develop thyroid orbitopathy, and the disease is clearly affected by several factors such as smoking, age, sex and race.

CONCLUSIONS

Clinical knowledge is essential for the early diagnosis of this disorder, and it is the most important factor for the proper management of the disease. The medical treatment must be initiated promptly and should be aggressive and based in the current phase of the disease, in order to avoid the severe damage that follows thyroid orbitopathy. The surgical approach must be logical and sequential, but, on the other hand, must be rapid and aggressive in order to return the patient to his/her labour, social and familiar environment.

Balanced orbital decompression combined with fat removal in Graves ophthalmopathy: do we really need to remove the third wall?

PURPOSE

To compare the reduction of proptosis and the incidence of new-onset diplopia after 3-wall (medial, lateral, and inferior) orbital decompression versus balanced medial and lateral wall decompression combined with orbital fat excision in patients with Graves ophthalmopathy.

METHODS

Three-wall orbital decompression including medial, inferior, and lateral walls was performed in 13 eyes of 7 patients (group 1), and balanced medial and lateral wall decompression combined with fat removal was performed in 18 eyes of 11 patients (group 2). A transnasal endoscopic approach was used for medial wall removal. A lateral canthotomy incision combined with a short upper eyelid incision was used for extended lateral wall removal, and this was combined with an inferior conjunctival fornix incision when floor decompression was performed.

RESULTS

The mean reduction of proptosis was 6.9+/-1.6 mm and 6.5+/-1.3 mm in the first and second groups, respectively; the difference was not statistically significant (P=0.37). After 3-wall decompression, 57.1% of the patients had permanent new-onset diplopia (group 1), whereas none of the patients had permanent postoperative diplopia after balanced medial and lateral wall decompression combined with fat removal (group 2). The difference in permanent new-onset postoperative diplopia between two groups was statistically significant (P<0.001).

CONCLUSIONS

Balanced medial and lateral wall decompression combined with orbital fat removal provides an effective reduction in proptosis and reduces the incidence of postoperative permanent diplopia when compared with 3-wall decompression. This technique may eliminate the need for orbital floor excision.

Pterional orbital decompression in diseases with acute increase of intraorbital pressure

BACKGROUND

Orbital cellulitis as well as traumatic or spontaneous intraorbital hemorrhages can lead to an acute rise of intraorbital pressure, threatening the function of orbital vascular, muscular and neural structures. The treatment of this rare entity with extended pterional orbital decompression is described in comparison with other methods of orbital decompression.

PATIENTS AND METHODS

Between 1991 and 2000 the authors treated 16 patients with sight-threatening acute elevations of intraorbital pressure due to orbital cellulitis (3 patients) and spontaneous (3 patients), postoperative (1 patient) or traumatic diffuse or localized intraorbital hemorrhage (9 patients) with extended pterional orbital decompression. Pre- and postoperative parameters, like visual acuity, exophthalmos, restrictions of extraocular motility and pupillary disturbances, were retrospectively analyzed.

RESULTS

In all patients, a distinct improvement of preoperative symptoms, like complete reduction of proptosis in all cases, improvement of visual acuity in 12 patients, improvement of eye motility disturbances in 14 patients and of afferent pupillary disturbances in 6 patients, was achieved by decompressing the orbital contents within a mean of 30.5 hours after onset of symptoms. Severe, operation-related complications were not seen.

CONCLUSION

Extended pterional orbital decompression represents an effective treatment alternative and supplement in cases of severe, ocular function-threatening cases of acute elevated orbital pressure, due, for example, to orbital cellulitis or diffuse or localized spontaneous and traumatic intraorbital hemorrhage, where immediate reduction of pressure on orbital neural, muscular and vascular structures is intended.

High dose intravenous methylprednisolone pulse therapy versus oral prednisone for thyroid-associated ophthalmopathy

PURPOSE

To compare the effectiveness of intravenous (i.v.) methylprednisolone pulse therapy and oral prednisone when used as the initial treatment of patients with mild or moderate thyroid-associated ophthalmopathy.

METHODS

Thirty-three consecutive patients with thyroid-associated ophthalmopathy in Helsinki and Turku University Hospitals were randomly assigned either i.v. methylprednisolone pulse therapy (group A, n = 18) or oral prednisone (group B, n = 15). Treatment outcomes were measured by subjective changes in the grade of diplopia and quantitatively in several ophthalmic variables at 3 and 12 months. Any decision to proceed with additional treatment at 3 months was made on clinical grounds. The study was open in respect of both the initial treatment and the need for additional therapy.

RESULTS

No significant differences in the grade of diplopia, proptosis or soft tissue activity scores were noted between groups A and B from 0 to 3 months. However, group A required additional forms of therapy at 3 months less frequently than did group B (p = 0.038).

CONCLUSIONS

Our data suggest that i.v. methylprednisolone pulse therapy and oral prednisone are equally effective as initial treatments for thyroid-associated ophthalmopathy where diplopia, proptosis and signs of soft tissue inflammation are concerned. When additional treatment is required, i.v. methylprednisolone pulse therapy may be more effective than oral prednisone. However, the study's limitations meant that any decision to give additional treatment after the initial therapy was made on clinical grounds.

Comparison of the effectiveness and tolerability of intravenous or oral glucocorticoids associated with orbital radiotherapy in the management of severe Graves' ophthalmopathy: results of a prospective, single-blind, randomized study

Eighty-two consecutive patients with moderate-to-severe and active Graves' ophthalmopathy were randomly treated with orbital radiotherapy combined with either oral (prednisone; starting dose, 100 mg/d; withdrawal after 5 months) or iv (methylprednisolone; 15 mg/kg for four cycles and then 7.5 mg/kg for four cycles; each cycle consisted of two infusions on alternate days at 2-wk intervals) glucocorticoids. The two groups did not differ for age, gender, duration of hyperthyroidism and ophthalmopathy, prevalence of smokers, thyroid volume, and pretreatment ocular conditions. Both groups of patients received radioiodine therapy shortly before treatment for Graves' ophthalmopathy. Follow-up lasted for 12 months. A significant reduction in proptosis (from 23.2 +/- 3.0 to 21.6 +/- 1.2 mm in the iv glucocorticoid group, P < 0.0001; and from 23 +/- 1.8 to 21.7 +/- 1.8 mm in oral glucocorticoid group, P < 0.0001) and in lid width (from 13.3 +/- 2.5 to 11.8 +/- 2.2 mm, and from 13.6 +/- 2.0 to 11.5 +/- 1.9 mm, respectively; P < 0.001 in both cases) occurred, with no difference between the two groups. Diplopia significantly improved in both groups: it disappeared in 13 of 27 (48.1%) iv glucocorticoid patients (P < 0.005) and in 12 of 33 (36.4%) oral glucocorticoid patients (P < 0.03). The degree of amelioration of diplopia did not significantly differ between the two groups (P = 0.82). Optic neuropathy improved in 11 of 14 iv glucocorticoid (P < 0.01) and only in 3 of 9 oral glucocorticoid (P = 0.57) patients, with no significant difference in these outcomes. The Clinical Activity Score decreased from 4.5 +/- 1.2 to 1.7 +/- 1.0 (P < 0.0001) in the iv glucocorticoid group and from 4.2 +/- 1.1 to 2.2 +/- 1.2 (P < 0.0001) in the oral glucocorticoid group; final Clinical Activity Score was significantly lower in iv glucocorticoid than in oral glucocorticoid patients (P < 0.01). By self-assessment evaluation, 35 (85.3%) iv glucocorticoid and 30 (73.2%) oral glucocorticoid patients reported an improvement of ocular conditions (P = 0.27). Overall, both treatments produced favorable effects in most patients, but responders in the iv glucocorticoid group (36 of 41, 87.8%) were more than in the oral glucocorticoid group (26 of 41, 63.4%) (P < 0.02). Moreover, iv glucocorticoid treatment was better tolerated than oral glucocorticoid treatment. Side effects occurred in 23 (56.1%) iv glucocorticoid and 35 (85.4%) oral glucocorticoid patients (P < 0.01); in particular, cushingoid features developed in 5 of the former and 35 of the latter patients. One iv glucocorticoid patient had severe hepatitis of undetermined origin at the end of glucocorticoid treatment, followed by spontaneous recovery. In conclusion, high-dose iv glucocorticoid and oral glucocorticoid (associated with orbital radiotherapy) are effective in the management of severe Graves' ophthalmopathy, but the iv route seems to be more effective and better tolerated than the oral route and associated with a lower rate of side effects.

Orbital varices: imaging findings and the role of color Doppler sonography in the diagnosis

The orbital varices are infrequent intraorbital masses, which cause intermittent, positional exophthalmos. They have low venous pressure inside which causes difficulties in detection by routine protocols of nearly all imaging modalities. Color Doppler sonography is a simple procedure that can easily detect orbital varices which avoids further evaluation in non-complicated patients. We report the imaging findings of a case of orbital varix and discuss the role of color Doppler sonography in the diagnosis and follow-up.

Follow-up of transnasal orbital decompression in severe Graves' ophthalmopathy

OBJECTIVE

To evaluate the safety and efficacy of transnasal orbital decompression for severe Graves' ophthalmopathy.

DESIGN

Retrospective noncomparative case series with extended clinical follow-up.

PARTICIPANTS

Seventy-eight consecutive subjects who were operated on for compressive optic neuropathy with loss of visual acuity or visual field defects after failure of medical and radiation therapy.

INTERVENTION

Strictly transnasal, endoscopic-controlled bilateral decompression of the medial and inferomedial wall of the orbit.

MAIN OUTCOME MEASUREMENTS

Preoperative and postoperative examination, including vision, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and notification of complications, intranasal signs of inflammation, and subjects' assessment of the procedure.

RESULTS

One hundred forty-five endonasal decompressions were performed on 78 subjects (63 women, 15 men, 52.2 +/- 10.3 years) during a 10-year period. Sixty five patients were bilaterally operated on; 15 required only unilateral decompression. Four of 78 needed repeat surgery. Visual acuity increased from a preoperative average of 0.50 +/- 0.27 (range, 0.01-1.25) to 0.75 +/- 0.21 (range, 0.01-1.25) postoperatively. An average reduction of proptosis of 3.94 +/- 2.73 mm (range, -1.0-11.0 mm) was achieved with a mean preoperative Hertel measurement of 22.19 +/- 3.13 mm (range, 15-34 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 of 78 cases. Twenty-six of these 58 cases were simultaneously operated on in the same surgical session immediately after the transnasal decompression, and the others after a period of 2 to 3 months.

CONCLUSIONS

The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques, and had favorable cosmetic results without additional disfiguration by scars. Morbidity was far less than with other approaches. Postdecompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.

Results of a neurosurgical two-wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy

PURPOSE

Follow-up of patients with severe thyroid associated ophthalmopathy treated with a transcranial two-wall orbital decompression and reconstruction.

METHODS

A two-wall transcranial orbital decompression was performed in 30 such patients (50 eyes). The patients were evaluated one month postoperatively, and long-term evaluation (median 14 months, range 2-54 months) was carried out. The main outcome measures were visual acuity, proptosis measured by Hertel ophthalmometry, soft tissue involvement, and restriction of eye motility.

RESULT

Visual acuity improved rapidly in 28 of 32 affected eyes with normalization in 19 eyes (p<0.001). Worsening was not seen. Median proptosis was reduced by 4.0 mm, range 0-10.0 (p<0.001). Double vision was present in 24 patients before operation 14 of whom achieved binocular vision (p<0.001). Three patients had unchanged complaints and the double vision worsened in one patient. Seventeen of 20 patients on preoperative corticosteroid treatment discontinued this medication in relation to surgery. Complications included one case of perioperative minor stroke and two cases of facial nerve frontal branch palsy.

CONCLUSION

The transcranial two-wall decompression is a simple, an efficient and a low-risk procedure for treatment of patients with severe thyroid associated ophthalmopathy.

Intraocular pressure changes after treatment for Graves' orbitopathy

OBJECTIVE

To evaluate the change in intraocular pressure (IOP) in subjects with Graves' orbitopathy (GO) after orbital decompression, strabismus surgery, and orbital radiation.

DESIGN

Retrospective case review.

METHODS

The charts of 172 consecutive subjects from the Neuro-ophthalmology Service at Wills Eye Hospital (Philadelphia, PA) with GO who underwent either orbital decompression, strabismus surgery, or orbital radiation between 1994 and 1999 were analyzed. Subject age, gender, diagnosis of glaucoma in either eye, use of systemic steroids or topical glaucoma medications, procedure performed, and the preoperative and postoperative IOP (in primary position and upgaze) were evaluated.

RESULTS

Of 116 eyes that underwent orbital decompression, the mean preoperative IOP was 21.6+/-4.6 mmHg (standard deviation) in primary position and 27.9+/-6.8 mmHg in upgaze. The postoperative IOP was 17.5 mmHg +/- 3.0 mmHg in primary position and 20.1+/-4.7 mmHg in upgaze, a decrease in IOP of 18.9% in primary position and 27.9% in upgaze (P<0.001). Subjects taking glaucoma medication or who had IOP greater than 21 mmHg demonstrated a significantly (P<0.001) greater reduction in IOP postoperatively. The mean preoperative IOP in the 32 subjects who had strabismus surgery was 18.5+/-2.8 mmHg (primary position), and 24.7+/-4.3 mmHg (upgaze). Postoperative IOP was 16.1 mmHg (primary position) and 16.9 mmHg (upgaze), a decrease of 2.4 mmHg (13.3%, P<0.01 in primary position) and 7.8 mmHg (31.2%, P<0.01 in upgaze). There was no statistically significant reduction in IOP after orbital radiation.

CONCLUSIONS

In the selected subgroup of subjects with GO who required intervention, orbital decompression and strabismus surgery resulted in a significant reduction in IOP in the early postoperative period, especially in subjects with preoperative IOP greater than 21 mmHg.

The course of Graves' ophthalmopathy is not influenced by near total thyroidectomy: a case-control study

OBJECTIVE

The relationship between the method of treatment of hyperthyroidism due to Graves' disease and the course of Graves' ophthalmopathy is debated. Antithyroid drug therapy is associated with no change, or even amelioration, of ophthalmopathy. Although controversial, radioiodine may be followed by progression of eye disease, preventable by glucocorticoid administration. Whether thyroidectomy affects the course of ophthalmopathy is uncertain.

DESIGN

In a case control study, the course of non-severe Graves' ophthalmopathy after thyroidectomy was investigated and the results compared with those observed in patients treated with methimazole.

PATIENTS

Thirty patients with Graves' hyperthyroidism and non-severe/absent ophthalmopathy were treated with near-total thyroidectomy (Group 1, Tx), after achievement of euthyroidism with methimazole. After surgery, all patients started levothyroxine replacement therapy. Sixty patients treated with methimazole, matched for age, sex, duration of hyperthyroidism, degree of ocular involvement and smoking habits, were used as controls (Group 2, MMI).

MEASUREMENTS

Patients were seen every 1-2 months for 12 months for thyroid tests and ocular evaluation.

RESULTS

In Group 1, ocular parameters did not change in 17 of 18 patients with pre-existing ophthalmopathy, and in 12 patients without ophthalmopathy. Eye manifestations worsened only in one (3.3%) patient with pre-existing ophthalmopathy. In Group 2, ocular parameters did not change in 58 patients (33 with, and 25 without ophthalmopathy), while new ophthalmopathy occurred in two without pre-existing eye disease. One of the 30 patients treated by surgery (3.3%) had permanent hypoparathyroidism.

CONCLUSIONS

Treatment of Graves' hyperthyroidism with near-total thyroidectomy in patients with non-severe or absent pre-existing ophthalmopathy is not associated in the short term with significant effects on the course of ophthalmopathy.