Intraocular pressure lowering effect of orbital decompression is related to increased venous outflow in Graves orbitopathy

The potential role of adipokines and hepatokines in age-related ocular diseases

Age-related ocular diseases, including diabetic retinopathy (DR), age-related macular degeneration (AMD), cataract and glaucoma may lead to visual impairment and even to blindness. Metabolic diseases, such as obesity and metabolic dysfunction-associated steatotic liver disease (MASLD) have emerged as potential risk factors of age-related ocular diseases, especially DR. Visceral adiposity has been associated with increased risk of DR and AMD in most clinical studies, although body mass index has to-date provided conflicting association with DR and AMD. In addition, obesity is recognized as a risk factor of cataract and glaucoma. Similarly to obesity, MASLD appears to be associated with DR in patients with type 1 diabetes mellitus, but probably not in those with type 2 diabetes mellitus. A potential positive association between MASLD and AMD, glaucoma and cataract is supported by limited evidence to-date, thus needing further investigation. Altered secretion patterns of adipokines (adiponectin, leptin, lipocalin-2, resistin) and hepatokines [adropin, fetuin-A, fibroblast growth factor (FGF)-21, retinol binding protein (RBP)-4] seem to disrupt ocular homeostasis and contribute to the development of age-related ocular diseases in the context of obesity and MASLD. In this regard, novel adipokine-based and hepatokine-based therapies may be added to the treatment options for ocular diseases in the future. This narrative review aimed to summarize evidence on the interconnection of obesity and MASLD with age-related ocular diseases, with a specific focus on the roles of adipokines and hepatokines as mediators of these potential associations.

Alterations in blood flow at the optic nerve head in patients with thyroid eye disease using optic coherence tomography angiography

Introduction

This study aimed to evaluate changes in blood flow at the optic nerve head (ONH) in patients with thyroid eye disease (TED) using optical coherence tomography angiography (OCTA).

Methods

A total of 59 eyes from 59 patients with TED and 39 eyes from 39 healthy controls (HCs) were included. Patients with TED were categorized into the active and inactive groups based on clinical activity scores. All participants underwent ophthalmological and endocrinological tests. Peripapillary vessel density (VD) and retinal nerve fiber layer thickness (RNFLT) were measured using OCTA. All eyes underwent a 4.5*4.5-mm scan pattern centered on the ONH. The peripapillary region was divided into eight sectors: superior nasal (SN), nasal upper (NU), nasal lower (NL), inferior nasal (IN), inferior temporal (IT), temporal lower (TL), temporal upper (TU), and superior temporal (ST). A correlation analysis was used to explore the association between blood flow changes and relevant factors.

Results

Compared to the eyes of HCs, the eyes of patients in the inactive TED group demonstrated lower radial peripapillary capillary VD, with significant differences observed in the SN and ST sectors of the peripapillary region (p < 0.05). No differences were observed in the peripapillary RNFLT between the groups. Additionally, there was no significant correlation between the whole peripapillary VD and RNFLT or visual functional parameters. Moreover, visual acuity impairment was positively correlated with IN-VD, NU-VD, ST-VD, and NU-RNFLT in the peripapillary region. Intraocular pressure was positively correlated with IN-RNFLT.

Conclusion

OCTA can detect microvascular ONH changes in patients with TED.

Correlation Between Changes in Extraocular Muscles and Intraocular Pressure Following Anti-Inflammatory Therapy in Active Thyroid Eye Disease

Objectives: We investigate the correlation between functional and morphological changes in extraocular muscles (EOMs) and intraocular pressure (IOP) changes before and after thyroid eye disease (TED) treatment. Methods: A multicenter study with a retrospective chart review was conducted. Patients with active TED receiving corticosteroid therapy without glaucoma eye drops between 2014 and 2023 were reviewed. Various parameters were measured by magnetic resonance imaging. The primary outcome measure was the correlation between changes in the IOP and the cross-sectional area (CSA) of the EOMs before and after treatment. Secondary outcome measures were comparisons of IOP, the signal intensity ratio (SIR) of the EOMs and orbital fatty tissue (OFT), and the CSA of the EOMs before and after treatment. Results: The IOP in 99 eyes in 51 patients significantly decreased from 18 ± 3.4 mmHg to 15.5 ± 2.9 mmHg before and after treatment (p < 0.01)). The CSA and SIR of all EOMs and OFT significantly decreased after treatment (p < 0.05). Factors that had a significant positive correlation with the IOP change rate before and after treatment were the CSA change rate of the inferior rectus muscle (IRM) before and after treatment (Spearman's correlation coefficient, R2 = 0.24, p < 0.05) and the CSA change rate of the total EOMs before and after treatment (Spearman's correlation coefficient, R2 = 0.22, p < 0.05). Conclusions: In TED patients, IOP decreased with anti-inflammatory treatment alone. The most significant parameter that correlated with the decrease in IOP was the CSA change rate of the IRM.

Comparative effectiveness of various orbital decompression techniques in treating thyroid-associated ophthalmopathy: a systematic review and meta-analysis

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.

Intraocular Pressure Changes After Combined Orbital Decompression and Glucocorticoid Treatment for Graves Orbitopathy

OBJECTIVE

To evaluate the change in the intraocular pressure (IOP) in subjects with Graves orbitopathy (GO) after orbital decompression (OD) with glucocorticoids (GCs).

METHODS

Ninety-nine orbits of 76 patients with GO were retrospectively reviewed, with either OD (Group A), OD with intravenous glucocorticoids (i.v.GC) (Group B) or parabulbar GC (Group C) administration. The main outcome measures included pre-and post-operative IOP in the primary and upward gazes.

RESULTS

Mean postoperative IOPs in the primary gaze were lower than the preoperative values for groups A and C (P < 0.05). The IOPs during the upward gaze were higher than those in the primary gaze before and after OD (all groups, P < 0.05). The mean postoperative and preoperative IOPs during upward gaze were similar in all groups except group C (P = 0.001). The mean decrease in IOP in the primary gaze was 1.57 ± 6.00 mm Hg and 2.22 ± 2.62 mm Hg in groups A and C, respectively (P < 0.05). Only in group C, the mean IOPs during upward gaze decrease by 5.29 ± 4.89 mm Hg (active GO before OD), and the mean gaze-related IOP decreased from 7.75 ± 6.02 to 2.57 ± 4.21 mm Hg (P < 0.05).

CONCLUSIONS

A pbGC treatment before OD can effectively reduce the primary and upward gaze IOPs and lead to a greater postoperative reduction in the upward gaze IOP to approximate that in the primary gaze. A pbGC treatment may be preferred for patients with GO in the active or congestive phase before OD considering the IOP.

Increased choroidal stromal area in patients with active Graves' ophthalmopathy based on binarisation method of optical coherence tomographic images

OBJECTIVE

To investigate the change in choroidal components of patients with Graves' ophthalmopathy (GO) with different degrees of disease activity and severity by using the image binarisation method of optical coherence tomography (OCT).

METHODS

This cross-sectional study included 151 eyes of 90 patients with GO. Patients were grouped according to the clinical activity score (CAS) and disease severity. Total choroidal area (TCA), luminal area, stromal area (SA) and choroidal vascularity index (CVI) were acquired by image binarisation of the OCT. Ocular parameters between groups were compared using generalised estimating equations, accounting for intereye correlation and adjusting for relevant factors.

RESULTS

As for the included eyes, 104 eyes were inactive GO and 47 eyes were active GO. Local choroidal thicknesses were thicker in active GO than in inactive GO. TCA and SA were significantly larger in active GO than in inactive GO group (3.44±0.91 mm2 vs 3.14±0.88 mm2, p=0.046; 1.16 (1.03-1.50) mm2 vs 1.10 (0.96-1.27) mm2, p=0.002, respectively). CAS was positively correlated with TCA (r=0.171, p=0.036) and SA (r=0.172, p=0.035), and negatively associated with CVI (r=-0.174, p=0.032). In multiple regression models, age, diopter and intraocular pressure (IOP) exhibited significant correlations with the SA (β=-0.006, p=0.010; β=0.076, p<0.001; β=0.015, p=0.010, respectively).

CONCLUSIONS

Thickened choroid was observed in active GO compared with inactive GO. The proportional increase of SA was augmented as the disease activity progressed. Age, diopter and IOP were independent factors that affected choroidal area and components in patients with GO. Multicentre prospective cohort studies with a large sample size are still needed.

Superficial ocular vascular changes after orbital decompression in patients with thyroid ophthalmopathy measured by anterior segment OCT angiography; an observational study

Thyroid eye disease (TED) is a common ophthalmologic manifestation of thyroid dysfunction. Despite various imaging techniques available, there hasn't been a widely adopted method for assessing the anterior segment vasculature in TED patients. Our study aimed to evaluate alterations in ocular surface circulation following orbital decompression surgery in TED patients and investigate factors influencing these changes. Using anterior segment optical coherence tomography-angiography (AS-OCTA), we measured ocular surface vascularity features, including vessel density (VD), vessel diameter index (VDI), and vessel length density (VLD), both before and after decompression surgery, alongside standard ophthalmic examinations. Our AS-OCTA analysis revealed a significant decrease in most of the temporal vasculature measurements six weeks post-surgery (p < 0.05). However, differences in the nasal region were not statistically significant. These findings indicate notable changes in ocular surface circulation following orbital decompression in TED patients, which may have implications for intraocular pressure (IOP) control and ocular surface symptoms management. AS-OCTA holds promise as a tool for evaluating the effectiveness of decompression surgery and assessing the need for further interventions.

Diagnostic methods for dysthyroid optic neuropathy: A systematic review and analysis

Diagnosis of dysthyroid optic neuropathy (DON) typically relies on a set of diagnostic clinical features, including decreased visual acuity, impaired color vision, presence of relative afferent pupillary defect, optic disc swelling and ancillary tests including visual field (VF), pattern visual evoked potential (pVEP), and apical crowding or optic nerve stretching on neuroimaging. We summarize various diagnostic methods to establish or rule out DON. A total of 95 studies (involving 4619 DON eyes) met the inclusion criteria. All of the studies considered clinical features as evidence of DON, while most of the studies confirmed DON diagnosis by combining clinical features with ancillary tests. Forty studies (42.1%) used at least 2 out of the 3 tests (VF, pVEP and neuroimaging) and 13 studies (13.7%) used all 3 tests to diagnose DON. In 64 % of the published studies regarding DON, the diagnostic methods of DON were not specified. It is important to note the limitations of relying solely on clinical features for diagnosing DON. On the other hand, since some eyes with optic neuropathy can be normal in one ancillary test, but abnormal in another, using more than one ancillary test to aid diagnosis is crucial and should be interpreted in correlation with clinical features. We found that the diagnostic methods of DON in most studies involved using a combination of specific clinical features and at least 2 ancillary tests.

Refractive Associations With Whole Eye Movement Distance and Time Among Chinese University Students: A Corvis ST Study

Purpose

Eye movement has been frequently studied in clinical conditions, but the association with myopia has been less explored, especially in population-based samples. The purpose of this study was to assess the associations of eye movement measured by the Corvis ST with refractive status in healthy university students.

Methods

A total of 1640 healthy students were included in the study (19.0 ± 0.9 years). Eye movement parameters (whole eye movement [WEM]; whole eye movement time [WEMT]) were measured by the Corvis ST. Spherical equivalent (SE) was measured using an autorefractor without cycloplegia. IOL Master was used to assess axial length (AL).

Results

AL was negatively correlated with WEM and WEMT (rWEM = -0.28, rWEMT = -0.08), and SE was positively correlated with WEM and WEMT (rWEM = 0.21, rWEMT = 0.14). For the risk of high myopia, breakpoint analysis and restricted cubic spline model showed that the knots of the significant steep downward trend of WEM and WEMT were 0.27 mm and 20.4 ms, respectively. The piecewise linear regression model revealed a significant correlation between AL, SE, and WEM when the value of WEM was below 0.27 mm. Additionally, when WEMT exceeded 20.4 ms, a significant decrease in AL and an increase in SE were observed with increasing WEMT.

Conclusions

A larger distance and longer duration of eye movement were correlated with a lower degree of myopia and shorter AL, and there was a threshold effect.

Translational Relevance

The findings might aid in understanding the pathogenesis of myopia and provide a theoretical foundation for clinical diagnosis and prediction.

Alterations in retrobulbar haemodynamics in thyroid eye disease

PURPOSE

To study the orbital perfusion parameters of ophthalmic artery (OA) and central retinal artery (CRA) in inactive TED and the changes following surgical decompression.

METHODS

Non-randomised clinical trial. 24 inactive moderate-to-severe TED orbits of 24 euthyroid cases underwent surgical decompression and examined again at 3 months. The peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) of OA and CRA were evaluated using colour doppler imaging and normative database was established using 18 healthy controls.

RESULTS

The mean age was 39.38 ± 12.56 years and male: female ratio was 1: 1.18. Intraocular pressure was higher, and CRA-PSV, CRA-RI, OA-PSV, and OA-EDV were lower in TED in comparison to heathy orbits. The CRA-PSV, CRA-EDV, OA-PSV, and OA-EDV negatively correlated with proptosis and duration of thyroid disease. The area under curve of OA-PSV (95% CI:0.964-1.000, p < 0.001) and OA-EDV (95% CI:0.699-0.905, p < 0.001) helped in differentiating TED orbits from HC, and in predicting the severity of disease. Post decompression, CRA-PSV, CRA-EDV, OA-PSV, and OA-EDV improved, with decrease in CRA-RI and OA-RI in both lipogenic and MO.

CONCLUSIONS

The orbital perfusion is reduced in inactive TED. The changes in OA flow velocities can help in differentiating inactive TED from healthy orbits and progression of TED. Sequential orbital CDI of OA and CRA can serve as an objective tool for case selection and monitoring response to surgical decompression.

[Graves' orbitopathy: Current concepts for medical treatment]

BACKGROUND

The therapy of severe manifestations of Graves' orbitopathy (GO) is still a challenge and requires good interdisciplinary cooperation. It is especially important to use stage-adapted anti-inflammatory therapy to avoid irreversible damage.

MATERIAL AND METHODS

Discussion of the latest results of multicentre randomised therapy studies on anti-inflammatory treatments for Graves' orbitopathy, as well as new therapeutic concepts.

RESULTS

Mild cases of GO can be treated with only selenium supplementation and a watchful waiting strategy. In the moderate-to-severe active form of GO, primary therapy consists of i. v. steroids (cumulative 4-5 g) in combination with orbital irradiation in patients with impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening disease, bony orbital decompression is usually necessary. As basic research has improved our understanding of the underlying pathophysiology of GO, it has been possible to develop targeted therapies for GO. Teprotumumab, an IGF-1 receptor antibody, was effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe.

CONCLUSION

The current therapy concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This may soon be modified, due to the use of targeted therapies.

Choroidal vascularity index in thyroid-associated ophthalmopathy

OBJECTIVE

To investigate the choroidal vascularity index (CVI) in patients with thyroid-associated ophthalmopathy (TAO) and its relationship with clinical features and clinical activity score METHODS: Right eyes of 53 patients with TAO and 53 healthy subjects were scanned for subfoveal choroidal thickness (SFCT), CVI, choroid-stromal area (C-SA), choroid-luminal area (C-LA), choroidal stromal index (CSI), choroid-stromal-to-luminal-area ratio, and CVI and CSI within the central 1500 µm of the macula (CVI₁₅₀₀ and CSI₁₅₀₀) by enhanced-depth imaging optical coherence tomography. The results of the TAO group and the healthy controls were compared.

RESULTS

The SFCT was significantly greater in the TAO group than in the control group (p = 0.02). The values of C-LA, C-SA, and total choroidal area (TCA) in the TAO group were significantly higher than those in the control group (p = 0.01, p = 0.04, and p = 0.01, respectively). The increases in SFCT, C-LA, C-SA, and TCA were 12.1%, 12.2%, 16.2%, and 13.6%, respectively. There was no statistically significant difference between the groups for CVI, CSI, CVI₁₅₀₀, CSI₁₅₀₀, and choroid-stromal-to-luminal-area ratio (p > 0.05). CVI₁₅₀₀ and CSI₁₅₀₀ have displayed a statistically significant correlation with exophthalmometry and clinical activity score (p < 0.05).

CONCLUSION

The alterations in stromal and vascular structures are proportionally similar in TAO; thus CVI may not be affected significantly. However, CVI₁₅₀₀ and CSI₁₅₀₀ may be associated with disease activity. The choroidal thickening in TAO may be the result not only of vascular mechanisms but also by an increase in stromal contents.

Orbital and ocular perfusion in thyroid eye disease

Thyroid eye disease (TED) is characterized by enlargement of extraocular muscles, an increase in retrobulbar fat, orbital fibrosis, and fluctuations in plasma thyroid hormone levels in most patients, often associated with raised autoantibody titers. The occurrence of orbital space conflict compromises the orbital perfusion, unchecked progression of which results in irreversible loss of visual acuity and visual fields. The quantitative assessment of orbital perfusion can be done by measurement of blood flow velocities in the superior ophthalmic vein (SOV), ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary artery by color Doppler imaging. The retinal and choroidal microvasculature is studied by optical coherence tomography and optical coherence tomography angiography. The orbital and ocular perfusion fluctuates during the course of TED. Orbital congestion is reflected by the reduction or reversal of SOV flow and an increase in subfoveal choroidal thickness. The active phase is characterized by high blood flow velocities of the OA and CRA. The onset of dysthyroid optic neuropathy is associated with reduced arterial perfusion and reduction in parafoveal and peripapillary vascular density. Orbital decompression improves the SOV flow and decreases the resistivity index of CRA. Sequential evaluation of orbital hemodynamic changes can thus supplement the clinical scoring systems for monitoring and planning intervention in TED.

Secondary Effects of Orbital Decompression in Thyroid Eye Disease: A Review

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.

Peripapillary structural and microvascular alterations in early dysthyroid optic neuropathy

Background

To explore the changes in blood supply and structure around the optic nerve head (ONH) in thyroid-associated ophthalmopathy (TAO) patients with suspected dysthyroid optic neuropathy (DON).

Methods

TAO patients [19 with DON; 24 non-DON (NDON); 20 with equivocal DON (EDON)], and 34 control subjects were examined. Optical coherence tomography angiography (OCTA) was used to obtain peripapillary retinal nerve fiber layer (p-RNFL) and vessel density parameters, including the ONH whole image vessel density (ONH-wiVD) and the radial peripapillary capillary vessel density (RPC-VD) in early DON.

Results

Although there were no differences in p-RNFL thickness among the groups, there were differences in the ONH-wiVD of each grid section and the RPC-VD in all areas (P < 0.01). Compared with healthy controls, the EDON eyes had significantly lower RPC-VDs in all aeras (P < 0.05).The peripapillary region was further divided into eight sectors, and the RPC-VD in the temporal upper, superior temporal, and temporal lower sectors in the EDON group were significantly lower than in the controls. The visual impairment was closely related to the loss of peripapillary capillary vessel density. Univariate correlation analysis showed that the ONH-wiVD and RPC-VD of the TAO groups were negatively correlated with the intraocular pressure (r = − 0.296, P = 0.006; r = − 0.258, P = 0.016 respectively).

Conclusions

EDON patients had significantly lower ONH-wiVD and RPC-VD than control subjects, and the temporal and upper VDs were more likely to be affected in the early stage of TAO. The combined use of spectral domain optical coherence tomography and OCTA technologies offer a new method for early diagnosis of suspected DON patients.

Obesity and risk of age-related eye diseases: a systematic review of prospective population-based studies

BACKGROUND

Obesity is a public health challenge worldwide. The relationship between obesity and age-related eye diseases including cataract, glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy (DR) have remained elusive.

DESIGN AND METHODS

We conducted a systematic review of three electronic databases for longitudinal population-based studies that described associations between measures of obesity including body mass index (BMI), waist-circumference (WC), and waist-to-hip ratio (WHR), and age-related eye diseases.

RESULTS

Our search yielded 1731 articles, of which 14, 10, 16 and 8 articles met our eligibility criteria for cataract, glaucoma, AMD and DR, respectively. BMI-defined obesity was positively associated with incident cataract, incident AMD and incident DR in Western populations, but in Asian populations associations for incident AMD were not significant and associations for incident DR were inverse. WC-defined obesity was associated with incident glaucoma in non-Western populations. WHR-defined obesity but not BMI-defined obesity was associated with the incidence or progression of AMD in two Western studies.

CONCLUSIONS

Overall, we found strong evidence supporting associations between obesity and age-related eye diseases. Further research on the association of abdominal obesity and effect of weight loss and physical activity on age-related eye diseases is warranted to support clinical and public health recommendations.

Intraocular Pressure and Glaucoma in Thyroid Eye Disease

PURPOSE

Current literature lacks a summary of knowledge on intraocular pressure (IOP) elevation and glaucoma in thyroid eye disease (TED). This review aims to augment existing literature by providing such a summary. It qualitatively evaluates current knowledge on the pathogenesis, prevalence, and management of concomitant ocular hypertension or glaucoma in TED patients.

METHODS

In this narrative review, relevant publications were identified through a computerized database search. Search results were screened for relevance. Correspondence, Editorials, and Letters to the Editors were excluded. References cited within the identified articles were used to further augment the search. Information extracted for qualitative analysis included epidemiologic data, methods of IOP assessment, management protocols, and response to treatment.

RESULTS

Studies in current literature are relatively heterogenous, differing in country of origin, TED cohort sizes, and IOP measurement techniques. Further studies are required to elucidate the true epidemiologic relationship between TED and ocular hypertension or glaucoma. Proposed models of IOP elevation include elevation of episcleral venous pressure, mucopolysaccharide deposition within the trabecular meshwork, restrictive myopathy, steroid-induced glaucoma, and secondary glaucoma. IOP-reducing effects of TED treatment options are discussed.

CONCLUSIONS

While raised IOP in TED is a common phenomenon, the diagnosis of glaucoma in TED requires a high index of suspicion before any intervention.

Extraocular muscle expansion after deep lateral orbital wall decompression: influence on proptosis reduction and its predictive factors

PURPOSE

To examine the relationship between extraocular muscle expansion and proptosis reduction (Δproptosis) in patients with thyroid eye disease who underwent deep lateral orbital wall decompression and to analyze the factors that contribute to extraocular muscle expansion.

METHODS

This retrospective, observational study included 133 sides from 77 patients with thyroid eye disease. The cross-sectional areas of the greater wing of the sphenoid bone (trigone), extraocular muscles, and superior ophthalmic vein were measured on computed tomographic images. Variables influencing Δproptosis were analyzed using multivariate linear regression analyses with stepwise variable selection. Predictive factors for the rate of postoperative increase in the cross-sectional extraocular muscle areas (Δextraocular muscle) were analyzed using the same statistical method.

RESULTS

The amount of orbital fat removed (P < 0.001) and rate of Δlateral rectus muscle (P < 0.001) were positively and negatively correlated with Δproptosis, respectively (r = 0.425; adjusted r² = 0.168; P < 0.001). The cross-sectional trigone area (P < 0.001) was positively correlated with the rate of Δlateral rectus muscle, whereas the preoperative cross-sectional lateral rectus muscle area (P < 0.001) and amount of orbital fat removed (P = 0.036) were negatively correlated with the rate of Δlateral rectus muscle (r = 0.551; adjusted r² = 0.288; P < 0.001).

CONCLUSION

Lateral rectus muscle expansion was negatively correlated with proptosis reduction and proved to be predictable before surgery. The results of this study will help predict proptosis reduction after deep lateral orbital wall decompression and to preoperatively plan additional orbital bony and fat decompression.

Changes in ocular biomechanics after treatment for active Graves' orbitopathy

PURPOSE

To evaluate the changes in ocular biomechanical properties in active moderate-to-severe Graves' orbitopathy (GO) after intravenous glucocorticoids (IVGCs), and to clarify correlations between clinical findings and ocular biomechanical properties.

METHODS

A prospective study. A total of 20 consecutive GO patients and 20 age- and sex-matched healthy control subjects were included. GO was diagnosed on the basis of the recommendation by the European Group on Graves' Orbitopathy (EUGOGO), and disease activity was assessed by the clinical activity score (CAS). Patients were assigned to receive once weekly IVGCs (0.5 g, then 0.25 g, 6 weeks each). All participants received a full ophthalmic examination and biomechanical evaluation was performed with dynamic Scheimpflug analyzer (Corvis ST) at baseline and 12th weeks after therapy.

RESULTS

The biomechanically corrected intraocular pressure (bIOP) in GO patients was significantly higher than that in healthy subjects. In contrast, the whole eye movement (WEM) in GO patients was significantly lower than in healthy subjects after adjusting for bIOP. The CAS, NOSPECS score, and exophthalmos were significantly positively correlated with the bIOP and negatively correlated with the WEM after adjusting for bIOP, CCT and age. The WEM significantly increased, whereas bIOP significantly decreased after IVGCs (P < 0.001, P = 0.001 respectively). The overall response rate at the 12th week was 85% (17 of 20).

CONCLUSIONS

The changes of ocular biomechanical properties measured by Corvis ST were an objective indicator of inflammatory activity and severity of GO. Combining CAS and ocular biomechanical properties could better evaluate the therapeutic outcome of active moderate-to-severe GO.

Graves' Orbitopathy: Current Concepts for Medical Treatment

BACKGROUND

The therapy of severe manifestations of Graves' orbitopathy (GO) is still a challenge and requires good interdisciplinary cooperation. It is especially important to use stage-adapted anti-inflammatory therapy to avoid irreversible damage.

MATERIAL AND METHODS

Discussion of the latest results of multicentre randomised therapy studies on anti-inflammatory treatments for Graves' orbitopathy, as well as new therapeutic concepts.

RESULTS

Mild cases of GO can be treated with only selenium supplementation and a watchful waiting strategy. In the moderate-to-severe active form of GO, primary therapy consists of i. v. steroids (cumulative 4 - 5 g) in combination with orbital irradiation in patients with impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening disease, bony orbital decompression is usually necessary. As basic research has improved our understanding of the underlying pathophysiology of GO, it has been possible to develop targeted therapies for GO. Teprotumumab, an IGF-1 receptor antibody, was effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe.

CONCLUSION

The current therapy concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This may soon be modified, due to the use of targeted therapies.

Topical Treatment of Elevated Intraocular Pressure in Patients with Graves' Orbitopathy

Purpose: In this study, we evaluated the efficacy of topical hypotensive treatment and/or systemic corticosteroids therapy in patients with elevated intraocular pressure and Graves’ orbitopathy (GO). Methods: We included 172 eyes in 86 individuals with duration of GO ≥ 3 months, intraocular pressure in either eye ≥ 25.0 mmHg, and GO ranked ≥ 3 at least in one eye in modified CAS form. The study subjects were divided into three treatment subgroups: subgroup I was administered latanoprost once a day; subgroup II was administered a combined preparation of brimonidine and timolol BID; subgroup III was the control group, not receiving any topical hypotensive treatment. All the study participants received systemic treatment, intravenous corticosteroid therapy at the same dose, according to the European Group of Graves’ Orbitopathy (EUGOGO) guideline. Results: On the final visit, the mean IOP value was significantly lower in all treatment subgroups compared to the initial values. In both subgroups receiving topical treatment, the IOP reduction was higher than in the control group receiving systemic corticosteroids only. However, the latanoprost eye drops decreased intraocular pressure more effectively than drops containing brimonidine and timolol. Conclusion: Topical ocular hypotensive treatment is effective in reducing intraocular pressure in GO and decreases intraocular pressure more effectively than systemic corticosteroid therapy alone.

Evaluation of retinal and choroidal variations in thyroid-associated ophthalmopathy using optical coherence tomography angiography

Background

To investigate the difference in retinal nerve fiber layer (RNFL) thickness, choroidal thickness (CT) and superficial retinal vessels between thyroid-associated ophthalmopathy (TAO) patients and healthy controls. To identify the potential influencing factors for these parameters and evaluate their diagnostic abilities in TAO.

Methods

Twenty active TAO patients, 33 inactive TAO patients and 29 healthy participants were enrolled. TAO patients were divided according to the clinical activity score (CAS). RNFL thickness and CT were measured by HD-OCT, while foveal avascular zone (FAZ), vascular density and perfusion density were measured by optical coherence tomography angiography (OCTA). SPSS software was used for statistical analysis.

Results

Active TAO patients had thinner RNFL thickness than the other two groups (P < 0.001, P < 0.001). Both active and inactive TAO patients had significantly higher CT in the macular region (all P < 0.05). The FAZ area in the active TAO group was significantly larger than the other two groups (P = 0.045, P = 0.001). The inactive TAO group had significantly higher vascular density than the other two groups (all P < 0.05). With regard to the perfusion density, significant differences were observed in the temporal and inferior areas (P = 0.045, P = 0.001), as well as the average values (P = 0.032). The FAZ area was positively correlated with intraocular pressure (r = 0.274, P = 0.013), while it was negatively correlated with axial length (r = − 0.344, P = 0.002). The vascular density and perfusion density were not significantly correlated with different clinical variables (all P > 0.05). The AUC analysis indicated these parameters also exhibited a significant discriminatory power in TAO diagnosis.

Conclusions

TAO patients had significant variations in RNFL thickness, choroidal thickness, FAZ area and superficial retinal vessels. These parameters appeared to be potential adjuncts in the evaluation of TAO patients.

ROLE OF MAGNETIC RESONANCE IMAGING IN THE ASSESSMENT OF ACTIVE THYROID-ASSOCIATED OPHTHALMOPATHY PATIENTS WITH LONG DISEASE DURATION

Objective: In thyroid-associated ophthalmopathy (TAO), long disease duration is negatively correlated with the response to immunosuppression treatment. The current treatment decision-making process does not involve magnetic resonance imaging (MRI); thus, we investigated the predictive value of MRI parameters for the immunosuppressive response in active moderate to severe TAO patients with different disease durations. Methods: We retrospectively analyzed the baseline MRI parameters of active TAO patients treated with guideline-recommended weekly glucocorticoid therapy in our center. Data were stratified by the quartile of disease duration. The signal intensity ratio (SIR) of T2-weighted images was used to describe the activity of extraocular muscles (EOMs). Results: Compared to the lowest quartile of disease duration, SIR values of EOMs were significantly lower in quartile 3 (Q3) and quartile 4 (Q4). Meanwhile, the clinical activity score (CAS) curve did not change in parallel and was not correlated with the SIR curve. In the highest quartile of disease duration, nonresponders had significantly lower SIR values of the most inflamed muscle (P = .03) and the medial rectus (P = .004) than did the responders, while no such significance was observed in patients within the lower 3 quartiles. A multivariable predictive model (including CAS, TAO duration, and SIR value) was established in each quartile. The fit of the model was better than CAS with regard to prognostic prediction and showed a high positive predictive value (Model 1: 86.67%; Model 2: 92.86%) and negative predictive value (Model 1: 88.89%; Model 2: 90%) in the top quartile. Conclusion: The anterior manifestation assessed by CAS is not always consistent with retro-orbital activity in long-term TAO patients. CAS is sufficient to reflect disease activity in short-term TAO patients. The supplementation of CAS with orbital MRI would be valuable in selecting appropriate active patients with a long disease duration. Abbreviations: AUC = area under the curve; CAS = clinical activity score; EOM = extraocular muscle; FT3 = free triiodothyronine; FT4 = free thyroxine; GC = glucocorticoid; ivGC = intravenous glucocorticoids; MRI = magnetic resonance imaging; NPV = negative predictive value; PPV = positive predictive value; SIR = signal intensity ratio; TAO = thyroid-associated ophthalmopathy; TRAb = thyroid-stimulating hormone receptor antibody; TSH = thyroid-stimulating hormone.

The Increment of Choroidal Thickness in Euthyroid Graves' Ophthalmopathy: Is It an Early Sign of Venous Congestion?

Objective

Clinical manifestations of Graves' ophthalmopathy (GO) are caused by the overcompression of orbital tissues within the restricted orbital bone cavity. Impaired ocular blood flow may disrupt the retinal microstructure and functions. In this study, we aimed to investigate the macular and choroidal thickness changes in GO compared with healthy subjects.

Materials and Methods

The study group comprised 50 adult patients with previously diagnosed Graves' disease with ophthalmopathy who were on antithyroid treatment. For the assessment of GO activity, the VISA (vision, inflammation, strabismus, and appearance) inflammatory score was used. When euthyroidism was achieved without side effects, the patients were referred to the ophthalmology clinic for spectral-domain optical coherence tomography (SD-OCT) evaluation.

Results

Subfoveal, mean, and temporal choroidal thicknesses were increased significantly in the study group according to the controls. The mean choroidal thickness was elevated.

Conclusions

This elevation is because of the intraorbital inflammation even in this nonsevere GO group. Choroidal thickness might be affected from the venous obstruction and congestion in patients with GO. The elevation of the choroidal thickness might be an early sign of venous congestion that occurs before the elevation of intraocular pressure.

Orbital decompression for thyroid eye disease: methods, outcomes, and complications

PurposeTo determine the safety and effectiveness of orbital decompression for thyroid eye disease (TED) in our unit. To put this in the context of previously published literature.Patients and methodsA retrospective case review of all patients undergoing orbital decompression for TED under the care of one orbital surgeon (SMS) between January 2009 and December 2015. A systematic literature review of orbital decompression for TED.ResultsWithin the reviewed period, 93 orbits of 55 patients underwent decompression surgery for TED. There were 61 lateral (single) wall decompressions, 17 medial one-and-a-half wall, 11 two-and-a-half wall, 2 balanced two wall, and 2 orbital fat only decompressions. For the lateral (single) wall decompressions, mean reduction in exophthalmometry (95% confidence interval (CI) was 4.2 mm (3.7-4.8), for the medial one-and-a-half walls it was 2.9 mm (2.1-3.7), and for the two-and-a-half walls it was 7.6 mm (5.8-9.4). The most common complications were temporary postoperative numbness (29% of lateral decompressions, 17% of other bony decompressions, OR 0.50, 95% CI 0.12-2.11) and new postoperative diplopia (9% of lateral decompressions, 39% of other bony decompressions, OR 6.8, 95% CI 1. 5-30.9). Systematic literature searching showed reduction in exophthalmometry for lateral wall surgery of 3.6-4.8 mm, with new diplopia 0-38% and postoperative numbness 12-50%. For other bony decompressions, reduction in exophthalmometry was 2.5-8.0 mm with new diplopia 0-45% and postoperative numbness up to 52%.ConclusionDiffering approaches to orbital decompression exist. If the correct type of surgery is chosen, then safe, adequate surgical outcomes can be achieved.

Thyroid-associated orbitopathy in patients with thyroid carcinoma: A case report of 5 cases

RATIONALE

Thyroid-associated orbitopathy (TAO) is most often seen in patients with autoimmune thyroid disease. Data about TAO occurred in patients with thyroid carcinoma are rare. We give a report of 5 patients to present the clinical characteristics, treatment, and prognosis of this type of case.

PATIENT CONCERNS

Five thyroid carcinoma patients presented with orbitopathy. Among them, two patients (patient 1 and 4) were hyperthyroid and TSH receptor antibody (TRAb) positive, two patients (patient 3 and 5) were euthyroid and displayed slightly elevated TRAb titres, one patient (patient 2) was euthyroid and TRAb negative.

DIAGNOSES

They were diagnosed as thyroid carcinoma and TAO.

INTERVENTIONS

Patient 1 underwent total thyroidectomy, intravenous glucocorticoids (GCs) therapy, orbital decompression surgery and oral GCs therapy. Patient 2 and 3 only received total thyroidectomy. Patient 4 received sub-total thyroidectomy and oral GCs therapy. patient 5 didn't received thyroidectomy and underwent intravenous GCs therapy for 2 courses.

OUTCOMES

Patient 1,2,3 showed an improvement of TAO at the final follow-up. Patient 4,5 showed no improvement of TAO at the final follow-up.

LESSONS

When TAO present in patients with thyroid nodules, the possibility of thyroid carcinoma should be considered, and the nature of these nodules should be carefully evaluated. In some patients with thyroid carcinoma and TAO, the remission of TAO can be seen post total thyroidectomy. But for other patients, besides thyroidectomy, an adequate dose and course of intravenous GCs treatment and even ocular surgery are also needed.

[Orbital decompression : Indications, technique, results]

Orbital decompression is an effective surgical procedure to reduce intraorbital pressure. Causes may diseases leading to rapid pressure increases, e. g., bleedings, and those causing slower, progressive pressure increases, e. g., tumors or Graves' orbitopathy. During fat tissue decompression, peri- and retrobulbar adipose tissue is removed; in bony decompression, one or more bony orbital walls are removed (one-, two-, or three-wall decompression). In many cases the procedures are combined. Recent developments are the transconjunctival approaches for removing parts of bony orbital walls. Complications include double vision, which occurs in up to 30% of cases depending on the approach, hemorrhage, infections, development of chronic sinusitis, and iatrogenic skull base lesions with consecutive meningitis. In the hands of an experienced rhino- and head and neck surgeon, the intervention has low complication rates.

The Association between Adiposity and the Risk of Glaucoma: A Meta-Analysis

Purpose

This meta-analysis was conducted to determine the potential association between adiposity and glaucoma incidence.

Materials and Methods

A comprehensive literature search was performed in PubMed and ISI Web of Science. A meta-analysis was conducted using STATA software.

Results

Fifteen eligible studies involving 2,445,980 individuals were included to investigate the association between adiposity and glaucoma incidence. The relative risks (RRs) were pooled with 95% confidence intervals (CI) by using a random-effects model. The pooled RR between adiposity and elevated intraocular pressure (IOP) was 1.73 (95% CI, 1.18–2.54), whereas that between adiposity and open-angle glaucoma (OAG) was 0.97 (95% CI, 0.83–1.13). The pooled RR between abdominal adiposity and glaucoma was 1.28 (95% CI, 1.15–1.41), whereas that between general adiposity and glaucoma was 1.09 (95% CI, 0.87–1.37). Results of subgroup analysis by sex indicated the association between adiposity and glaucoma in the female group (RR, 1.31; 95% CI, 1.05–1.64), but not in the male group (RR, 1.11; 95% CI, 0.77–1.60). The pooled RR of cohort studies and cross-sectional studies were 1.00 (95% CI, 0.84–1.20) and 1.22 (95% CI, 0.89–1.66), respectively.

Conclusions

Adiposity has a higher risk of elevated IOP, and abdominal adiposity has a positive association with glaucoma, especially in female patients.

Rituximab Treatment in a Patient with Active Graves' Orbitopathy and Psoriasis

Management of Graves’ orbitopathy remains an important therapeutic challenge. Current therapeutic modalities are unsatisfactory in about one third of patients. Rituximab is a monoclonal antibody against CD20 antigen that is expressed in mature and immature B cells. Early experience with rituximab suggests that it is a promising alternative therapy for Graves’ orbitopathy. Here we report a case of a 49-year-old woman with Graves’ orbitopathy and psoriasis. The patient received 2 infusions of 1 g rituximab 2 weeks apart. Although there was improvement in inflammatory signs of the disease, proptosis did not change after the treatment.

THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy

Management of Graves' orbitopathy (GO) must be based on the correct assessment of activity and severity of the disease. Activity is usually assessed with the Clinical Activity Score, whereas severity is classified according to a European Group On Graves' Orbitopathy (EUGOGO) consensus statement as mild, moderate-to-severe, and sight-threatening. Myopathic and chronic congestive forms are uncommon clinical presentations of GO. Restoration and maintenance of stable euthyroidism are recommended in the presence of GO.In moderate-to-severe disease, steroids have been widely employed and have shown to possess an anti-inflammatory activity, but about 20-30% of patients are not responsive and present recurrence. Some novel immunosuppressors have already been employed in clinical studies and have shown interesting results, although the lack of randomized and controlled trials suggests caution for their use in clinical practice. Potential targets for therapy in GO are the thyroid-stimulating hormone and the insulin-like growth factor 1 receptor on the fibroblasts, inflammatory cytokines, B and T cells, and the PIK3/mTORC1 signaling cascades for adipogenesis. A recent open study has shown that tocilizumab, an anti-sIL-6R antibody, inactivates GO. Consistent reports on the efficacy of rituximab have recently been challenged by randomized controlled trials.As the main goal of treatment is the well-being of the patient, the therapeutic strategy should be addressed to better suit the patient needs, more than improving one or more biological parameters. The increasing availability of new therapies will expand the therapeutic options for GO patients and allow the clinician to really personalize the treatment to better suit the patients' personal needs.

Effect of smoking on retrobulbar blood flow in thyroid eye disease

PurposeTo evaluate the effect of smoking on retrobulbar blood flow parameters by color Doppler imaging in patients with thyroid eye disease.Patients and methodsIn this observational case series, blood flow parameters in the ophthalmic artery, superior ophthalmic vein, central retinal artery, and vein were determined by color Doppler imaging in patients with thyroid eye disease. Patients were grouped as smokers and non-smokers. Never smokers and those who had stopped smoking for at least 1 year before onset of ophthalmopathy were considered as non-smokers. A thorough ophthalmic examination including Hertel exophthalmometry was performed. Orbital CT scan was also carried out in all patients.ResultsFifty-one orbits from 30 patients between 21 and 62 years old (mean±SD: 40.8±12.0) were enrolled in this study. Smokers had greater proptosis and more active and sever disease. (P<0.05) Muscle involvement based on CT scan did not vary in smokers and non-smokers. Maximum velocity (3.78±1.74 vs 5.27±2.14, P<0.001; t-test) and minimum velocity (1.74±0.78 vs 3.26±1.36, P =0.014; t-test) in superior ophthalmic vein were significantly lower in smokers than non-smokers. Even after adjusting for age, sex, and clinical activity score and severity, smokers had a lower minimum velocity in superior ophthalmic vein (P =0.01; ANCOVA analysis).ConclusionCigarette smoking may correlate with increase in orbital venous congestion in thyroid eye disease.

Choroidal changes observed with enhanced depth imaging optical coherence tomography in patients with mild Graves orbitopathy

PurposeTo evaluate the choroidal thickness in patients with Graves orbitopathy (GO) using enhanced depth imaging-optical coherence tomography (EDI-OCT).MethodsThirty-one patients with GO were evaluated prospectively. All subjects underwent ophthalmologic examination including best-corrected visual acuity, intraocular pressure measurement, biomicroscopic, and fundus examination. Choroidal thickness was measured at the central fovea. In addition, visual evoked potential measurement and visual field evaluation were performed.ResultsThe mean choroidal thickness was 377.8±7.4 μ in the GO group, and 334±13.7 μ in the control group. (P=0.004). There was a strong correlation between the choridal thickness and the clinical activity scores (CAS) of the patients (r=0.281, P=0.027). Additionally, there was a correlation between the choroidal thickness and the visual-evoked potential (VEP) P100 latency measurements of the patients (r=0.439, P=0.001).ConclusionsThe results of this study demonstrate that choroid is thicker in patients with GO. The choroidal thickness is also correlated with the CAS and VEP P100 latency measurements in these patients.

The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.

Clinical factors affecting intraocular pressure change after orbital decompression surgery in thyroid-associated ophthalmopathy

OBJECTIVE

To report the physiological monitoring of intraocular pressure (IOP) during the postoperative periods after orbital decompression surgery and ascertain the correlation between the clinical factors and IOP changes.

METHODS

The medical records of 113 orbits from 60 patients who underwent orbital decompression surgery were reviewed retrospectively. IOP measurement during the postoperative periods was classified based on the postoperative day: week 1 (1-7 days), month 1 (8-41 days), month 2 (42-70 days), month 3 (71-97 days), month 4 (98-126 days), and final (after 127 days). The mean postoperative follow-up was 286.5 days for orbits with at least 6 months of follow-up. Univariate and multivariate linear regression analyses were performed to assess the correlation between the IOP reduction percentage and clinical factors.

RESULTS

The mean IOP increased from 16.9 to 18.6 mmHg (10.1%) at postoperative week 1 and decreased to 14.4 mmHg (14.5%) after 2 months. Minimal little changes were observed postoperatively in the IOP after 2 months. Preoperative IOP had a significant positive effect on the reduction percentage both at postoperative week 1 (β=2.51, P=0.001) and after 2 months (β=1.07, P=0.029), and the spherical equivalent showed a positive correlation with the reduction level at postoperative week 1 (β=1.71, P=0.021).

CONCLUSION

Surgical decompression caused a significant reduction in the IOP in thyroid-associated orbitopathy, and the amount of reduction was closely related to preoperative IOP; however, it may also cause a transient elevation in the IOP during the early postoperative phase in highly myopic eyes.