Effect and Prognostic Factors of Systemic Steroid Treatment for Strabismus Associated Thyroid Ophthalmopathy

PURPOSE: To investigate the effect of steroid treatment on strabismus associated with thyroid ophthalmopathy. METHODS: The present retrospective study was conducted on 22 patients diagnosed with strabismus associated with thyroid ophthalmopathy, who were treated with steroids orally or intravenously and followed up for more than one year. Patients were divided into three groups for analysis: an improved group, with no strabismus at the final follow-up visit; a stable group, with no change in the strabismus angle; and a deteriorated group, in which the strabismus angle had worsened. We investigated the characteristics of each group. RESULTS: In the gender/sex distribution of the 22 patients, 11 of the 15 patients in the improved or stable group were female; six of seven patients in the deteriorated group were male (p = 0.012). Two of the 15 patients in the improved or stable group had a smoking history. However, none smoked after the treatment had started. On the other hand, five of seven patients in the deteriorated group had a smoking history and continued to smoke during and after treatment (p = 0.001). No significant between-group differences were observed with respect to age, diplopia period, strabismus angle, or thyroid function level. CONCLUSIONS: Treatment with steroids may improve or stabilize strabismus associated with thyroid ophthalmopathy. However, the effect of treatment may differ, depending on whether the patient continues to smoke after treatment is initiated.

Current Trends in the Management of Thyroid Ophthalmopathy / 한양의대학술지

Thyroid ophthalmopathy (TO) is an autoimmune inflammatory disorder involving the orbit characterized by inflammation and swelling of the extraocular muscles and an increase in orbital fat and connective tissue. Despite extensive research, TO continues to be a difficult condition for the patient to cope with and for the clinician to treat. Current treatments consist of systemic immunosuppression, orbital irradiation, and surgery. It is promising for patient refractory to conventional therapy that pathogenesis of TO at molecular level which advance development of new therapies targeting cellular immunity are now better understood. Future therapies targeting immune system or specific molecules are under investigation and show promise for the future. This review will describe current trends in the management of TO, from well-established therapies such as glucocorticoids, orbital irradiation and orbital decompression to more innovative therapies targeting immune system or specific molecules involved in TO pathogenesis.

Results of diplopia and strabismus in patients with severe thyroid ophthalmopathy after orbital decompression.

Purpose: It has been frequently stated that the orbital decompression, in patients with thyroid ophthalmopathy, does not usually improve extraocular muscles function and that after the operation there is often a deterioration of these functions. The purpose of this article is evaluation of extraocular muscles function after applying personal method of 3 wall orbital decompression. Materials And Methods: Retrospective review of case records of 119 patients with severe thyroid ophthalmopathy seen and treated by the author between December 1986 and December 2010. All patents underwent 3 wall orbital decompression combined with removal of the periorbital, intraorbital and retrobulbar fat. Correction of coexistent eyelid retraction and deformities were also performed. Results: Comparison of preoperative and postoperative results was conducted in 65 patients three months after 3 wall decompression. All patients showed a significant reduction of exophthalmos [5-11 mm, 7.2 mm on average], reduction of intraocular pressure, marked improvement in ocular muscle function as well as considerable reduction in or disappearance of subjective symptoms. There were no cases of subsequent impairment of ocular motility. Strabismus surgery was performed in 6 patients with residual diplopia. There was an improvement in vision in 68% patients who had impaired vision before the operation. Less evident relapse of exophthalmos was recorded in 3 cases only and only one patient required unilateral reoperation. Conclusion: It can be concluded that this method of orbital decompression is logical, based on an understanding of the pathology, has less complication rates, is relatively easy to perform, gives very good functional and aesthetic long term results and allows rapid recovery.

Oftalmopatia tireoidea revisitada: [revisão] / Thyroid ophthalmopathy revisited: [review]

A oftalmopatia tireoidea é doença orbitária autoimune intimamente associada com o hipertireoidismo, porém podendo existir separadamente. Pode preceder, coincidir ou suceder o início da disfunção tireoidea, raramente ocorrendo em eutireoideos ou hipotireoideos. Os músculos extraoculares são os principais alvos acometidos e tornam-se aumentados de volume, determinando oftalmoplegia e proptose. Outros sinais importantes incluem retração palpebral, hiperemia conjuntival e edema periorbitário. Perda visual pode ocorrer se há compressão do nervo óptico no ápice orbitário. A oftalmopatia tireoidea é caracterizada por inflamação, congestão, hipertrofia e fibrose da gordura e músculos orbitários. A atividade da doença é dividida em fase aguda ou inflamatória, seguida pela fase inativa associada com alterações fibróticas e infiltração gordurosa. O diagnóstico é clínico, e quando este é difícil ou se suspeita de neuropatia óptica os métodos de imagem são indicados. A tomografia computadorizada e a ressonância magnética podem confirmar o diagnóstico e avaliar a área crítica do ápice orbitário. A ressonância magnética é superior, em virtude da resolução tecidual e da sua capacidade de avaliar a atividade da doença (mediante sequências com TR longo) e detectar alterações inflamatórias, auxiliando o planejamento terapêutico no momento certo, melhorando o prognóstico.

Thyroid ophthalmopathy is an autoimmune orbital disorder closely associated with Graves' disease, although both conditions may also occur isolatedly. Thyroid ophthalmopathy may precede, coincide or follow the thyroid dysfunction onset and may rarely occur in euthyroid and hypothyroid patients. The extraocular muscles are most frequently involved and become enlarged resulting in ophthalmoplegia and proptosis. Other relevant signs include palpebral retraction, conjuctival hyperemia and periorbitary edema. Visual loss may occur in association with compressive optic neuropathy at the orbital apex. Thyroid ophthalmopathy is characterized by inflammation, congestion, hypertrophy and fibrosis involving fat and the orbital muscles. The disease activity is divided into two phases: an acute or inflammatory phase and a second one corresponding to an inactive phase associated with fibrotic changes and fat infiltration of the retrobulbar tissues. The diagnosis is based on clinical findings and imaging methods are indicated in case of doubt or suspicion of optic neuropathy. Computed tomography and magnetic resonance imaging can confirm the diagnosis, allowing the evaluation of the critical region of the orbital apex. Magnetic resonance imaging is the method of choice considering the superior tissue contrast resolution, besides the capacity of evaluating the disease activity by means of long TR sequences and detecting inflammatory changes, with a relevant role in a timely therapeutic planning, which may improve the prognosis.

Uso de Triamcinolona en Orbitopatía Tiroidea / Use of triamcinolone in thyroid orbitopathy

La oftalmopatía tiroidea caracterizada por exoftalmos y retracción palpebral bilateral, usualmente debida a infiltración muscular o del tejido graso orbitario, constituye una manifestación extratiroidea de la enfermedad de Graves-Basedow, enfermedad de naturaleza autoinmune. Por las múlitples teorías sobre su etiopatogenia el tratamiento sigue siendo un tema de controversia, dificultando el desarrollo de una terapeútica específica. Actualmente, el tratamiento de la oftalmopatía tiroidea toma como piedra angular en su esquema el uso de corticoides. El presente estudio muestra los siguientes casos clínicos de evaluación del uso de la Triamcinolona intraorbitaria, en el tratamiento de tres pacientes se sexo femenino, quienes acudieron a consulta por exoftalmos o diplopía, como inicio de su enfermedad. La evolución de ellas posterior al tratamiento fue completamente satisfactoria. Por tanto, se plantea el uso de esta terapia como una alternativa de tratamiento.

Thyroid ophthalmology is an inflammatory disease caracterizad by exophthalmos and bilateral palpebral retraction, an extrathyroid sign of Graves-Basedow, an autoimmune disease. Because of the multiple theories in its ethiopatogenics the treatment is still a controversy subject, making difficult the specific therapeutic development. At the moment, the treatment of the Thyroid ophthalmopathy takes as angular stone in its scheme the use of corticoids. The following clinical cases show the intraorbithary use of Triamcinolona, , in the treatment of three patients of feminine sex, who came referring exophtalmus and diplopia, one year before the of beginning of the disease, the evolution of both subsequent to the treatment was completely satisfactory. Therefore, the effectiveness of the use of this therapy is shown to be an alternative treatment to consider.

A Case of Remarkable Variation of Strabismic Angle in Thyroid Ophthalmopathy

PURPOSE: We report a patient with strabismus associated with thyroid ophthalmopathy whose condition changed remarkably for 6 years of a natural course. CASE SUMMARY: A 69-year-old woman with Graves' disease presented with diplopia in April 1999. On examination, she showed left hypotropia of 50 prism diopters (Delta) accompanied by supraduction limitation and lid lag in the left eye. She was diagnosed with strabismus associated with thyroid ophthalmopathy and was observed without any intervention. In October 2000, her left hypotropia decreased to 16Delta, and esotropia of 14Delta developed. Both eyes showed limitation of supraduction, and the left eye showed limitation of abduction. In December 2003, the esotropia increased to 35Delta, and the direction of vertical strabismus changed to 40Delta of right hypotropia. Supraduction limitation of the right eye and abduction restriction of both eyes increased, and infraduction limitation of the left eye developed. In April 2005, esotropia increased to 75Delta, and the amount of right hypotropia was 35Delta. The abduction limitation of both eyes increased. CONCLUSION: The natural course of strabismus associated with thyroid ophthalmopathy can show continuous and remarkable changes.

Central Retinal Vein Occlusion Associated with Thyroid Ophthalmopathy

PURPOSE: To report the first case of central retinal vein occlusion (CRVO) in association with thyroid ophthalmopathy. METHODS: A 40-year-old woman was came to the ophthalmologic clinic due to conjunctival injection, lid swelling and decreased visual acuity in the left eye. She was ill with hyperthyroidism and was recovered completely. At the first visit, best corrected visual acuity of her left eye was 0.3. The left eye showed proptosis, episcleral vessel dilation, and moderate limitation of ocular movement. Orbit MRI revealed the enlargement of extraocular muscles. Fundus examination showed diffuse retinal hemorrhages with macular edema and retinal veins were dilated and tortuous. Fluorescein angiogram showed the diffuse leakage from the retinal vessels on the posterior pole, but nonperfusion area was not seen. RESULTS: One month after the first visit, best corrected visual acuity of her left eye was improved to 0.6. Proptosis and limitation of ocular movement was improved, and retinal hemorrhages with macular edema were decreased remarkably. CONCLUSIONS: Possible retinal vascular complications such as CRVO may occur in patients with thyroid ophthalmopathy. Therefore, in these cases, fundus examination along with other ophthalmologic examinations are necessary.

The Result of Botulinum Toxin A Injection in the Upper Eyelid Retraction of Thyroid-Associated Ophthalmopathy Patients

PURPOSE: This study is to determine the effects of botulinum toxin injection on patients who suffer from upper eyelid retraction caused by thyroid ophthalmopathy. METHODS: We injected 10-15 units botulinum toxin (Botox(R), Allergan, USA) on the upper tarsus of 12 eyes of 12 thyroid ophthalmopathy patients and compared duration of disease, clinical activity scores (CAS), intraocular pressures (mmHg), exophthalmometry (mm), upper eyelid retraction (mm), marginal reflex distance1 (MRD1, mm), levator function test (mm), lid lag (mm), limitation of ocular movement (mm), lid tension test results, phenylephrine test results, and orbital computed tomography results before and after the injection. RESULTS: The patient group with smaller-sized cross section of superior rectus/levator complex before the injection showed a greater decrease of upper eyelid retraction after the injection (p=0.04). Other clinical parameters showed no significant relations on the effect of the toxin injection. CONCLUSIONS: Botulinum toxin injection can have variable effects on the upper eyelid retraction of thyroid ophthalmopathy patients. The patients who had smaller volume of superior rectus/levator complex measured in orbital cross sections on CT, could expect good results after botulinum toxin injection.

The Epidemiologic and Clinical Characteristics of Thyroid-Associated Orbitopathy

PURPOSE: To determine the epidemiologic and clinical characteristics of thyroid-associated orbitopathy (TAO). METHODS: We retrospectively studied the clinical data of 385 patients from the New York City area diagnosed with TAO from January 1990 to December 2000. The total cases were divided into male and female groups and age-adjusted relative incidence rates were obtained to plot the incidence curve and clinical characteristics. Statistical analysis was applied to the collected data. RESULTS: The average age of patients with TAO was 46.3 years for females and 50.1 years for males. The female-male ratio was 5.31:1. In 23.3% of patients, the diagnosis of TAO was made simultaneously with their thyroid disease. In 75% of cases, the diagnosis was made within 18 months of the presentation of thyroid disease. Soft tissue involvement was noted most frequently in 311 (80.8%), eyelid retraction in 306 (79.5%), proptosis in 278 (72.2%), restrictive myopathy in 234 (60.8%), and compressive optic neuropathy in 43 (11.2%) of 385 patients. CONCLUSIONS: TAO has variable and different epidemiologic and clinical characteristics according to sex and age.

Stem Cell Transplantation in Retinitis Pigmentosa Patients

PURPOSE: This study was to evaluate the effect of stem cell transplantation into the sub-retinal space in retinitis pigmentosa (RP) patients for improving their visual acuity. RP is a progressive hereditary disease that leads to the blindness, and there is no reliable treatment for recover the disease until now. METHODS: The author transplanted mesenchymal stem cell extracted from umbilical cord blood into the sub-retina of four RP patients recommended by Korea RP association, and checked the changes of their visual acuity and electroretinograms. RESULTS: There was no obvious improvement in their visual acuity and elecroretinograms compared with preoperative state. Two patients, however, experienced slight improvements of their color sense and peripheral visual fields, and slight decrease of photophobia. Although there were no any obvious complications in relation to the stem cell transplantation, surgical procedures developed complications such as vitreous hemorrhage and retinal detachment. CONCLUSIONS: Mesenchymal stem cell derived from umbilical cord blood could not improve visual acuity and electroretinogram of RP patients.

The Natural Course of Strabismus associated with Thyroid Ophthalmopathy

PURPOSE: This study investigated the natural course of strabismus associated with thyroid ophthalmopathy. METHODS: A retrospective review was performed on the medical records of 31 patients with strabismus associated with thyroid ophthalmopathy who had been followed up for more than 6 months and had not received surgery. For the purpose of this study, a significant change of deviation angle was defined as more than 10 prism diopters in the primary position. RESULTS: Forty-two percent of patients showed a significant change in deviation angle during the observation period of 23.8+/-17.7 months. The direction of the change was vertical in 32%, horizontal in 3%, and vertical and horizontal in 6% of patients. A significant change of deviation angle developed in 30% of patients within 6 months from the initial ophthalmologic examination, in 24% between 6 and 12 months, and in 13% of patients between 12 and 18 months from the initial examination. CONCLUSIONS: Although the deviation angle of strabismus associated with thyroid ophthalmopathy tended to stabilize with time, it nonetheless was susceptible to change even 12 months after the initial ophthalmologic examination. In addition, a vertical change in the deviation angle was more frequent than a horizontal change.

The Effect of Previous Orbital Decompression on Outcome of Strabismus Surgery in Patients with Thyroid Ophthalmopathy

PURPOSE: To determine the effect of prior orbital decompression on the outcome of strabismus surgery in patients with thyroid ophthalmopathy. METHODS: The medical records of patients operated on for strabismus related to thyroid ophthalmopathy were retrospectively reviewed RESULTS: Thirty patients were included in this study. Seventeen patients had previously undergone orbital decompression, thirteen patients had not. There was no significant difference between the two groups in the average angle of preoperative horizontal or vertical deviation, the average numbers of muscle operated on, the percentage of unidirectional surgery and the outcome of strabismus surgery. CONCLUSIONS: The previous orbital decompression surgery has no significant effect on the outcome of strabismus surgery in patients with thyroid ophthalmopathy.

Strabismus Surgery for Thyroid Ophthalmopathy

PURPOSE: To investigate the result of strabismus surgery for thyroid ophthalmopathy. METHODS: This retrospective study included 13 patients with strabismus due to thyroid ophthalmopathy.These patients underwent strabismus surgery with intraoperative adjustable suture technique under topical anesthesia in the period between January 1997 and December 2000. Mean postoperative follow-up examination period was 13.2+/-9.9 months. RESULTS: Eleven of thirteen patients (84.6%) had heterotropia less than 8 prism diopter at last postoperative follow up examination. CONCLUSIONS: With relatively short period of preoperative examination, we achieved satisfactory surgical outcome for the treatment of strabismus due to thyroid ophthalmopathy.

Surgical treatment modalities of thyroid ophthalmopathy

This report presents the use of various surgical treatment modalities in patients who were diagnosed as having thyroid ophthalmopathy. The records of 53 patients who received surgery because of thyroid ophthalmopathy at the Department of Ophthalmology, Yonsei University College of Medicine between Sept. 1996 and Jan. 2000 were retrospectively evaluated. Among the 53 patients, there were 30 females and 23 males. The mean ages of the patients were 40.8 +/- 17.1 years. Orbital wall decompression (52.8%) was the most frequently performed surgery followed by lid surgery (49.1%) and strabismus surgery (26.4%). Only one type of surgery was performed on 86.8% of the patients while 13.2% received more than one type of surgery. Among the many different types of surgeries possible in patients that have thyroid ophthalmopathy, orbital wall decompression, lid surgery, and strabismus surgery are the most commonly used surgical methods for treatment.

Central Retinal Artery Occlusion in Association with Thyroid Ophthalmopathy

Thyroid ophthalmolopathy causes bilateral proptosis, restricted ocular movements and optic neuropathy due to inflammatory cell infiltration into the soft tissue. We report a case of central retinal artery occlusion after thyroid ophthalmopathy by swelling of retrobulbar soft tussue and compression of optic nerve and brief review of related literature was presented.