Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES: To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS: Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS: Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS: IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Descolamento de retina exsudativo bilateral associado a alteracões de comportamento em paciente com diagnóstico de neurossífilis: relato de caso / Exudative bilateral retinal detachment and behavior changes in a patient with neurosyphilis: case report

OBJETIVO: Descrever caso de descolamento de retina bilateral associado a alteracões de comportamento. RESULTADO: Paciente de 62 anos, sexo feminino, apresentou-se com baixa de visão bilateral, progressiva, de 3 meses de duracão, associada a alteracões de comportamento e agitacão psicomotora. Ao exame oftalmológico apresentava acuidade visual de percepcão luminosa em olho direito; e conta dedos a 30 cm em olho esquerdo. A biomicroscopia evidenciou reacão de câmara anterior; à fundoscopia, apresentava edema e hiperemia do disco óptico bilateralmente, áreas extensas de descolamento de retina seroso, placas sub-retinianas amareladas peripapilares e exsudacão sub-retiniana e intra-retiniana em ambos os olhos. O exame sorológico para sífilis foi positivo (FTA-Abs e VDRL). A análise liquórica revelou FTA-Abs e teste de hemaglutinacão indireta positivos. Foi feito, então, diagnóstico de neurossífilis, e a paciente foi internada para antibioticoterapia endovenosa, e prednisona oral 40 mg/dia (0,5 mg/kg). Após 2 semanas, a paciente passou a apresentar melhora importante do quadro ocular com reabsorcão da exsudacão e melhora da acuidade visual. CONCLUSAO: A sífilis é doenca pleomórfica, podendo ter como manifestacão ocular uma uveíte difusa associada a descolamento de retina exsudativo bilateral. O envolvimento do sistema nervoso central deve sempre ser considerado e descartado, e o tratamento eficaz da doenca pode promover melhora da funcão visual e diminuir suas seqüelas.