Características de orbitopatía asociada al tiroides y tasa de requerimiento de cirugía / Thyroid-associated orbitopathy characteristics and surgery requirement rate

RESUMO Objetivo: Conheça as características demográficas e clínicas da Órbita Associada da Tiroide (OAT), bem como a taxa de exigência da cirurgia orbital em pacientes do Centro Médico Nacional do Oeste. Métodos. Estudo observacional, transversal, descritivo e retrospetivo realizado analisando os registos de pacientes diagnosticados com OAT tratados num centro de cuidados de terceiro nível de janeiro de 2005 a julho de 2016. Os resultados. Um total de 236 órbitas de 118 pacientes foram avaliados, com uma idade média de 47,3 (13,2 anos, 74,6% eram do sexo feminino e 25,4% masculinos. 4,2% dos doentes foram tratados com hipotiroidismo, 94,1% com hipertireoidismo e 1,7% com goiter tóxico difuso. 44,9% dos doentes estudados com restrição de movimento ocular,10,2% com queratopatia de exposição e 51,7% com hipertensão intraocular. 34,7% dos doentes avaliados no serviço necessitaram de descompressão orbital, 16,1% de cirurgia palpebral e 8,5% de correção do hatrabisma. Na gestão conservadora destes doentes, 48,3% exigiam o uso de lubrificantes tópicos dos olhos, enquanto 52,5% dos pacientes necessitavam do uso de hipotensivos oculares em número variável. As conclusões. A OAT foi associada principalmente ao hipertiroidismo, sendo mais comum em pacientes do sexo feminino entre os 40 e os 59 anos; mais de 50% dos pacientes necessitaram do uso de hipotensivos oculares. Da mesma forma, a gestão cirúrgica foi realizada em mais de 50% dos pacientes, sendo a descompressão orbital a intervenção mais frequente.

ABSTRACT Objective. To know the demographic and clinical characteristics of Thyroid Associated Orbitopathy (TAO), as well as the requirement rate of orbital surgery in patients of the Orbit Service in the National Medical Center of the West, IMSS. Methods. Observational, cross-cutting, descriptive and retrospective study carried out analyzing the records of patients diagnosed with TAO and treated at a third-level care center from January 2005 to July 2016. Results. A total of 236 orbits of 118 patients were valued, with an average age of 47.3 ± 13.2 years, 74.6% were female and 25.4% male. 4.2% of patients were treated with hypothyroidism, 94.1% with hyperthyroidism and 1.7% with diffuse toxic goiter. 44.9% of patients studied had eye movement restriction,10.2% exposure keratopathy and 51.7% intraocular hypertension. 34.7% of patients valued in the service required orbital decompression, 16.1% palpebral surgery and 8.5% strabism correction. In the conservative management of these patients 48.3% required the use of topical eye lubricants, while 52.5% required the use of eye hypotensives in variable numbers. Conclusions. TAO was mainly associated with hyperthyroidism, being more common in female patients between the age of 40 and 59; more than 50% of patients required the use of eye hypotensives. Likewise, surgical management was performed in more than 50% of patients, with orbital decompression being the most frequent intervention.

Pérdida de agudeza visual progresiva en paciente con proptosis. Caso clínico y revisión de la literatura / Progressive visual impairment in a patient with proptosis. Case report and review of the literature.

Introducción: a raíz del siguiente reporte de caso clínico se pretende repensar el diagnóstico diferencial de los tumores orbitales y revisar la literatura existente al respecto. Caso: paciente de 54 años, fumadora, acude a nuestro centro por una pérdida de agudeza visual progresiva de dos años de evolución en el ojo derecho, que se acompañaba de proptosis. Las pruebas de imagen basadas en resonancia magnética y tomografía por emisión de positrones ­ tomografía computarizada (PET-TC) realizadas describían una lesión intraconal derecha de morfología indefinida, que rodeaba el nervio óptico. El estudio inmunohistoquímico y molecular anatomopatológico confirmó la sospecha de síndrome linfoproliferativo extranodal de bajo grado. Discusión: el manejo endoscópico de estas lesiones puede resultar en una menor comorbilidad en comparación con el abordaje externo tradicional. El papel de la cirugía radica en la obtención de una muestra de la lesión que permita un correcto diagnóstico. Conclusiones: el abordaje multidisciplinar con oftalmólogos, hematólogos y expertos en radioterapia permite obtener buenos resultados quirúrgicos y clínicos en la inmensa mayoría de casos.

Introduction: as result of the following clinical case report, we intend to review the differential diagnosis of orbital tumors and review the existing literature in this regard. Case report: a 54-year-old smoking patient, consulted to our department due to a progressive visual impairment over the last two years in her right eye. She presented proptosis in her clinical examination. Imaging studies based on MRI and PET-CT described a right intraconal lesion with an undefined morphology surrounding the optic nerve. Orbital tumors differential diagnosis is delicate. Nevertheless, Non-Hodgkin lymphomas followed by metastasis are the two most common found in this location. The immunohistochemistry and molecular studies, confirmed the suspected diagnosis of extranodal low-grade lymphoproliferative syndrome. Discussion: endoscopic management of these lesions may result in a lower comorbidity compared to traditional external approaches. Role of surgery lays in obtainment of a quality sample which allows a proper diagnosis. Conclusions: multidisciplinary approach with ophthalmologists, hematologists and radiotherapy experts enhance good surgical and clinical results in the vast majority of cases.

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.

Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy

PURPOSE: To evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO). METHODS: Twenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0). RESULTS: Forty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 +/- 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 +/- 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 +/- 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 +/- 0.8 to 3.8 +/- 0.5 mm postoperatively. CONCLUSIONS: The customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.

Change in quality of life after medical and surgical treatment of Graves' ophthalmopathy

To assess the changes in quality of life [QOL] of patients after treatment of their Graves' ophthalmopathy [GO]. In this prospective, cross-sectional study, the GO-QOL questionnaire was completed by 67 subjects before and at least 6 months after steroid treatment [61 subjects, group 1] or optic neuropathy orbital decompression [6 subjects, group 2]. Visual, psychosocial, education and counseling scores [higher score = better health], GO severity and clinical activity scores and minimal clinically important difference [MCID] were recorded and analyzed for correlation and statistical significance. A P-value <0.05 was considered statistically significant. The mean age of patient enrolled in the study was 38.3 years, with 43 females [64.2%]. The mean duration of thyroid dysfunction and GO were 40.1 and 26.5 months, respectively. Two treatment groups were similar for all the variables [0.06 < P < 0.9], except for higher mean age in the orbital decompression group [45.2 versus 37.7 years] [P = 0.03]. Mean severity, activity, visual function and psychosocial function scores significantly improved in group 1 [steroid group] [P < 0.05, all cases]. A significant improvement in clinical activity score and psychosocial scores occurred in group 2 [decompression group] [P < 0.05]. MCID was achieved in two-thirds of the patients, with no significant difference between groups [P > 0.05]. There was no significant effect of duration of thyroid disease and GO and severity and activity of GO on QOL scores either before or after treatment [P > 0.05, all cases]. Steroid treatment and orbital decompression significantly improve the QOL in GO. Duration, severity and activity of GO did not have a significant impact on the QOL

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

Proptosis de ojo izquierdo / Left eye proptosis

Se presenta el caso clínico de una paciente joven que acude al Servicio de Oftalmología del Hospital Nacional con leve disminución de la agudeza visual y proptosis del ojo izquierdo, sin antecedentes de traumatismo, cefalea, ni diplopía...(GG)

Descompresión orbitaria en la orbitopatía tiroidea / Orbital decompresion in thyroid-related orbitopathy

La orbitopatía tiroidea, se caracteriza por: exoftalmos, retracción palpebral y neuropatía óptica comprensiva en los casos más severos. La descompresión orbitaria se realiza en estos casos para preservar la visión. Objetivo: Mostrar la experiencia de nuestro hospital en esta cirugía por diferentes vías de abordaje: transcraneal, anterior y endoscópica nasal. Métodos: Se realizó un corte evaluativo de 30 casos operados en el período de enero de 1999 a febrero del 2005. La efectividad de la cirugía se evaluó en cuanto a: disminución del exoftalmos y mejoría visual por las tres vías de abordaje. Resultados: Todos los casos operados disminuyeron el exoftalmos y mejoraron su visión. En la vía endoscópica se obtienen excelentes resultados con menor trauma quirúrgico. Conclusiones: Se concluye que la descompresión orbitaria es un tratamiento muy efectivo en la orbitopatía tiroidea y que la vía endoscópica es un procedimiento de acceso mínimo con buenos resultados.

Thyroid-related orbitopathy is characterized by exophthalmos, palpebral retraction and compressive optic neuropathy in the most severe cases. Orbital decompression is performed to preserve the vision in these patients. Objective: To show the experience gained by our hospital in performing this type of surgery using several approaches such as transcranial, anterior and nasal endoscopic paths. Methods: An evaluating study was carried out in 30 cases operated on from January 1999 to February 2005. The surgical effectiveness was evaluated in terms of reduction of exophthalmos and visual improvement using the three approaches. Results: According to data from tables 1, 2 and 3, all the operated patients reduced exophthalmos and improved their vision. The endoscopic approach exhibited excellent results with lower surgical trauma. Conclusions: It was concluded that orbital decompression is a very effective treatment for thyroid-related orbitopathy and that endoscopic approach is a minimum access procedure with good results.

Proptosis secondary to rosiglitazone treatment

To report a case of new onset proptosis secondary to treatment with rosiglitazone Case report A patient developed symptomatic bilateral proptosis requiring surgical intervention, two years and a half after treatment with rosiglitazone. Asymptomatic eye protrussion is a frequent finding in patients treated with thiazolidinediones. In a few cases, the proptosis may be clinically significant and may present in patients with or without a previous history of thyroid disease

Descompressäo orbitária antro-etmoidal na orbitopatia distireoidiana / Antro-ethmoidal orbital descompression in dysthyroid orbiotopathy

Objetivo: Avaliar os resultados e as complicaçöes da descompressäo orbitária antro-etmoidal em pacientes com orbitopatia distireoidiana. Métodos: 14 pacientes sendo 10 do sexo feminino, com média de idade de 41,7 anos, foram submetidos a 22 cirurgias de descompressäo orbitária. Em 3 cirurgias (2 pacientes), na fase ativa da oftalmopatia a indicaçäo cirúrgica foi ulceraçäo de córnea, com risco de perfuraçäo corneana. Estes pacientes estavam recebendo corticosteróides associados a ciclofosfamida e radioterapia tendo o tratamento prosseguido após a cirurgia. Dezenove órbitas foram operadas em fase inativa da orbitopatia por indicaçäo cosmética associada a desconforto ocular por exposiçäo corneana. Resultados: A reduçäo da proptose oscilou entre 1 e 6 mm (média 3,91 mm). Nos pacientes operados na fase aguda a reduçäo média foi de 5,33 ñ 0,27 mm e na fase sequelar foi de 3,68 ñ 0,25 mm. Nenhum paciente apresentou diplopia conseqüente a cirurgia. Correçäo de estrabismo prexistente foi realizada em 2 pacientes e tarsorrafia temporária foi associada a cirurgia descompressiva nas 3 cirurgias realizadas na fase aguda. Seis pacientes foram subseqüentemente submetidos à correçäo de retraçäo palpebral prexistente. Em uma paciente houve piora da retraçäo palpebral inferior como conseqüência da descompressäo orbitária. Houve diminuiçäo transitória da sensibilidade na regiäo malar em quase todos os pacientes mas em nenhum deles ela foi definitiva. Conclusöes: A descompressäo óssea antro-etmoidal da órbita é eficiente em reduzir a proptose em pacientes com orbitopatia distireoidiana e apresenta baixa incidência de complicaçöes. Associada a outras modalidades terapêuticas pode ser um procedimento útil em casos graves na fase congestiva. Da mesma forma, se mostrou benéfica na reabilitaçäo cosmética de indivíduos na fase seqüelar.

Descompresión orbitaria por cirugía endoscópica intranasal / Endoscopic intranasal surgical orbitary descompression

Se trata de un estudio descriptivo, longitudinal, observacional y prospectivo de 16 pacientes (18 órbitas) con exoftalmopatía de graves, atendidos en los departamentos de Otorrinolaringología y Oftalmología del Hospital de Especialidades, Centro Médico Nacional Siglo XXI, de enero de 1995 a octubre de 1997, sin respuesta a tratamiento conservador. Se les realizó descompresión orbitaria por cirugía endoscópica intranasal con técnica de Kennedy, lo cual evita incisiones externas y sus complicaciones son mínimas. Cuatro meses después de la cirugía el promedio de reducción de los exoftalmos fue de 3.8 mm, con rangos de 2 a 5 mm

Descompresión orbitaria en oftalmopatía tiroidea. Descripción de 12 casos / Orbital decompression in thyroid opthalmopathy. 12 cases description

La descompresión orbitaria es un método efectivo para la corrección de exoftalmos por oftalmopatía tiroidea, en la que se presenta queriatitis, exoftalmos maligno, compresión del nervio óptico o por razones cosméticas. Nosotros realizamos descompresión orbitaria con la técnica de Ogura y Walsh en siete pacientes (12 órbitas); 5 femeninos (71.4 por ciento) y 2 masculinos (28.6 por ciento), con promedio de edad de 26.8 años. Exoftalmometrías para el ojo derecho en promedio de 24.8 mm y para el ojo izquierdo de 23.4 mm; siete ojos fueron derechos y cinco izquierdos. En todos los casos con proptosis tuvieron reducción para el ojo derecho en promedio de 4.12 mm y para el izquierdo de 5.8 mm. Controlando en todos los pacientes la exposición conjuntivo-corneal. En el postoperatorio inmediato todos los pacientes presentaron diplopia, la cual se corrigió en todos excepto en uno, en un seguimiento de 2.8 años en promedio

Descompressäo orbital no tratamento da orbitopatia distireoidiana / Orbital descompression in dysthroid orbitopathy treatment

Há muitos anos a descompressäo orbital tem sido indicada no tratamento de complicaçöes oculares graves relacionadas à orbitopatia de Graves, principalmente a ceratopatia de exposiçäo associada a exoftalmia intensa e a neuropatia óptica. Neste trabalho apresentamos resultados da descompressäo orbital de 23 órbital (1 pacientes) e discute-se a indicaçäo desta terapêutica em casos essencialmente estéticos de orbitopatia de Graves.

Treatment of optic neuropathy and disfiguring proptosis by orbital decompression in patients with Graves' orbitopathy

Compressive optic neuropathy by apical muscle crowding is a rare, but serious complication of Graves' orbitopathy. Proptosis is a frequent and cosmetically disturbing effect of Graves' orbitopathy. Both conditions can be treated effectively and safely by orbital decompression. However, many different decompression techniques have been described and different complication rates have been reported. We present our results with the inferomedial and coronal decompression techniques. Four patients with dysthyroid optic neuropathy and 42 patients with disfiguring proptosis and / or retrobulbar pain underwent orbital decompression. Twenty-three were operated by an inferomedial approach and the same number by a coronal approach. The inferomedial approach was used in women with unilateral proptosis, bilateral but moderate proptosis and in men. The coronal approach was used in all other patients. In the inferomedial approach, the orbital floor and the anterior part of the medial wall are removed. In the coronal approach, a part of the lateral wall, the floor and a larger part of the medial wall are removed. All eyes operated because of optic neuropathy improved to almost normal vision. Patients operated because of disfiguring proptosis had a mean proptosis reduction of 3 mm after inferomedial decompression, and of 5 mm after coronal decompression; iatrogenic diplopia and paresthesia were the main but infrequent complications, occurring in 4 [9%] and 6 [13%] patients respectively. Inferomedial and coronal orbital decompression effectively combat dysthyroid optic neuropathy and disfiguring proptosis. The complication rates were favorable compared to other techniques

Tratamento do exoftalmo residual pela resseccao de gordura orbitaria / Treatment of residual exophthalmos by resection of orbital fat

O corpo adiposo da orbita e um conjunto que pode ser dividido em dois grupos, um situado externamente ao cone muscular, envolto por fina membrana que emite prolongamentos anteriores denominados bolsas palpebrais. O outro, situado internamente aos musculos extrinsecos, envolve o nervo optico e atravessado pelos ramos do nervo oculomotor, abducente e troclear, que inervam os musculos por sua face interna. Os dois grupos comunicam-se na regiao posterior da orbita. O tratamento do exoftalmo residual pela resseccao parcial do corpo adiposo da orbita externo ao cone muscular pode ser feito atraves de incisoes semelhantes a da blefaroplastia. Este procedimento foi aplicado em seis pacientes e permitiu a remocao de 4 a 10 ml de gordura por orbita com melhoria significativa da proptose e da oclusao palpebral.

Emergency surgery in orbital trauma: a neurosurgical view.

This study is an analysis of five cases of orbital trauma causing proptosis, paralysis of extraocular muscles with or without associated visual failure. All the cases were treated by a Neurosurgical team. Either a frontal craniotomy or a lateral orbitotomy was performed. Plain X-rays of the skull and Computerised Tomography (C.T. Scanning) were the main investigations. Results were encouraging both functionally and cosmetically. Early diagnosis and an aggressive approach to orbital decompression can achieve good results.

Exoftalmo endócrino e descompressäo orbitária / Endocrine exophthalmos and orbital decompression

Dez órbitas de cinco portadores de exoftalmo endócrino foram descomprimidas através da remoçäo das paredes orbitárias inferior e medial. Houve melhora estética e da exoftalmometria em quatro casos e da neuropatia óptica presente em um dos pacientes. Verificaram-se efeitos iatrogênicos temporários sobre a musculatura extrínseca e sobre a área inervada pelo nervo infra-orbitário. É apresentada também pequena revisäo bibliográficas sobre o assunto

Oclusäo intraluminar de fístula carótido cavernosa com baläo de prolo: relato de um caso / Intraluminal occlusion of carotid cavernous fistula with balloon catheter: report of a case

É apresentado um caso de fístula carótido-cavernosa traumática, cujo traumatismo crânio-encefálico ocorreu há cinco anos. Apresentou alternância de exoftalmo. Após exames comprovou-se presença de fístula à esquerda com exoftalmo à direita. Colocado catéter baläo de Prolo com controle radioscópio, seguido do desaparecimento da fístula e regressäo do quadro oftálmico