Técnica endonasal para cirurgia de descompressão orbitária em paciente com exoftalmopatia de Graves / Endonasal technique for orbital decompression surgery in a patient with Graves' exophthalmopathy

Resumo Paciente do sexo feminino, 29 anos, ex-tabagista, diagnosticada em setembro de 2012 com doença de Graves e apresentação rápida de exoftalmia bilateral. Na avaliação oftalmológica, apresentava motilidade preservada, proptose e bolsa de gordura superior em AO com retração de PPSS e PPII e exoftalmetria em OD de 26 mm,e em OE de 24 mm. Em maio de 2014,fez o mapeamento da retina que evidenciou cicatrizes de coriorretinite em ambos os olhos e campimetria computadorizada, apresentando degrau nasal em OD, contração superior, depressão centro-inferior. Em junho de 2016, realizou cirurgia de descompressão orbitária de paredes medial e inferior bilateral por via endoscópica com uso de endoscópio nasal Karl Storz, em 30 graus de óptica. A abordagem cirúrgica da oftalmopatia de Graves deve ser empregada na fase cicatricial exceto nos casos com risco de perda da visão. Antes realizada por acesso externo, atualmente a descompressão orbitária pode ser realizada via endoscópica, com mínima invasividade e permite a remoção da parede inferior e medial sem necessidade de incisões externas. É um procedimento seguro para o tratamento da orbitopatia distireoidiana associada a menor morbidade, no qual se evita lesões ao ducto nasolacrimal, nasofrontal ou ao infraorbital e se possibilita redução da proptose entre 3 a 4 mm. Os benefícios da descompressão estão relacionados com a melhora da acuidade visual, além do resultado estético. A continuidade do tratamento cirúrgico será realizada por meio de correção de retração palpebral seguida de blefaroplastia.

Abstract Female, 29, former smoker, diagnosed in September 2012 with Graves' disease and rapid presentation of bilateral exophthalmos. In the ophthalmologic evaluation, it presented preserved motility, proptosis and upper fat sac in OA with retraction of PPSS and PPII and exophthalmetry in OD of 26 mm, and in OE of 24 mm. In May 2014, he performed the mapping of the retina that showed scars of chorioretinitis in both eyes and computerized campimetry, presenting a nasal step in OD, superior contraction, central-inferior depression. In June 2016, he underwent orbital decompression surgery of the medial and inferior bilateral walls by endoscopic approach using the Karl Storz nasal endoscope at 30 degrees of optics. The surgical approach of Graves' ophthalmopathy should be used in the cicatricial phase except in cases with risk of loss of vision. Before performed by external access, orbital decompression can now be performed endoscopically, with minimal invasiveness and allows the removal of the inferior wall and Without external incisions. It is a safe procedure for the treatment of dysthyroidal orbitopathy, associated with lower morbidity, in which lesions are avoided in the nasolacrimal, nasofrontal, or infraorbital ducts and it is possible to reduce proptosis between 3 and 4 mm. The benefits of decompression are related to Improvement of visual acuity, besides the aesthetic result. The continuation of the surgical treatment will be performed by correction of palpebral retraction followed by blepharoplasty.

TSH-receptor antibodies may prevent bone loss in pre- and postmenopausal women with Graves' disease and Graves' orbitopathy

ABSTRACT Objective Thyrotoxicosis is established risk factor for osteoporosis due to increased bone turnover. Glucocorticoids often administered for Graves' orbitopathy (GO) have additional negative effect on bone mineral density (BMD). Our aim was to examine the influence of thyroid hormones, TSH, TSH-receptor antibodies (TRAb) and glucocorticoid treatment on bone in women with Graves' thyrotoxicosis and Graves' orbitopathy (GO). Subjects and methods Forty seven women with Graves' disease, mean age 55.6 ± 12.8 (23 women with thyrotoxicosis and 24 hyperthyroid with concomitant GO and glucocorticoid therapy) and 40 age-matched healthy female controls were enrolled in the study. We analyzed clinical features, TSH, FT4, FT3, TRAb, TPO antibodies. BMD of lumbar spine and hip was measured by DEXA and 10-year fracture risk was calculated with FRAX tool. Results The study showed significantly lower spine and femoral BMD (g/cm2) in patients with and without GO compared to controls, as well as significantly higher fracture risk. Comparison between hyperthyroid patients without and with orbitopathy found out significantly lower spine BMD in the first group (p = 0.0049). Negative correlations between FT3 and femoral neck BMD (p = 0.0001), between FT4 and BMD (p = 0.049) and positive between TSH and BMD (p = 0.0001), TRAb and BMD (p = 0.026) were observed. Fracture risk for major fractures and TRAb were negatively associated (p = 0.05). We found negative correlation of BMD to duration of thyrotoxicosis and cumulative steroid dose. Conclusions Our results confirm the negative effect of hyperthyroid status on BMD. TRAb, often in high titers in patients with GO, may have protective role for the bone, but further research is needed.

Descompresión orbitaria por vía endoscópica nasal en la orbitopatía tiroidea: nuestra experiencia / Endoscopic orbital decompression for the management of thyroid eye disease: our experience / Decompressão orbitaria por via nasal endoscópica na orbitopatia tírida: nossa experiência

INTRODUCCIÓN: La orbitopatía tiroidea es una de las manifestaciones extratiroideas más frecuentes de la enfermedad de graves. El diagnóstico es clínico y con estudios de imágenes. El tratamiento depende de la etapa en que se encuentre la enfermedad, pudiendo ser conservador o quirúrgico, siendo la descompresión orbitaria el pilar del tratamiento. OBJETIVOS: Describir la técnica quirúrgica y las complicaciones más frecuentes. Comprobar los beneficios en la reducción del exoftalmos, la mejoría de la agudeza visual y la descompresión del nervio óptico...

INTRODUCTION: Thyroid orbitopathy is one of the most frequent extra thyroid manifestations of Graves' disease. The diagnosis is clinical and with imaging studies. The treatment depends on the stage in which the disease is found; can be conservative or surgical, the orbital decompression is the pillar of the treatment. OBJECTIVES: Describe the surgical technique and the most frequent complications checking the benefits in the reduction of exophthalmos, the improvement of visual acuity and decompression of the optic nerve…

INTRODUÇÃO: A orbitopatia tireoidiana é uma das manifestações extra tireóides mais freqüentes da doença de graves. O diagnóstico é clínico e com estudos de imagem. O tratamento depende da fase em que a doença é encontrada; podendo ser conservador ou cirúrgico, sendo a descompressão orbital o pilar do tratamento. OBJETIVOS: Descreva a técnica cirúrgica e as complicações mais frequentes. Verificar os benefícios na redução do exoftalmos, a melhora da acuidade visual e descompressão do nervo óptico...

Frecuencia y características clínicas de la orbitopatía asociada al tiroides en pacientes hipertiroideos de reciente diagnóstico / Frequency and clinical characteristics of thyroid-associated orbitopathy in recently diagnosed hyperthyroid patients

Introducción: la orbitopatía asociada al tiroides es una complicación frecuente del hipertiroidismo. Objetivo: describir la frecuencia y características de la orbitopatía asociada a la enfermedad autoinmune del tiroides, en pacientes con diagnóstico reciente de hipertiroidismo. Métodos: estudio descriptivo transversal. A cada caso se le determinó al diagnóstico hormonas tiroideas, y anticuerpos antiperoxidasa. Se examinaron al diagnóstico para evaluar la presencia de orbitopatía, y se identificaron los síntomas y signos oculares presentes en los que la presentaron. Se compararon los resultados a través de estadística descriptiva, utilizando chi². La significación estadística fue para una p< 0,05. Resultados: el 70 por ciento de los pacientes presentó orbitopatía tiroidea al diagnóstico. Predominó el sexo femenino y la raza blanca en el grupo de estudio. La forma leve inactiva prevaleció en los pacientes con orbitopatía, y ninguno presentó la forma severa de esta. El signo más frecuente fue la retracción palpebral, con 90,32 por ciento. No hubo asociación estadística con la edad, el hábito de fumar, el color de piel, las hormonas tiroideas ni los anticuerpos. Conclusiones: la orbitopatía es frecuente al diagnóstico del hipertiroidismo, la retracción palpebral es su signo más común, y no se asoció con los factores clínicos y bioquímicos estudiados(AU)

Introduction: thyroid-associated orbitopathy is a frequent complication of hyperthyroidism. Objective: to describe the frequency and the characteristics of orbitopathy related to autoimmune disease of thyroids in patients who were recently diagnosed as hyperthyroidism cases. Methods: cross-sectional descriptive study. Every case was detected thyroid hormones and antiperoxidase antibodies at time of diagnosis. They were examined to evaluate the possible presence of orbitopathy whose ocular symptoms and signs were identified in those who had it. The comparison of results was made through summary statistics by using chi-square test. The statistical significance was p< 0.05. Results: seventy percent of patients had thyroid orbitopathy at the time of diagnosis. Females and Caucasians prevailed in the study group. The slight inactive form prevailed whereas the severe form was absent. The most common sign was palpebral retraction accounting for 90.32 percent. There was no statistical association with age, smoking, race, thyroid hormone or antibody presence. Conclusions: orbitopathy is common at time of diagnosis of hyperthyroidism, palpebral retraction is the commonest sign and it was not associated to the studied clinical and biochemical factors(AU)

Surgical treatment of globe subluxation in the active phase of the myogenic type of Graves orbitopathy: case reports / Tratamento cirúrgico da subluxação do globo ocular na fase ativa do subtipo miogênico da orbitopatia de Graves: relatos de casos

The purpose of the present article is to present and discuss two cases of globe su­blu­xation in the active phase of myogenic Graves' orbitopathy and to evaluate the prevalence of this phenomenon. Two patients with the myogenic variant of Graves' orbitopathy that had being treated with oral and intravenous steroid pulses developed globe subluxation. Both had to have urgent eyelid and orbital decompression. After these observations, we reviewed the medical records of a sample of 284 patients (482 orbits) who had had orbital decompression at our Institution from 1992 to 2010, with a search for cases presenting severe proptosis or globe subluxation in the active phase of myogenic Graves' orbitopathy. No patient had to have decompression for globe subluxation in the active phase of Graves' orbitopathy. The prevalence of this event as an indication for surgery in the myogenic variant of Graves' orbitopathy was therefore 0.7% (2/284) or even less. The combination of lowering the upper eyelid and orbital decompression had a dramatic therapeutic effect on these patients des­pite the presence of intense inflammatory signs in the orbits. In conclusion, patients affected with the myogenic variant of Graves' orbitopathy may develop globe subluxation. Urgent surgical treatments should not be postponed despite the presence of active inflammation.

O objetivo do presente trabalho é apresentar e discutir dois casos de subluxação do globo ocular na fase ativa do subtipo miogênico da orbitopatia de Graves e avaliar a prevalência desse fenômeno. Dois pacientes com o subtipo miogênico da orbitopatia de Graves tratados com corticosteroide oral e pulsos intravenosos desenvolveram subluxação do globo ocular. Após estas observações, analisamos os prontuários de uma amostra de 284 pacientes (482 órbitas) que foram submetidos à descompressão orbitária em nossa Instituição no período de 1992 a 2010, buscando os casos que apresentaram proptose severa ou subluxação do globo ocular na fase ativa da orbitopatia de Graves miogênica. Nenhum paciente tinha sido descomprimido para subluxação do globo ocular na fase ativa da orbitopatia de Graves. A prevalência desse evento como uma indicação para cirurgia na variante miogênica da orbitopatia de Graves foi 0,7% (2/284) ou até menos. A combinação da correção da retração da pálpebra superior e da descompressão da órbita obteve um efeito terapêutico excelente nesses pacientes, apesar da intensa presença de sinais inflamatórios nas órbitas. Em conclusão, pacientes afetados com orbitopatia de Graves do subtipo miogênico podem desenvolver subluxação do globo. Tratamentos cirúrgicos de urgência não devem ser adiados apesar da presença de inflamação ativa.

Tratamiento quirúrgico del estrabismo en la enfermedad de graves / Surgical treatment of strabismus in graves disease

El estrabismo en la Oftalmopatía (Orbitopatía) de Graves se origina en la fibrosis post inflamatoria de uno o varios músculos, en uno o ambos ojos. Esto provoca un desalineamiento de los ejes visuales con diplopia que puede llegar a ser invalidante. Los músculos más frecuentemente comprometidos son los Rectos Inferiores y Medios. Algunos pacientes compensan su diplopia con posiciones anómalas de la cabeza. La cirugía se plantea en la etapa inactiva de la inflamación orbitaria, con ángulos estables por al menos seis meses; con los objetivos de eliminar la diplopia al menos en mirada al frente y en posición de lectura, eliminar las posiciones viciosas y mejorar la estética. La técnica quirúrgica, en la mayoría de los casos, consiste en el retroceso de todos los músculos responsables del estrabismo; idealmente con técnica ajustable, la que permite dosificar mejor la cirugía. La cirugía del estrabismo debe hacerse después de la descompresión orbitaria (si corresponde) y antes de la eventual cirugía de párpados. Los resultados en general son satisfactorios, pero con limitaciones

Strabismus in Graves Ophthalmopathy is caused by postinflammatory retraction in one or more muscles of one or both eyes. The most frequently involved muscles are inferior and medial rectus. This event provokes the loss of visual axes alignment, and, eventually, invalidant diplopia. Some patients compensate their diplopia with anomalous head positions. Surgery is indicated in the inactive phase of the orbital inflammatory process, with the goals of eliminate diplopia and abnormal head positions and to restore aesthetics. Surgical technique, in the majority of cases, consists in recessing all muscles involved in the strabismus; ideally with an adjustable technique that grants a better dosing of surgery. Strabismus surgery must be done after orbital decompression (if indicated) and before the eventual lid surgery. Results in general are satisfactory, but with some limitations in most cases

Manejo quirúrgico de la orbitopatía de graves / Surgical management in graves' orbitopathy

La enfermedad de Graves corresponde a un síndrome que comprende: bocio hipertiroídeo habitualmente, oftalmopatía asociada a la tiroides y dermatopatía. No se cuenta con estadísticas nacionales, sin embargo la mayoría de los estudios internacionales muestran una frecuencia mayor en la mujer. Desde el punto de vista del manejo quirúrgico de esta enfermedad, éste se basa en tres etapas fundamentales: descompresión orbitaria, cirugía de los músculos extraoculares y finalmente la cirugía de reposicionamiento palpebral, no todos los pacientes requieren estos tres tipos de tratamiento, pero en caso de necesitarlos esta debe ser la secuencia. La indicación quirúrgica dependerá de la fase en que se encuentre el paciente, idealmente deberá realizarse en la fase de inactividad de la enfermedad caracterizada por la ausencia de signología inflamatoria periocular. Este artículo está destinado a mostrar las alternativas quirúrgicas en el tratamiento de las complicaciones oculares de la Orbitopatía de Graves orientado principalmente hacia el exoftálmo y la patología palpebral

Graves' disease is a syndrome comprising usually hyperthyroid goiter, thyroid-associated ophthalmopathy and dermopathy. We do not have national statistics, however International studies show a grater frequency in females. Surgical management is based in three stages: orbital decompression, eye muscle surgery and finally eyelid repositioning, not every patient needs all of these surgical treatments, but in case they do need them this must be the sequence. Surgical indication will depend on the phase of the disease; ideally it will be performed in the phase of inactivity of the disease, which is characterized by the absence of periocular inflammatory signs. This article describes the surgical alternatives in the treatment of the ocular complications in the Graves' orbitopathy, oriented mainly towards exophthalmos and palpebral disease

Neuropatía óptica distiroidea como manifestación de orbitopatía de Graves / Dysthyroid optic neuropathy: report of one case

Dysthyroid optic neuropathy is an uncommon and severe form of presentation of Graves ophtalmopathy, caused by compression and elongation of the optic nerve. Use of high dose steroids is the treatment of choice. Decompressive surgery is reserved for refractory cases. We report a 41 years old female with a dysthyroid optic neuropathy that appeared 18 years after the diagnosis of Graves disease, manifested by a marked reduction in visual acuity. Orbit CAT scan did not show compression or elongation of optic nerve. She was treated with prednisone 60 mg per day, obtaining a complete remission after 19 days of treatment. After 90 days of follow up with low doses of steroids, the patient remains asymptomatic.

Comparative evaluation of oculometric variables in graves' ophthalmopathy

OBJECTIVES: To estimate oculometric parameters of Graves' ophthalmopathy in comparison to healthy eyes using digital photography and digital image analysis. INTRODUCTION: Graves' ophthalmopathy is the main cause of eye proptosis. Because these protrusions cause clinically perceived distortions in orbital architecture, digital photographs can be used to detect and quantify these changes. METHODS: We carried out a cross-sectional study comprising 12 healthy volunteers and 15 Graves' ophthalmopathy patients with the purpose of evaluating the use of simple, non-invasive digital photography to estimate oculometric parameters of Graves' ophthalmopathy and compare them with the parameters of unaffected eyes. Facial photographs of cases and controls were taken in a standardized manner. Oculometric parameters were compared between the groups and then correlated to proptometer measures. RESULTS: All estimated oculometric variables showed significant differences between the groups, in particular with regard to mediopupilar aperture, lateral height, distance from the iris edge to the lateral boundary of the palpebral fissure, and distance from the higher point of the iris to the lateral limit of the palpebral fissure. The product of medial aperture and horizontal palpebral fissure also revealed greater discrepancy between the groups. Proptometer measures showed significant linear correlation between the distance from the iris edge to the lateral boundary of the palpebral fissure and between the distance from the higher point of the iris to the lateral limit of palpebral fissure (p<0.05). CONCLUSIONS: Comparative analysis of oculometric parameters in Graves' ophthalmopathy suggests that eye proptosis is related to an asymmetric increase in lateral oculometric measures. Standardized digital photographs can be used in clinical practice to objectively estimate oculometric parameters of Graves' ophthalmopathy patients.

Cirurgia de estrabismo ajustável no peroperatório com anestesia tópica em pacientes com orbitopatia de Graves / Intraoperative adjustable strabismus surgery under drop anesthesia in patients with Graves' orbitopathy

OBJETIVO: Descrever as características clínicas pré-operatórias dos pacientes com estrabismo secundário à orbitopatia de Graves e os resultados da cirurgia com anestesia tópica e sutura ajustável. MÉTODOS: Estudo retrospectivo realizado no Hospital das Clínicas da Universidade de São Paulo. Foram pesquisados os prontuários de todos os pacientes atendidos no ambulatório de estrabismo no período de março de 1994 a maio de 2004. Destes, foram separados aqueles com estrabismo associado à orbitopatia de Graves submetidos à cirurgia ajustável com anestesia tópica. As características clínicas pré-operatórias e os resultados cirúrgicos foram levantados a partir desta análise. RESULTADOS: Foram incluídos 13 pacientes. O tipo de desvio mais freqüentemente encontrado foi esotropia com hipotropia. Em 9 pacientes modificou-se o retrocesso programado no pré-operatório. Três casos necessitaram de uma segunda cirurgia. Após 6 meses de seguimento, 8 dos 13 pacientes estavam ortotrópicos ou com foria pequena e com algum grau de estereopsia. CONCLUSÃO: Neste estudo observou-se que 62 por cento (8/13) dos pacientes apresentavam hipotropia com esotropia, provavelmente por causa do comprometimento associado do reto inferior e reto medial. Nove dos 13 pacientes necessitaram de ajuste no peroperatório e apenas 3 foram reoperados, indicando a importância da técnica ajustável para melhor alinhamento ocular no pós-operatório, possibilitando obter resultados mais satisfatórios.

PURPOSE: To report the clinical features of strabismus associated with Graves' orbitopathy, and the results of surgery with adjustable suture under drop anesthesia. METHODS: The charts of 13 patients who had surgical treatment for strabismus related to Graves' orbitopathy at Hospital das Clínicas of University of São Paulo were retrospectively reviewed. Ocular motility, sensorial examination and the follow-up after strabismus correction were studied. RESULTS: Preoperatively, the most common type of deviation was esotropia with hypotropia. Adjustable recession was done in nine patients and a second surgery occurred in 3 patients. After follow-up of at least six months, 8 of 13 patients were orthotropic or had a small phoria with some degree of binocular vision. CONCLUSION: In this study, 62 percent (8/13) of patients showed hypotropia with esotropia, probably because fibrotic and restrictive muscles (medial and inferior rectus). In nine of 13 patients adjustable recession with a good postoperative alignment of the eyes was performed. Adjustment of strabismus surgery under drop anesthesia in patients with Graves' orbitopathy was successful in restoring binocular vision with minimum complications.

Análise do filme lacrimal e sua relação com a largura da fenda palpebral e a exoftalmia na oftalmopatia de Graves / Tear film analysis and its relation with palpebral fissure height and exophthalmos in Graves' ophthalmopathy

OBJETIVO: Avaliar qualidade do filme lacrimal pelo corante rosa bengala e sua estabilidade por meio do tempo de ruptura, relacionando com a largura da fenda palpebral e a exoftalmia em pacientes com oftalmopatia de Graves. MÉTODOS: Foram estudados 54 olhos de 27 pacientes com oftalmopatia de Graves, tanto em fase inflamatória quanto em fase crônica. A avaliação consistiu de análise qualitativa do filme lacrimal pelo corante rosa bengala por meio da classificação de van Bijsterveld, análise da estabilidade do filme lacrimal pelo tempo de ruptura, medida da largura da fenda palpebral e exoftalmometria. A análise estatística foi realizada com o teste do Qui-quadrado. RESULTADOS: Entre os 27 pacientes estudados, 77,8 por cento eram do sexo feminino e 22,2 por cento do masculino. A idade média foi de 44,26 anos (DP 12,67). O tempo médio de doença foi de 5,85 anos (DP 4,47) e o de oftalmopatia foi de 5,81 anos (DP 5,37). Dos 54 olhos em estudo, 37 por cento apresentaram teste positivo pela escala de graduação de van Bijsterveld, 33,3 por cento tempo de ruptura do filme lacrimal menor que 5 segundos, 57,4 por cento largura da fenda palpebral maior que 11 mm e 55,6 por cento exoftalmometria maior que 19 mm. Quando relacionamos o tempo de ruptura do filme lacrimal menor que 5 segundos com a largura da fenda palpebral maior que 11 mm encontramos odds ratio igual a 11,2 (p=0,0008). As demais relações estudadas não mostraram significância estatística. CONCLUSÕES: O olho seco diagnosticado pela coloração com rosa bengala e pelo tempo de ruptura do filme lacrimal ocorre com freqüência na oftalmopatia de Graves. A largura da fenda palpebral correlaciona-se com o tempo de ruptura do filme lacrimal na oftalmopatia de Graves. Seu aumento pode levar à instabilidade do filme lacrimal.