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Cruz AAV, Rocha VHS, Peres MM, Todo M, Cunha BS. Cerebral and optic nerve complications following bony orbital decompression for Graves' orbitopathy. A systematic review. Orbit 2025:1-9. [PMID: 40434016 DOI: 10.1080/01676830.2025.2507387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2025] [Accepted: 05/11/2025] [Indexed: 05/29/2025]
Abstract
PURPOSE To perform a systematic literature review on major complications of orbital decompression and describe our experience with three new unpublished cases. METHODS The PubMed and Embase databases were searched using the keywords ("orbital decompression") AND (Graves) or (thyroid eye disease) in January 2025. Only articles in English, Spanish, or French were included. Major complications were defined as cerebrospinal fluid leaks, intracranial complications, and vision loss. The authors also reviewed all medical records of patients who underwent orbital decompression over 34 years (1990-2024) for Graves' orbitopathy at the teaching hospital of the School of Medicine of Ribeirão Preto, Brazil. RESULTS Cerebrospinal fluid leaks occurring during medial and lateral decompressions have been reported in 22 articles, with an estimated rate ranging from 1.0% to 2.0%. Several severe neurological side effects were reported in 14 articles, most occurring during medial decompression. Blindness after orbital decompression was documented in nine papers as a multifactorial event. CONCLUSIONS The surgical factors involved in major complications associated with orbital decompression have not been discussed in detail. The analysis of the three new cases, along with those cited in the literature, shows that careful multiplanar radiological reconstruction of the olfactory fossa and posterior ethmoid pneumatization is an essential step to avoid intracranial complications during medial decompression. In deep lateral decompressions, the risk of major complications is minimized with careful bleeding control and avoidance of dural exposure.
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Affiliation(s)
- Antonio A V Cruz
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, Clinical Hospital of Ribeirão Preto - University of São Paulo, Ribeirao Preto, Brazil
| | - Victória H S Rocha
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, Clinical Hospital of Ribeirão Preto - University of São Paulo, Ribeirao Preto, Brazil
| | - Marcelo M Peres
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, Clinical Hospital of Ribeirão Preto - University of São Paulo, Ribeirao Preto, Brazil
| | - Marcia Todo
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, Clinical Hospital of Ribeirão Preto - University of São Paulo, Ribeirao Preto, Brazil
| | - Barbara S Cunha
- Ophthalmology, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Brazil
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Peraza LR, Fearington FW, Hernandez-Herrerra GA, Awadallah AS, Wagner LH, Tooley AA, Bradley EA, Stan MN, Stokken JK. Orbital Decompression for Thyroid Eye Disease: Outcomes by Preoperative Severity and Technique. Am J Rhinol Allergy 2025:19458924251330947. [PMID: 40207636 DOI: 10.1177/19458924251330947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2025]
Abstract
BackgroundOrbital decompression is an essential tool for reducing proptosis in thyroid eye disease (TED), yet the impact of surgical approach and preoperative factors on outcomes remains uncertain.ObjectiveTo compare proptosis reduction following different orbital decompression techniques, identify additional risk factors that may play a role in surgical orbital decompression outcomes, and develop clinical decision-making recommendations based on these results.MethodsA retrospective analysis was performed on TED patients who underwent endoscopic medial wall, orbital floor, and/or open lateral wall decompression. We evaluated the influence of preoperative comorbidities, anatomic and laboratory values, and surgical approach on postdecompression Hertel exophthalmometry outcomes.ResultsAnalysis encompassed 130 orbits from 80 patients, 83% female, 48 with preoperative diplopia, and mean age of 54.4 years. Preoperative Hertel measurement was predictive of extent of proptosis reduction (P < .0001), indicating that higher initial Hertel measurement predicts greater absolute reduction following surgical intervention. Surgical technique correlated with outcome on univariate analysis (P = .04), but not multivariate (P = .13) analyses. When categorized into preoperative Hertel ranges, combined endoscopic medial and open lateral wall decompression resulted in mean proptosis reduction of 3.13 mm for range 20.01 to 24 mm and 3.85 mm for range 24.01 to 28 mm. Three-wall decompression resulted in mean proptosis reduction of 2.49 mm for and 3.84 mm for these ranges, respectively. Variables such as smoking, body mass index, orbital wall height, and TRAb level, did not affect outcomes. Nine patients had new onset diplopia.ConclusionsPreoperative Hertel exophthalmometry is the strongest predictor of proptosis reduction following orbital decompression in TED. Surgical technique appears to be less impactful on outcome than expected. Surgical decision making should be individualized based on patient goals; these findings can be used to achieve proptosis reduction and limit the risk of new onset diplopia.
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Affiliation(s)
- Lazaro R Peraza
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Lilly H Wagner
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Andrea A Tooley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | | | - Marius N Stan
- Department of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Janalee K Stokken
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN, USA
- Division of Rhinology and Skull Base Surgery, Mayo Clinic, Rochester, MN, USA
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Guo W, Geng J, Li D. Comparative effectiveness of various orbital decompression techniques in treating thyroid-associated ophthalmopathy: a systematic review and meta-analysis. BMC Ophthalmol 2024; 24:526. [PMID: 39696149 DOI: 10.1186/s12886-024-03749-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 10/29/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND In thyroid-associated ophthalmopathy (TAO), orbital decompression is a critical surgical approach for functional and aesthetic reasons. Meanwhile, the presence of surgical complications, especially the new onset of primary gaze diplopia, also influences postoperative patient satisfaction. This research investigates the effectiveness and potential risks associated with different orbital decompression in patients with TAO. METHODS Systematic searches were conducted to identify pertinent studies from PubMed, Embase, and the Cochrane Library databases. The search was completed on October 11, 2023. And after retrieval, the publication dates of the articles included in the analysis ranged from January 1, 2008, to February 22, 2023. The overall postoperative outcomes were determined using random-effects meta-analyses with corresponding 95% confidence intervals (CI). A network meta-analysis was performed to integrate both direct and indirect evidence. The primary outcomes were defined as the status of exophthalmos and the new onset of primary gaze diplopia. RESULTS From 1,538 identified records, 87 studies were selected, encompassing 5102 patients and 8,779 procedures. The studies reported varying degrees of exophthalmos reduction based on different surgical techniques: -3.46 mm (95% CI -3.76 to -3.15 mm) for fat removal orbital decompression, -4.02 mm (95% CI -5.14 to -2.89 mm) for the medial wall technique, -3.89 mm (95% CI -4.22 to -3.55 mm) for the lateral wall technique, -5.23 mm (95% CI -5.69 to -4.77 mm) for the balanced wall technique, -3.91 mm (95% CI -4.37 to -3.46 mm) for the infero-medial wall technique, and - 5.80 mm (95% CI -6.47 to -5.13 mm) for the three-wall technique. The incidence of new-onset primary gaze diplopia was reported in 31 studies involving 214 out of 2001 patients, resulting in a weighted proportion of 0.11 (95% CI 0.06-0.14). Notably, the lowest rates were associated with the lateral approach and fat removal orbital decompression, with pooled proportion (95% CI) rates of 3% (1-6) and 3% (2-4), respectively, suggesting that these two techniques may be more effective in preventing the occurrence of this complication during the postoperative period. CONCLUSIONS This meta-analysis establishes that orbital decompression is a beneficial and safe surgical approach. While this study enhances the evidence hierarchy for orbital decompression in treating TAO, it requires further validation through larger, prospective, and randomized studies with long-term follow-up periods.
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Affiliation(s)
- Wei Guo
- Beijing Tongren Eye Center, and Beijing Ophthalmology Visual Science Key Lab, Beijing Tongren Hospital, Capital Medical University, No.1 Dong Jiao Min Xiang, Beijing, 100730, China
| | - Jialu Geng
- Beijing Tongren Eye Center, and Beijing Ophthalmology Visual Science Key Lab, Beijing Tongren Hospital, Capital Medical University, No.1 Dong Jiao Min Xiang, Beijing, 100730, China
| | - Dongmei Li
- Beijing Tongren Eye Center, and Beijing Ophthalmology Visual Science Key Lab, Beijing Tongren Hospital, Capital Medical University, No.1 Dong Jiao Min Xiang, Beijing, 100730, China.
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4
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Jinhai Y, Yunxiu C, Chao X, Yaohua W, Kai Y, Hongfei L. A meta-analysis of the efficacy of two-wall orbital decompression operations for thyroid-associated ophthalmopathy. Int Ophthalmol 2024; 44:81. [PMID: 38358400 DOI: 10.1007/s10792-024-03039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/12/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND The main treatment for the symptoms of proptosis and optic nerve compression caused by thyroid-associated ophthalmopathy is orbital decompression surgery. Medial inferior wall decompression and balanced decompression are two frequently used surgical procedures. However, there is no unified consensus on how to choose different surgical options for orbital decompression in clinical practice. AIMS To compare the effects of medial inferior wall decompression and balanced decompression surgery through meta-analysis and to provide reference for clinical optimal decision making. METHODS Databases, including PubMed, Web of Science, Ovid, Cochrane Library, and ClinicalTrials.gov, were searched for randomized controlled trials and cohort studies on decompression surgery for thyroid-associated ophthalmopathy published from inception to March 21, 2023. Using RevMan 5.3 software, a meta-analysis was conducted based on the following outcome indicators: proptosis, diplopia rate, intraocular pressure, visual acuity, and complication rate. RESULTS Two randomized controlled trials and five cohort studies with a total of 377 patients were included in this analysis. After balanced decompression surgery, patients with thyroid-associated ophthalmopathy experienced a significant decrease in proptosis [MD = 4.92, 95% CI (4.26, 5.58), P < 0.0001]. Balanced decompression can improve postoperative visual acuity [MD = - 0.35, 95% CI (- 0.56, - 0.13), P = 0.001] and intraocular pressure [MD = 5.33, 95% CI (3.34, 7.32), P < 0.0001]. The rates of proptosis [MD = 0.33, 95% CI (- 1.80, 2.46), P = 0.76] and diplopia [OR = 1.20, 95% CI (0.38, 3.76), P = 0.76] did not differ between patients who underwent medial inferior wall decompression and those who underwent balanced decompression. CONCLUSION Balanced decompression and medial inferior wall decompression are both effective options for surgical treatment of thyroid-associated ophthalmopathy in clinical practice.
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Affiliation(s)
- Yu Jinhai
- School of Optometry, Jiangxi Medical College, Nanchang University, No. 463 Bayi Avenue, Nanchang, 330006, Jiangxi, China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang, China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang, China
| | - Chen Yunxiu
- School of Optometry, Jiangxi Medical College, Nanchang University, No. 463 Bayi Avenue, Nanchang, 330006, Jiangxi, China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang, China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang, China
| | - Xiong Chao
- School of Optometry, Jiangxi Medical College, Nanchang University, No. 463 Bayi Avenue, Nanchang, 330006, Jiangxi, China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang, China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang, China
| | - Wang Yaohua
- The Affiliated Eye Hospital, Jiangxi Medical College Nanchang University, No. 463 Bayi Avenue, Nanchang, 330006, Jiangxi, China.
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang, China.
| | - Yuan Kai
- The Affiliated Eye Hospital, Jiangxi Medical College Nanchang University, No. 463 Bayi Avenue, Nanchang, 330006, Jiangxi, China
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang, China
| | - Liao Hongfei
- The Affiliated Eye Hospital, Jiangxi Medical College Nanchang University, No. 463 Bayi Avenue, Nanchang, 330006, Jiangxi, China.
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang, China.
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Takahashi Y, Vaidya A. Secondary Effects of Orbital Decompression in Thyroid Eye Disease: A Review. Semin Ophthalmol 2023:1-10. [PMID: 36631972 DOI: 10.1080/08820538.2023.2166354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE Orbital decompression is mainly performed in thyroid eye disease to reduce proptosis and retrobulbar pressure, to improve venous congestion, and to relieve optic nerve compression. Secondary effects of orbital decompression are also occasionally encountered. The aim of this study was to review the secondary effects of orbital decompression. METHODS This is a comprehensive literature review that summarizes the secondary effects of orbital decompression. RESULTS Decreased intraocular pressure, inter-pupillary distance, and eyelid pressure, and improvement of eyelid retraction, lateral flare, orbital discomfort, and psychosocial condition after orbital decompression are favorable changes for patients. In contrast, refractive changes in some patients and decreased Bell's phenomenon and nasal function worsen patients' condition. CONCLUSION These favorable changes may reduce the patients' burden for treatment of thyroid eye disease. In contrast, as some of the adverse effects significantly worsen the patients' disease condition, we should carefully monitor these changes.
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Affiliation(s)
- Yasuhiro Takahashi
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, Aichi, Japan
| | - Aric Vaidya
- Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, Aichi, Japan.,Department of Oculoplastic, Orbital & Lacrimal Surgery, Kirtipur Eye Hospital, Kathmandu, Nepal
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Dallan I, Cristofani-Mencacci L, Fiacchini G, Turri-Zanoni M, van Furth W, de Notaris M, Picariello M, Alexandre E, Georgalas C, Bruschini L. Endoscopic-assisted transorbital surgery: Where do we stand on the scott’s parabola? personal considerations after a 10-year experience. Front Oncol 2022; 12:937818. [PMID: 35912254 PMCID: PMC9334664 DOI: 10.3389/fonc.2022.937818] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their “new” trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment.
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Affiliation(s)
- Iacopo Dallan
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Lodovica Cristofani-Mencacci
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
- *Correspondence: Lodovica Cristofani-Mencacci,
| | - Giacomo Fiacchini
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Mario Turri-Zanoni
- ENT Unit, Department of Biotechnology and Life Sciences, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Wouter van Furth
- Neurosurgery Unit, Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | - Matteo de Notaris
- Neurosurgery Operative Unit, Department of Neuroscience, “San Pio” Hospital, Benevento, Italy
| | - Miriana Picariello
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Enrico Alexandre
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | | | - Luca Bruschini
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
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Woo T, Li C, Ganesananthan S, Rajendram R, Uddin J, Lee RWJ, Dayan C, Taylor P. The Effect of Ophthalmic Surgery for Graves' Orbitopathy on Quality of Life: A Systematic Review and Meta-Analysis. Thyroid 2022; 32:177-187. [PMID: 34877883 DOI: 10.1089/thy.2021.0411] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Graves' orbitopathy (GO) has a profound negative impact on quality of life. Surgery is undertaken to preserve vision, correct diplopia, and improve aesthetics. We sought to quantify the effect of different surgical approaches on quality of life. Methods: Electronic databases Ovid-MEDLINE and EMBASE were used from inception until March 22, 2021, to identify studies assessing quality of life pre- and postsurgical intervention for GO. Two reviewers independently extracted data and performed quality assessments. Random-effects and Bayesian models for meta-analyses were utilized. Results: Ten articles comprising 632 patients with a mean age of 48.4 years (range 16-85 years) were included. All used the Graves' Ophthalmopathy Quality of Life (GO-QOL) questionnaire. For GO-QOL appearance, the pooled standardized mean improvement for patients after surgery was +0.72 (95% confidence interval [CI 0.50-0.94]), I2 = 69% [CI 52-80%]. For GO-QOL visual functioning, the pooled standardized mean difference (SMD) for patients after surgery was +0.41 [CI 0.25-0.58], I2 = 60% [CI 36-74%]. For visual appearance, orbital decompression yielded the greatest improvement (SMD +0.84 [CI 0.54-1.13]) followed by eyelid surgery (SMD +0.38 [CI 0.05-0.70]), while strabismus correction had no significant effect (SMD +0.94 [CI -0.10 to 1.99]). Conversely strabismus correction was associated with the greatest improvement (SMD +1.25 [CI 0.29-2.21]) in visual functioning, outperforming orbital decompression (SMD +0.29 [CI 0.15-0.43]) and eyelid surgery (SMD +0.12 [CI -0.18 to 0.41]). A mean improvement in GO-QOL of greater than 10 points after orbital decompression surgery was achieved in 12/14 (86%) patient groups for appearance and 5/14 (36%) patient groups for visual functioning. A mean improvement of greater than 6 points was achieved in 5 of 6 (83%) patient groups for strabismus surgery for both appearance and visual functioning. A mean improvement of greater than 6 points after eyelid surgery was achieved in 2/3 (67%) patient groups and 0/3 patient groups for visual appearance and functioning, respectively. Conclusion: Ophthalmic surgery results in substantial improvements in quality of life in patients with GO, with greater perceived effects on appearance than visual function. Orbital decompression has particular impact on visual appearance; strabismus surgery may benefit both visual appearance and function equally, whereas eyelid surgery benefits appearance alone.
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Affiliation(s)
- Timothy Woo
- Department of Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - ChunHei Li
- Department of Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - Rathie Rajendram
- Department of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Jimmy Uddin
- Department of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard W J Lee
- Department of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Ophthalmology, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Colin Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
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Stähr K, Eckstein A, Buschmeier M, Hussain T, Daser A, Oeverhaus M, Lang S, Mattheis S. Risk Factors for New Onset Diplopia After Graduated Orbital Decompression. Ophthalmic Plast Reconstr Surg 2021; 37:564-570. [PMID: 33587422 DOI: 10.1097/iop.0000000000001949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of the study was to identify possible risk factors for new onset diplopia in 20° of primary position (NOD PP) after orbital decompression. A predisposition for NOD has been established for patients with pre-existing diplopia in secondary gaze; therefore, the authors focused on patients without preoperative diplopia. METHODS Retrospective chart review of patients who underwent balanced orbital decompression between 2012 and 2019 due to Graves orbitopathy at the authors' institution. Exclusion criteria were incomplete clinical data set, revision surgery, and medial or lateral decompression only. The following clinical parameters were evaluated preoperatively and postoperatively: Hertel exophthalmometry, objective measurement of misalignment using the prism-cover-test, assessment of the field of binocular single vision, and measurement of monocular excursions. In addition, the diameter of the extraocular eye muscles was measured in all preoperative CT scans. RESULTS We included 327 patients (612 orbits), 126 patients (242 orbits) had no preoperative diplopia. In patients with NOD PP (34%, n = 43/126), enlargement of the medial rectus muscle and restriction of abduction and elevation were significantly more frequent than in patients with no NOD PP. The degree of exophthalmos decrease positively correlated with postoperative squint angle. CONCLUSION We were able to identify the diameter of the medial rectus muscle, restriction of abduction, and elevation as well as an extensive reduction of exophthalmos as risk factors for NOD PP in patients with no preoperative diplopia.
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Affiliation(s)
- Kerstin Stähr
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Anja Eckstein
- Department of Ophthalmology (Chair: Prof. Bechrakis), University Hospital Essen, Germany
| | - Maren Buschmeier
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Timon Hussain
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Anke Daser
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Michael Oeverhaus
- Department of Ophthalmology (Chair: Prof. Bechrakis), University Hospital Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Stefan Mattheis
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
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Current Management of Thyroid Eye Disease. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00675-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Management of Patients With Graves Orbitopathy Using Endonasal Endoscopic Techniques. J Craniofac Surg 2021; 32:1521-1525. [PMID: 33170828 DOI: 10.1097/scs.0000000000007107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE The aim of the authors' study is to show their surgical results in orbital decompression using different endonasal endoscopic techniques. These approaches are according to the degree of proptosis and the presence or not of sight threatening. METHODS The authors performed 31 orbital decompressions on 20 Graves orbitopathy patients. Average age at surgery was 52 years. There were 5 males and 15 females. Five patients were diagnosed as having severe or for sight-threatening Graves orbitopathy. These included 3 men and 2 women having an average age of 54 years old. Minimum postsurgical follow-up was 12 months in all patients. RESULTS Orbital decompression was performed in 15 patients for proptosis and in 5 patients for urgent sight threat. Thirteen orbits showed mild proptosis and 18 orbits presented moderate proptosis. In patients without sight threatening reduction of proptosis had a mean value of 2.8 mm as determined by exophtalmometry, being 3.3 mm when measured on magnetic resonance imaging. The mean millimeter in mild proptosis was between 1.5 and 1.7 and between 3.4 and 4.2 in moderate proptosis. In patients having sight threat mean visual acuity after surgery improved from 0.6 to 0.9.Only 1 patient without diplopia preoperative developed diplopia after surgery (17%). In 55% of patients strabismus and/or eyelid surgery were required.In postoperative follow-up, 2 patients developed a mucocele and 1 patient developed corneal erosion. CONCLUSION The authors recommend the preservation of the periorbital sling and the anterior ethmoido-maxillary angle in patients with mild-moderate exophthalmos and without threatened vision. In case of sight threatening the authors resected the most periorbita as much as possible.Evidence-based medicine Level V.
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11
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Changes in Field of Binocular Single Vision and Ocular Deviation Angle After Balanced Orbital Decompression in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2021; 37:154-160. [PMID: 32427735 DOI: 10.1097/iop.0000000000001712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate influential factors for changes in the binocular single vision (BSV) and ocular deviation angle in the medial direction after bilateral balanced orbital decompression in thyroid eye disease. METHODS This retrospective study included 41 patients. The areas of BSV and the angles of medial ocular deviation on the Hess chart were measured. The percentages of pre- and postoperative areas against the normal area (%BSV) and the change in BSV after surgery were calculated. Postoperative change in the angle was calculated by subtraction of the preoperative angle from the postoperative one. Influential factors for the change in BSV and that in the medial deviation angle were evaluated via multivariate linear regression analysis. RESULTS The maximum cross-sectional area of the medial rectus muscle, preoperative %BSV, and preoperative medial ocular deviation angle were significant factors of change in BSV (adjusted r2 = 0.449, p < 0.001), although age, history of anti-inflammatory treatment, volume of removed orbital fat, findings on CT images, maximum cross-sectional areas of the other rectus muscles, and presence or absence of a periosteal flap did not affect change in BSV (p > 0.050). On the contrary, all variables did not influence postoperative changes in the medial ocular deviation angle (p > 0.050). CONCLUSIONS In balanced orbital decompression, the maximum cross-sectional area of medial rectus muscle, preoperative field of BSV, and medial ocular deviation were significant influential factors for postoperative changes in field of BSV.
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Abstract
Hintergrund Die endokrine Orbitopathie ist die häufigste extrathyreoidale Manifestation des Morbus Basedow und tritt bei schätzungsweise 25–50 % der betroffenen Patienten auf. Krankheitsbedingt kommt es zu einer entzündlichen Schwellung der Orbitaweichteile. Die Behandlung erfolgt meist konservativ. Bei schweren Fällen mit beeinträchtigendem Exophthalmus oder akuter, steroidrefraktärer Visusbedrohung kann eine chirurgische Orbitadekompression die Beschwerden der Patienten lindern oder das Sehvermögen erhalten. Ein wesentlicher Aspekt der Versorgungsqualität besteht in der Vermeidung postoperativer Doppelbilder. Ziel der Arbeit Erfahrungs- und Ergebnisbericht von 100 chirurgischen Orbitadekompressionen bei 62 Patienten an einem interdisziplinären Orbitazentrum. Patienten mit Kompression der Orbitaspitze wurden mittels pterionaler Dekompression behandelt. Patienten ohne Hinweise auf Orbitaspitzenbeteiligung wurden mittels tiefer lateraler Wandresektion oder pterionaler Dekompression behandelt. Methodik Retrospektive Datenanalyse. Ergebnisse Die mittlere Exophthalmusreduktion betrug 2,9 mm. Augen mit visusbedrohendem Schweregrad gewannen im Mittel 2,2 Zeilen an Sehschärfe, der Visus bei rehabilitativer Indikation blieb stabil. Die Komplikationsrate betrug 4 %. Neue Doppelbilder wurden nach 2 Eingriffen beobachtet. Bei einem Patienten kam es zu einer Visusminderung von 0,8 auf 0,1. In 9 Fällen führte die Operation zu einem vollständigen Rückgang zuvor beklagter Doppelbilder. Diskussion Visusgewinn, Exophthalmusreduktion und Komplikationsrate sind in diesem Kollektiv vergleichbar mit zuvor publizierten Arbeiten. Diese Studie bestätigt die Rolle der Orbitadekompression bei visusbedrohender und schwer beeinträchtigender endokriner Orbitopathie.
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Gioacchini FM, Kaleci S, Cassandro E, Scarpa A, Tulli M, Cassandro C, Ralli M, Re M. Orbital wall decompression in the management of Graves' orbitopathy: a systematic review with meta-analysis. Eur Arch Otorhinolaryngol 2021; 278:4135-4145. [PMID: 33599843 DOI: 10.1007/s00405-021-06698-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To systematically review outcomes of orbital bony wall decompression for Grave's orbitopathy according to the surgical approach. METHODS A systematic search for studies published in "Ovid MEDLINE", "Web of Science" and "Embase" of patients with surgical treatment of Grave's orbitopathy was performed. The overall postoperative change in Hertel exophthalmometry was calculated by random-effect meta-analysis model with 95% confidence interval (CI). RESULTS A total of 33 studies, including 1686 patients and 2946 procedures, were included. The weighted mean Hertel value overall reduction was - 4.56 mm (95% CI - 5.05 to - 4.07 mm). According to surgical techniques the reduction was - 4.36 mm (95% CI - 5.22 to - 3.50) for infero-medial technique, - 4.88 mm (- 5.68 to - 4.08) for medial-lateral technique, - 4.32 mm (- 4.80to - 3.84) for lateral technique, - 5.45 mm (- 6.16 to - 4.74) for three-wall technique and - 3.47 mm (- 5.81 to - 1.12) for medial technique. The overall rate of new-onset of primary gaze diplopia was reported in 23 studies. The included procedures were 653 and results were heterogeneous (heterogeneity: Q = 78.8 df = 22, I2 = 72.09%, p < 0.01). The pooled proportion (95% CI) rate of new-onset of primary gaze diplopia was 12% (7-16). CONCLUSION Our metanalysis highlights that orbital bony wall decompression represents an effective surgical procedure. The three wall approach was associated with the best results in terms of exophthalmos reduction. Data suggest that an exclusive lateral approach may help to avoid the new-onset of primary gaze diplopia during the postoperative period.
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Affiliation(s)
- Federico Maria Gioacchini
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020, Ancona, Italy.
| | - Shaniko Kaleci
- Department of Diagnostic Medicine, Clinical and Public Health, University Hospital of Modena, Modena, Italy
| | - Ettore Cassandro
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Michele Tulli
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020, Ancona, Italy
| | | | - Massimo Ralli
- Department of Sense Organs, Sapienza University Rome, Rome, Italy
| | - Massimo Re
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020, Ancona, Italy
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Pterional Orbit Decompression in Grave Disease with Dysthyroid Optic Neuropathy. World Neurosurg 2021; 149:e1007-e1016. [PMID: 33476778 DOI: 10.1016/j.wneu.2021.01.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/09/2021] [Accepted: 01/10/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The choice of surgical technique in sight-threatening Grave orbitopathy remains controversial. Available data are mostly derived from mixed cohorts with multiple surgical indications and techniques. The authors assessed predictors for visual outcome after standardized pterional orbital decompression for dysthyroid optic neuropathy. METHODS Retrospective analysis of 62 pterional orbital decompressions performed on 40 patients with dysthyroid optic neuropathy. RESULTS Visual acuity improved by an average of 3.8 lines in eyes with preoperative visual impairment (95% confidence interval [CI]: 1.8-5.8 lines, P < 0.001) and remained stable in eyes without prior visual impairment (95% CI -1.3 to 1 line, P = 0.81). Proptosis was reduced by an average of 3.1 mm (95% CI 1.8-4.3 mm, P < 0.001). Higher degrees of proptosis were predictive of worse visual outcomes (P = 0.017). New-onset diplopia developed in 2 patients, while previous diplopia resolved after surgery in 6 patients. CONCLUSIONS This cohort is the largest series of pterional orbit decompressions and the first to focus exclusively on dysthyroid neuropathy. Complication rates were low. Decompression surgery was highly effective at restoring and maintaining visual acuity in patients with dysthyroid optic neuropathy.
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Leite CDA, Pereira TDS, Chiang J, Moritz RB, Gonçalves ACP, Monteiro MLR. Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study. Clinics (Sao Paulo) 2021; 76:e2592. [PMID: 33852655 PMCID: PMC8009066 DOI: 10.6061/clinics/2021/e2592] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Cristiane de Almeida Leite
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Thaís de Sousa Pereira
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Jeane Chiang
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Bernal Moritz
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Allan Christian Pieroni Gonçalves
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mário Luiz Ribeiro Monteiro
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Clarós P, Waląg A, López-Fortuny M, Clarós A. Impact of the ethmoid volume on endoscopic medial wall decompression outcomes in Graves' orbitopathy. Acta Otolaryngol 2020; 140:948-953. [PMID: 32957802 DOI: 10.1080/00016489.2020.1816655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endoscopic orbital decompression is a well-established technique for Graves orbitopathy treatment. AIMS Measurement of the ethmoid volume and its correlation with proptosis reduction in patients undergoing endoscopic orbital decompression for Graves' orbitopathy. METHODS We retrospectively reviewed clinical charts of 209 patients (319 orbits) operated by a surgeon at our institution between 1998 and 2019. RESULTS Average age was 46.9 years. About 83.3% of the patients were female, 54.6% were smokers, 93.8% were euthyroid at the time of decompression, 3.8% were hypothyroid and 2.4% were hyperthyroid. About 77.5% of the patients underwent bilateral surgery, the remainder and unilateral. Subsequent stages included strabismus surgery in 22.5% patients, Müllerectomy 37.8%, with or without canthoplasty (14.8 vs. 23%). Mean proptosis reduction was 4.61 mm. Mean ethmoid volume was 5.57 mm3. Ethmoid volume had a moderate positive correlation with proptosis reduction (r s = 0.49, p < .001). Further investigation, statistically significant moderate correlation was found only in the small (SE) and big (BE) ethmoid groups. CONCLUSION We advise evaluating ethmoid sinus pneumatization on computed tomography before decompression to estimate possible anatomical limitations. Additional wall decompression might be advocated in most severe cases.
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Affiliation(s)
| | - Agnieszka Waląg
- Scholarship at Clínica Clarós, Barcelona, Spain
- Department of Otolaryngology, Rydygier Memorial Hospital, Cracow, Poland
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Składzień J, Wiatr A, Wiatr M, Romanowska-Dixon B, Gniadek-Batko D, Gawlik J, Zielińska-Kubatko A, Wróbel A. Rehabilitation after surgical treatment of retrobulbar tumors. Otolaryngol Pol 2020; 74:7-10. [PMID: 34550093 DOI: 10.5604/01.3001.0014.1388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The authors propose a set of rehabilitation exercises concerning the muscles which are responsible for movement of the eyeball. After surgical treatments of retrobulbar tumors, the function of the eyeball muscles is often inadequate. Some compensation should be created at the level of the central nervous system, which means trigging adaptation, substitution and habituation. The exercises should be started just after the patient is awakened: first in the horizontal position, then sitting position and finally standing position. The highest number of exercises should be done in the direction of extreme diplopia.
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Affiliation(s)
- Jacek Składzień
- Department of Otolaryngology, Jagiellonian University Medical College in Krakow, Poland
| | - Agnieszka Wiatr
- Department of Otolaryngology, Jagiellonian University Medical College in Krakow, Poland
| | - Maciej Wiatr
- Department of Otolaryngology, Jagiellonian University Medical College in Krakow, Poland
| | | | - Dominika Gniadek-Batko
- Ophthalmology Department of the Jagiellonian University Collegium Medicum, Cracow, Poland
| | - Jolanta Gawlik
- Chair Otolaryngology of the Jagiellonian University Collegium Medicum, Cracow, Poland
| | - Anna Zielińska-Kubatko
- Ophthalmology Department of the Jagiellonian University Collegium Medicum, Cracow, Poland
| | - Agnieszka Wróbel
- Chair Otolaryngology of the Jagiellonian University Collegium Medicum, Cracow, Poland
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Marinò M, Ionni I, Lanzolla G, Sframeli A, Latrofa F, Rocchi R, Marcocci C. Orbital diseases mimicking graves' orbitopathy: a long-standing challenge in differential diagnosis. J Endocrinol Invest 2020; 43:401-411. [PMID: 31691261 DOI: 10.1007/s40618-019-01141-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023]
Abstract
Graves' orbitopathy (GO) is the most common cause of orbital tissue inflammation, accounting for ~ 60% of all orbital inflammatory conditions in the population aged 21-60 years, and for ~ 40% in the population aged > 60 year. GO is observed in 25-30% of patients with Graves' hyperthyroidism and more rarely in association with hypothyroid autoimmune thyroiditis. In addition, a small proportion of GO patients (1-2%) do not have a clinically overt thyroid dysfunction. Clinically, GO is characterized by proptosis, inflammation involving the eyelids and the conjunctiva, extraocular muscle hypertrophy, with consequent reduction of ocular motility and diplopia, and in the most severe cases, compression of the optic nerves at the orbital apex, with reduction of visual acuity. At CT scan or MRI, a muscle increase involving the superior, medial and inferior rectus is quite typical. In the most severe forms, compression of the optic nerves at the orbital apex can be observed. Euthyroid GO is usually an early sign of a full-blown Graves' disease; however, in some cases, the orbital disease can remain isolated. Moreover, euthyroid GO can rarely be unilateral, which makes the picture even more confusing. Under those circumstances, the diagnostic process becomes obviously quite difficult, having other conditions mimicking GO been excluded. A number of inflammatory conditions affecting orbital tissue can mimic GO, thereby requiring an accurate evaluation for a proper differential diagnosis. The majority of these conditions are immune mediated. Most of them are benign, but they can be rather aggressive and some can cause visual loss. The most common inflammatory condition affecting orbital tissues and mimicking GO is idiopathic orbital inflammation. Other, more rare, orbital diseases that should be considered in the differential diagnosis are infections, orbital manifestations of systemic diseases, primitive and secondary orbital neoplasms, and orbital vascular alterations. In most instances, when an orbitopathy occurs in the absence of hyperthyroidism, the diagnosis of the disease underlying the ocular symptoms and signs is based on exclusion of the other conditions. Here we review the conditions that can mimic GO and how to distinguish them from this obnoxious eye disease.
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Affiliation(s)
- M Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - I Ionni
- Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - G Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - A Sframeli
- Department of Surgical, Medical and Molecular Pathology, Ophthalmopathy Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Latrofa
- Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - R Rocchi
- Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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Abstract
PURPOSE OF REVIEW To offer an update on advances and controversies in the assessment, investigation and treatment of thyroid eye disease (TED), a disfiguring orbital autoimmune disease, which can manifest with diplopia and threaten not only sight - but also life. RECENT FINDINGS Developments in biomarkers and imaging are helping to tailor the management of patients. Emerging therapies target different pathways in the disease and are informed by studies into TED pathogenesis: the last 2 years has, for example, seen the culmination of a two-decade long bench-to-bedside story in which an original focus on the IGF1 receptor has translated into an effective treatment for proptosis in thyroid eye disease. Whether this will result in a real-world reduction in TED-related morbidity will depend on access; commercial pricing decisions may preclude widespread adoption of novel therapies. SUMMARY Thyroid eye disease research is enjoying a renaissance with advances in both monitoring and treatment coupled with a renewed emphasis on a holisitic approach, which includes aesthetic care for patients; this is perhaps the most exciting time to be part of the international thyroid eye disease community in decades - for physicians, surgeons and patients. The commercial window for break-through drugs are narrowing with an array of new therapeutic agents in the pipeline over the coming decade.
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Marinò M, Rotondo Dottore G, Ionni I, Lanzolla G, Sabini E, Ricci D, Sframeli A, Mazzi B, Menconi F, Latrofa F, Vitti P, Marcocci C, Chiovato L. Serum antibodies against the insulin-like growth factor-1 receptor (IGF-1R) in Graves' disease and Graves' orbitopathy. J Endocrinol Invest 2019; 42:471-480. [PMID: 30132285 DOI: 10.1007/s40618-018-0943-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A role of the insulin-like growth factor-1 receptor (IGF-1R) in the pathogenesis of Graves' orbitopathy (GO) has been proposed, but the existence and function of anti-IGF-1R-antibodies (IGF-1R-Abs) are debated. METHODS We designed a cross-sectional investigation to measure serum IGF-1R-Abs by a commercial assay in consecutive patients with Graves' disease (GD) compared with healthy subjects and patients with autoimmune thyroiditis (AT). A total of 134 subjects were screened including 27 healthy subjects, 80 GD patients (54 of whom with GO), and 27 AT patients. The main outcome measure was the prevalence of positive serum IGF-1R-Abs in GO, compared with GD without GO and with the other study groups. RESULTS Having established a cut-off value at 55.2 ng/ml for positive tests, positive IGF-1R-Abs were more frequent in GD (25%), than in AT (3.7%, P = 0.003) and healthy subjects (0%, P = 0.006). Within GD, there was no difference between patients with or without GO. Serum levels of IGF-1R-Abs differed across the study population (P < 0.0001), reflecting their higher concentrations in GD (P < 0.0001 vs both AT and healthy subjects), but with no difference between patients with or without GO. In patients with GO, there was an inverse correlation between serum IGF-1R-Abs and CAS (R = - 0.376, 95% CI: from - 0.373 to - 0.631; P = 0.005), the significance of which remains to be investigated. CONCLUSIONS Serum autoantibodies against the IFG-1R are present in one-fourth of GD patients, regardless of the presence of GO. Further functional studies are needed to investigate the significance of their inverse correlation with GO activity.
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Affiliation(s)
- M Marinò
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - G Rotondo Dottore
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - I Ionni
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - G Lanzolla
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - E Sabini
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
- Division of Immunology, Department of Pathology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - D Ricci
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - A Sframeli
- Ophthalmology Unit I, Department of Surgical, Medical and Molecular Pathology, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - B Mazzi
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Menconi
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Latrofa
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - P Vitti
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - C Marcocci
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Chiovato
- Unit of Endocrinology, Department of Internal Medicine and Medical Therapy, University of Pavia, Fondazione Salvatore Maugeri IRCCS, Pavia, Italy
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21
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Lanzolla G, Vannucchi G, Ionni I, Campi I, Sileo F, Lazzaroni E, Marinò M. Cholesterol Serum Levels and Use of Statins in Graves' Orbitopathy: A New Starting Point for the Therapy. Front Endocrinol (Lausanne) 2019; 10:933. [PMID: 32038490 PMCID: PMC6987298 DOI: 10.3389/fendo.2019.00933] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 12/14/2022] Open
Abstract
Graves' Orbitopathy (GO) is the most frequent extrathyroidal manifestation of Graves' disease (GD). Its ultimate cause remains unclear, but it is commonly considered an autoimmune disorder due to self recognition of autoantigens constitutively expressed by orbital fibroblasts (OFs), and thyroid epithelial cells. High dose intravenous glucocorticoids (ivGC) are the most commonly used treatment for moderately severe and active GO. However, based on the complex pathogenesis of GO, a number of factors may have a protective and maybe a therapeutic role. The use of other medications improving the effect of GC may increase the overall effectiveness of the therapy and reduce GC doses, thereby limiting side effects. Recently, a possible protective role of 3-hydroxy-3-methylglutaryl-coenzyme reductase inhibitors, the so-called statins, and perhaps of lowering cholesterol levels, has been proposed. Thus, statins have been reported to be associated with a reduced frequency of GO in GD patients and in recent cross-sectional and retrospective studies a significant correlation was found between the occurrence of GO and both total and LDL-cholesterol in patients with a GD of relatively recent onset, suggesting a role of cholesterol in the development of GO. Moreover, a correlation was found between the GO clinical activity score and total as well as LDL-cholesterol in untreated GO patients, depending on GO duration, indicating a role of cholesterol on GO activity. Therefore, statin treatment may be beneficial for GO. Here we review this subject, which offers new therapeutic perspectives for patients with GO.
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Affiliation(s)
- Giulia Lanzolla
- Endocrinology Units, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Guia Vannucchi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Ilaria Ionni
- Endocrinology Units, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Irene Campi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Federica Sileo
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Elisa Lazzaroni
- Endocrinology and Metabolism Unit, Fondazione IRCCS Cà Granda, University of Milan, Milan, Italy
| | - Michele Marinò
- Endocrinology Units, Department of Clinical and Experimental Medicine, University of Pisa and University Hospital of Pisa, Pisa, Italy
- *Correspondence: Michele Marinò
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