The effect of intravenous high-dose glucocorticoids and orbital decompression surgery on sight-threatening thyroid-associated ophthalmopathy

AIM: To report the effects of intravenous high-dose glucocorticoids (ivGC) and orbital decompression (OD) surgery for treatment of sight-threatening thyroid-associated ophthalmopathy (TAO). METHODS: A retrospective review of medical records from patients with sight-threatening TAO [definite or highly suspected dysthyroid optic neuropathy (DON)] treated with ivGC (60 cases) and OD (25 cases) was conducted at the Zhongshan Ophthalmic Center between January 2001 and January 2009. Patients were initially treated with ivGC (ivGC group). If no significant improvement in visual function was obtained, they then received OD surgery (OD group). The pre- versus post-treatment efficacies of either ivGC or OD in these patients were assessed using several indices, including visual acuity, intraocular pressure, ocular alignment, ocular motility, and exophthalmos. RESULTS: Nighty-one eyes had definite DON while 79 were considered to have highly suspected DON. In the ivGC group, 51 individuals (85.0%) eventually demonstrated normal vision, while 10 patients (16.7%) demonstrated a reduction in deviation (P<0.01), and 35 cases (58.3%) showed slight improvements in ocular motility (P<0.01). In OD group, visual acuity improved in 24 cases (96.0%, P<0.01) and all patients showed varying reductions of exophthalmos (mean: 4.35±1.13 mm, P<0.01). Eight cases (32.0%) experienced an 8-15 PD reduction of deviation and ocular motility improved in 12 cases (48.0%), while 3 patients (12.0%) developed new-onset strabismus with diplopia post-surgically (P<0.01). Patients were followed up at an average of 1.55±1.07y. CONCLUSION: Both ivGC and OD show good therapeutic efficacy in the treatment of sight-threatening TAO. The presence of extremely poor eyesight (≥0.5logMAR) was corrected in some patients with ivGC alone, thus sparing these patients from subsequent OD surgery. In patients who were refractory to steroids, subsequent OD surgery often provided satisfactory outcomes, however, new-onset strabismus with diplopia was observed in 12.0% of these cases.     

眼眶平衡减压术治疗甲状腺相关眼病

目的 探讨平衡眼眶减压术治疗甲状腺相关眼病的疗效和手术方法。方法 采用内外壁眼眶减压术治疗20例35眼甲状腺相关眼病患者。术后随访平均14个月。观察术后视力、眼球突出度和眼球运动等情况。结果 20例35眼中除1例行眶外壁减压外，其余均行内外壁平衡眼眶减压术。眼球突出度缓解3～11mm，其中3～4mm者5眼，5～9mm者28眼，10～11mm者2眼，平均6．32mm。视力从术前数指提高至0．1者6眼，提高2行以上者8眼，无变化21眼。术后眼球运动明显好转者9眼，运动障碍加重2眼。无视力丧失及术后感染。结论 平衡眼眶减压术是治疗甲状腺相关眼病的有效方法。     

The effect of orbital decompression surgery on refraction and intraocular pressure in patients with thyroid orbitopathy

Purpose

To investigate the effect of orbital decompression surgery in thyroid orbitopathy (TO) on both refractive status and intraocular pressure (IOP).

Patients and methods

A prospective, multicentre, consecutive audit of patients undergoing thyroid decompression surgery. Indications for surgery included cosmetically unacceptable proptosis or corneal exposure. Exclusion criteria included the following: previous orbital surgery, glaucoma, corneal disease, steroid use in the preceding 12 months, or an acute optic neuropathy. Automated refraction, keratometry, pachymetry, Hertel exophthalmometry, and IOP were recorded at 1 month pre- and 3 months postoperatively. IOP using the Tono-Pen (mean of three readings) was measured in the primary, upgaze, and downgaze positions.

Results

Data were collected from 52 orbits of 33 patients (East Grinstead, New York, and Adelaide). There was no significant difference between pre- and postoperative data for sphere, cylinder, or central corneal thickness (CCT). The mean spherical equivalent was −0.43±1.49 D pre-operatively and −0.28±1.52 D postoperatively. The steepest meridian of corneal curvature was 93.1 degrees pre- and 94.2 degrees postoperatively, with no significant difference. Mean IOP significantly decreased when measuring by Goldmann applanation tonometry (GAT) (2.28 mm Hg, ^* P=0.001) and Tono-Pen (3.06 mm Hg, ^* P=<0.0001). IOP measured in upgaze was significantly greater than that in the primary position. Regression analysis between change in IOP and either Hertel exophthalmometry or the number of orbital walls decompressed was non-significant (^*Student''s t-test).

Conclusion

Patients with TO undergoing orbital decompression had, on average, with-the-rule astigmatism not affected by orbital decompression surgery. IOP was significantly reduced by decompression surgery although no relationship between IOP and the degree of decompression was observed.     

Abducens nerve palsy after orbital decompression

Introduction: Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED.

Aim: We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery.

Results: Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring.

Discussion: Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.     

Sight-threatening orbital emphysema treated with needle decompression

Orbital emphysema is rare in the absence of trauma, and is unlikely to result in visual loss. The authors describe a patient with no prior trauma who presented with decreased vision and increased intraocular pressure due to severe orbital emphysema after a sneeze. Computed tomography revealed subcutaneous emphysema of the lid and extraconal air in the orbit. Emergency needle decompression resulted in improvement in vision and intraocular pressure.     

深外侧壁联合内侧壁眼眶减压术治疗甲状腺相关性眼病

目的：探究深外侧壁联合内侧壁眼眶减压术治疗甲状腺相关性眼病的临床治疗效果及安全性。

方法：分析我科既往住院患者病历,纳入2019-01/2020-05在我科住院的符合纳入标准的甲状腺相关性眼病患者17例。所有患者均在全身麻醉下行深外侧壁联合内侧壁眼眶减压术,比较患者术前术后的视力、暴露性角膜炎恢复情况、突眼度、眼压以及并发症情况。

结果：所纳入研究的对象中,有甲状腺相关眼病视神经病变(DON)8例9眼,术前的最佳矫正视力0.78±0.15,术后1mo 0.36±0.12,与术前视力相比有差异(P<0.01),术后6mo 0.38±0.12,与术后1mo无差异(P=0.594)。术前眼球突出度23.75±2.55mm,术后1mo为14.85±1.53mm,与术前突眼度相比有差异(P<0.01),术后6mo为14.60±1.64mm,与术后1mo基本保持稳定(P=0.658)。术前眼压25.56±3.23mmHg,术后1mo为18.42±2.35mmHg,与术前相比有差异(P<0.01),术后6mo眼压降至15.82±2.57mmHg,与术后1mo眼压相比有差异(P<0.01)。术前有暴露性角膜炎6例6眼,术后1mo有4眼好转,2眼治愈,术后6mo 6眼全部治愈。术后患者复视情况均有不同程度减轻,并有部分患者复视症状在此后6mo持续好转,未出现其他严重并发症。

结论：深外侧壁联合内侧壁眼眶减压术可以有效地改善眼突,对DON及暴露性角膜炎等严重并发症也有良好的疗效,并发症少,是治疗严重甲状腺相关性眼病的有效手术方案。     

眼眶减压术对甲状腺相关眼病患者脉络膜厚度的影响

目的:探究眼眶减压术对甲状腺相关眼病(TAO)患者黄斑区中心凹脉络膜厚度(CMCT)的影响。方法:前瞻性临床研究。分析2021-01/2022-01在我科治疗的TAO患者29例42眼,根据病情严重程度分为中重度组20例30眼和极重度组9例12眼。两组患者均接受眼眶减压术治疗,比较两组患者术前,术后3、6mo CMCT、最佳矫正视力、眼压、眼球突出度、活动度评分(CAS)的变化情况。结果:所有患者均完成随访。术后3、6mo,极重度组CMCT、眼球突出度、眼压、CAS评分为355.13±15.59、339.61±13.17μm, 19.33±2.23、17.83±1.70mm, 18.86±3.05、18.09±1.37mmHg, 3.75±0.87、2.42±1.00分;中重度组为325.00±10.48、321.04±11.34μm, 16.07±1.74、15.6±1.98mm, 16.65±2.04、16.03±2.3mmHg, 1.50±0.51、1.43±0.50分,与术前(极重度组：396.46±17.61μm, 22.00±2.3mm, 21.85±2.82mmHg, 5....     

Current trends in orbital decompression

A questionnaire was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and the Orbital Society in regard to indications, surgical techniques and results of orbital decompression for Graves' disease. It was found that more than 60% of orbital decompressions were performed for mild to severe exophthalmos to correct corneal exposure or disfigurement. A total of 3.9% of these procedures were performed to relieve visual loss in compressive neuropathy. The large majority of decompressions were performed using antral-ethmoidal decompression via a translid or fornix approach. The amount of retrodisplacement was greatest with Kennerdell-Maroon or four-wall decompression and the least with lateral wall decompression. The antral-ethmoidal and three-wall decompression techniques gave an average of 4 to 6 mm of retrodisplacement. It was determined from the survey that antral-ethmoidal decompressions performed through the transantral approach were more likely to relieve the pressure in compressive neuropathy and also more likely to induce a worsening of muscle balance. In contrast, antral-ethmoidal decompressions performed via the translid approach were not as effective in relieving compressive neuropathy but had a much lower incidence of worsened muscle balance, and in fact, resulted in a higher incidence of improved muscle balance. The same trends were confirmed in the author's surgical practice, and an anatomic explanation is offered. The importance of creating nasoantral windows following decompression is emphasized. The risks of cerebrospinal fluid leakage and changes in eyelid positioning following decompression are described.     

Color Doppler imaging of orbital vasculature before and after orbital decompression in thyroid eye disease

Purpose: To measure alterations in orbital blood flow parameters using color Doppler imaging (CDI) before and after orbital decompression in patients with moderate to severe thyroid eye disease (TED).

Methods: Resistance index (RI) and maximum and minimum velocity of ophthalmic artery (OA), superior ophthalmic vein (SOV), and central retinal artery (CRA) of 24 eyes (14 patients) with TED were measured before and at least 3 months after cosmetic orbital decompression procedure (single or double walls) using CDI. Complete eye examination was performed to define the severity (EUGOGO classification) and activity (clinical activity score) of TED.

Results: Median OA (p = 0.003) and CRA (p = 0.001) resistance indices were significantly reduced postoperatively. Significant differences were found in maximum (p = 0.001) and minimum (p = 0.014) velocity of SOV before and after surgery. While a significant decrease in exophthalmometry was observed after the orbital decompression (p = 0.031), intraocular pressure changes were not significant (p = 0.182).

Conclusion: Orbital decompression procedure led to a significant reduction of RI in both CRA and OA in patients with TED.     

改良三壁眶减压术治疗重症甲状腺相关性眼病的疗效观察

目的观察改良三壁眶减压术治疗重症甲状腺相关性眼病的效果。方法对我院收治的3例(6眼)经内科治疗无效的重症甲状腺相关性眼病患者实施改良三壁眶减压术,观察患者术后视力、眼球突出度及外观情况。结果术后4眼视力轻度提高,2眼保持不变;眼球后退5.3～12.6mm,平均9.5mm;睑裂闭合不全者术后均闭合良好,外观满意;1眼出现少量眶内血肿,治疗后吸收;4眼出现双眼复视,均于1个月内消失;术后CT显示眼眶减压良好。结论改良三壁眶减压术可有效扩大眼眶容积,降低眶内压,还纳眼球,减少眼球突出,改善外观,对内科保守治疗、常规眶减压术无效的重症甲状腺相关性眼病患者安全有效。     

眼眶减压术治疗Graves眼病的临床效果

目的:探讨眼眶减压术治疗Graves眼病的效果及安全性.方法:选取2011-02/2016-02在我院治疗的Graves眼病患者55例77眼,均行眼眶减压术治疗,观察患者术后6 mo视力、眼球突出度及并发症.结果:患者术后6 mo最佳矫正视力(0.23±0.09)明显较术前(0.46±0.07)有所提高,差异有统计学意义(P<0.05);患者术后6 mo眼球突出度(16.20±1.99 mm)明显较术前(20.13±1.87mm)有所减少,差异有统计学意义(P<0.05);术后CAS评分≤3分眼数为56眼(73%),明显较术前15眼(19%)有所增加,差异有统计学意义(P<0.05);术前共有50眼(65%)存在色觉障碍,术后有42眼(55%)视觉障碍明显改善,8眼(10%)无变化;77眼术后6 mo眼球突出度平均下降3.87±1.03 mm;术后出现新复视患者5例8眼,新发复视率10%,随访3 mo后,复视消失.结论:眼眶减压术治疗Graves眼病是一种有效方法,但应注意术后复视等并发症发生.     

眼眶减压术20眼临床分析

目的：探讨眼眶减压术对经保守治疗无效的甲状腺相关性眼病的临床疗效与合并症。方法：对12例20眼的术前临床表现、术后的疗效与并发症进行随访并统计。结果：三壁减压使眼球后退6－8mm,外下壁减压后退4－6mm,内下壁减压后退3－5mm。14／16眼（87．5％）角膜损害痊愈,2／16眼（12．5％）好转。17／20眼（85％）视力提高,3／20眼（15％）无改善。并发症包括2眼复视,5眼眶下神经损害,1眼眶继发出血。结论：眼眶减压术对保守治疗无效的甲状腺相关眼病是一种有效、安全、并发症少的治疗手段。可用于继发角膜损害,压迫视神经与要求美容 的病例。     

Orbital decompression surgery and horse chestnut seed extract improved superior orbital vein blood flow in patients with thyroid-associated ophthalmopathy

AIM: To evaluate the efficacy and safety of orbital decomposition (OD) surgery in combination with horse chestnut seed extract (HCSE), as compared to OD alone, in patients with thyroid-associated ophthalmopathy (TAO). METHODS: Sixty-two orbits from 62 TAO patients were randomly assigned to OD or OD+HCSE at 1:1 ratio (31 received OD alone, 31 received OD+HCSE). Forty-two orbits from 21 healthy subjects were used as controls. Complete ophthalmic examination and color Doppler flow imaging (CDFI) were performed before surgery and 3mo post-surgery on all 62 orbits from the TAO patients. CDFI were also performed on the 42 control orbits. The effect of OD+HCSE and OD alone on TAO orbits was compared on several endpoints, including superior ophthalmic vein blood flow (SOVBF) parameters, subjective assessment, soft tissue involvement, lid retraction, diplopia, eye movement restriction, degree of exophthalmos, and intraocular pressure. The control orbits were used as reference for the SOVBF parameters. RESULTS: OD surgery with or without HCSE improved SOVBF, symptoms and soft tissue involvement, decreased degree of exophthalmos and intraocular pressure in orbits of TAO patients. The OD+HCSE combination led to significantly better improvement of SOVBF than OD alone. The differences between the reductions of SOVBF in the two groups are 1.26 cm/s in max-volecity and 0.52 cm/s in min-volecity (P<0.0001). CONCLUSION: SOVBF is significantly reduced in the orbits affected with TAO, indicating that congestion may be an important factor contributing to TAO pathogenesis. OD surgery improves the SOVBF, and combination of HCSE medication and OD surgery further improved venous return than OD surgery alone.     

Ocular motility problems after orbital decompression for dysthyroid ophthalmopathy

Ocular motility problems of 50 consecutive patients following orbital decompression for dysthyroid (Graves') ophthalmopathy were analyzed retrospectively. No significant relationship to the development of postoperative diplopia was seen in the amount of retrodisplacement of the globe, the anatomical approach for orbital decompression, or the indication for decompression. Several clinical observations were made. Patients whose indication for orbital decompression was a vision-threatening ophthalmopathy were more likely (although not statistically significantly) to develop postoperative strabismus. Patients who developed changes in preoperative strabismus were more likely to develop increased esotropia and/or restrictive hypertropia. Of 32 patients who were orthotropic in the primary position before operation, 11 developed postoperative strabismus in the primary position. Only five patients had normal versions and ductions before operation. All five of these patients had normal versions and ductions after operation.     

Advantageous surgeon's position in deep lateral orbital wall decompression

The deep lateral orbital wall decompression is now the first surgical approach in orbital decompression ( Leone et al., 1989 ). Although it is a popular procedure with few complications and satisfactory results, tips for bone removal depend on each surgeon's experience. Here, I present differences of surgical effects, depending on the surgeon's standing positions.     

Cryo‐assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases

Acta Ophthalmol. 2010: 88: 675–680

Abstract.

Purpose: To describe and evaluate a cryo‐assisted, minimally invasive, anterior approach for orbital tumour surgery. Methods: Retrospective, non‐comparative, consecutive, interventional case series of 103 patients who were operated on by the same surgeon for retroocular orbital tumours over the last 16 years. Results: A cryo‐assisted, minimally invasive, anterior approach was employed in 63 out of the 103 patients (61.2%). In 37 patients (35.9%), anterior orbitotomy without the use of cryoprobe was employed for biopsy or excision of small, anteriorly located lesions. Lateral orbitotomy was used in three patients (2.9%). In a subgroup of 61 patients with circumscribed lesions (mainly cavernous haemangiomas and schwannomas), cryoextraction was used in 51 (83.6%). None of the procedures required conversion to lateral orbitotomy and there were no intraoperative complications. Conclusion: In contrast to other reports on the treatment of orbital lesions, in the current case series surgery of most solid tumours and many other cystic or infiltrative lesions was achieved here via an anterior, cryo‐assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favourable consideration because the combination of the anterior approach with the use of cryoprobe and surgical microscope can yield successful results, even in patients with large or deeply located tumours – obviating in most of them the need for lateral or transcranial orbitotomies with bone flaps.     

Orbital decompression and motility disturbances in endocrine ophthalmopathy

The changes in ocular motility in 15 patients with endocrine ophthalmopathy before and after orbital decompression according to Ogura-Walsh are discussed. The conclusion is that decompression of the orbita gives rise to a considerable risk of development or increase of limitations of ocular movements, with diplopia as a result.     

A case of orbital dirofilariasis in New York

A 39-year-old female presented with a 5-day history of left inferonasal periocular swelling and associated intermittent itching. Ophthalmologic examination demonstrated a 4 × 8 mm subcutaneous painless mass localized anterior to the medial left lower orbital rim. An excision of the mass was performed, and pathology revealed Dirofilaria. The patient improved over the 3 months of postoperative follow-up. Although several human cases of pulmonary dirofilariasis have been reported in the United States, periocular dirofilariasis has been rarely reported in the United States. The case report is in compliance with the Health Insurance Portability and Accountability Act.     

Graves眼病眼眶减压术术式选择及并发症的研究进展

Graves眼病(GO)是最常见且治疗相对复杂的眼眶疾病,发病率逐年增高,严重者会出现暴露性角膜病变、复视以及压迫性视神经病变,明显影响患者的生存质量。眼眶减压手术目前是治疗中重度GO的有效手段,且随着手术适应证的逐渐拓宽,越来越多的合并有眼球突出的轻中度GO患者要求手术治疗以改善外观。眼眶减压手术的术式种类繁多,究竟选择哪种眶减压术式能使患者获益最大,成为眼科医生最常遇到的问题。随着手术量的逐渐加大,并发症日益凸显,手术并发症的存在影响着患者术后满意度。为加深对并发症的认识,避免或减少并发症发生,优化手术方案,本文回顾了近年来国内外相关文献报道,对GO患者眼眶减压术的术式选择及手术相关并发症作一综述。     

Successful delayed treatment of the traumatic orbital apex syndrome by nasal endoscopic decompression surgery

To report a patient with traumatic orbital apex syndrome, who fully recovered visual and extraocular function following surgery. A 34-year-old male presented with visual and extraocular function disorders in his right eye following traffic accident, who was referred to our hospital 5 weeks after accident. The patient underwent endoscopic optic nerve and orbital apex decompression with topical and systemic application of nerve growth factor and steroids after a failed trial of mega-dose intravenous corticosteroids. Visual acuity improved to 20/20 at 3 weeks after surgery, and the right eye globe moved in most directions at 1 year, which remained stable at 3 years. Surgical decompression should be considered even when symptoms have been present for over a month.