Thyroid Orbitopathy.(TO) Our experience

I'm sending the following paper to the supercourse site. A personal experience is shown in the diagnosis and treatment of 65 patients presented with TO, through pictures, tables and graphics. I agree to allow reproduction rights in the use of my supersourse information, including permission to third persons as it is required. All the information included in the supercourse has been investigated and verified.

The thyroid orbitopathy is an inflammatory chronic or subacute disorder It's characteristics are. Eyelid retraction. Edema. Exophthalmos Diplopia. Optic neuropathy

Age In Chart # 1, you can see average values of the TO onset age in study cases. These values are similar to that published by other authors, as for the clinical beginning of this disease.

Classification Graph # 1, shows patient classification according to OT severity degree. The less affected ones (Slight) are non infiltrative OT. The mild and severe ones have an infiltrative OT. Theree is evidence that autoimmune mechanisms exist on the last one topic. Pérez Moreiras et al. classification was used.

Age and severity degree In graph # 2, you can note that severe cases begin with an average of age higher than the mild and slight ones. These conclusions are similar to those pointed out by most of the consulted authors. Following are outlined some of the cases that are examples of the above.

This patient, aged 65, debuted with severe TO; She lost her left eye (OS) due to an ocular perforation and endoftalmitis. In the picture to the left, we see a close up to her only eye. We applied steroids therapy, before orbital decompression surgery of inner wall and orbital floor.

This patient aged 65, with diabetes and thyrotoxicosis subtle cardiac abnormalities , debuted with a severe OT. The exophthalmos lack was due to the compression on the optic nerve by enlarged extraocular muscles at the orbit vertex with a resistant orbitarium septum avoiding proptosis. Orbital decompression by nasal endoscopy was carried out with good results.

This picture shows a young patient that was classified as a less affected case (Slight). Lack of exophthalmos is seen with a 1 millimeter (mm.) superior eyelid retraction. Vision is normal in both eyes. Treatment in this case consisted in ocular lubricants and Müller muscle section in OS.

This picture shows a case classified as mild This picture shows a case classified as mild. She has exophthalmos of both eyes. It was more pronounced in right eye (RE) and had a 2 mm superior and inferior eyelid retraction. She also had an enlargement of all the extraocular muscles of both eyes, except the lateral rectum.

This is a case classified as severe This is a case classified as severe. You can note exophthalmos, eyelid retraction and conjuntival chemosis. He had diplopia due to restrictive strabismus and visual deficit by compressive optic neuropathy. Note that he’s a black man.

Amount of analyzed cases: 65 Relationship woman-man: 4 : 1 In graph # 3, you can note prevalence of the female sex: male sex, with a relationship woman-man of 4:1. All the consulted authors coincide with this prevalence, where a relationship woman-man can be until of 8 : 1 and even more.

Sex In graph # 4, you can note a prevalence of the female sex in the slight, mild and severe cases, with a bigger amount of male patient in the mild and severe cases with regard to the slight ones. This fact wasn’t statistically significant.

Distribution by race Graph # 5 shows a prevalence of the white race in comparison to the black and the mixed race. This is how it's shown in the related reference.

RACE In graph # 6, you can note a prevalence of the white race in the 3 groups. However there is a bigger amount of black patients presenting a severe TO: correlation was statistically significant (p=0.005). This association has not been reported by other authors.

Thyroid Status Graph # 7 shows, a prevalence of euthyroid status in the case studies. Some researchers report similar results and others a bigger hyperthyroid percentage.

Graph # 8 represents data on treatment. Therapy Medical treatment Surgery Lubricants Steroids Ptosis Müller section Decompression Strabismus Slight 22 2 1   Mild 25 18 12 11 6 Severe  15 15 5 Medical treatment Surgery Graph # 8 represents data on treatment. In most of the less affected cases (slight), the treatment consisted in ocular lubricant. While in the severe and mild ones, the use of steroids and surgery, similar to that reported by other authors.

Average Value of VA before and after treatment According to graph # 9, there isn’t change in the average value of visual acuity, (VA) before and after treatment in the mild cases. However in severe ones, you can note the improvement of VA in the RE, that was significant in OS. The slight cases aren’t tabulated as having a normal VA.

Exophthalmos values befote treatment Graph # 10 shows maximum, minimum, average, and ED of exophthalmos degree in study cases presenting with TO, classified as mild and severe, before the medical or surgical treatment. The slight group isn’t tabulated by lack of this characteristic.

Exophthalmos Values alter treatment If we compare Graph # 10 with the previous one, you can observe a decrease in maximum values of exophthalmos after treatment with steroid and surgery which was carried out in 100% of severe cases and in 44% of the mild ones. These results are comparable to those reported by other authors.

This female black patient, debuted with a severe left TO This female black patient, debuted with a severe left TO. In the scan, you can note enlargement of the inferior and medius rectus muscles. The right superior view, shows the optic nerve stretching which joined to above mentioned muscles, provoked an optic neuropathy in this case.

The right pictures show postoperative results of orbital decompression by nasal endoscopy. In the axial and coronal cut, you can note the displacement of right medius rectus muscle toward the etmoidal sinus. Thus, the compression is eliminated in the optic nerve. The VA of OS was improved from 0.05 to 0.6

In the left picture, you can see the patient with a severe TO in his OS. Another doctor had performed an orbital decompression surgery by transcraneal via in RE, causing a section of the superior eyelid elevator to drop. In right picture, you can note the improvement, after inner wall decompression by anterior via, sparing the elevator muscle.

This patient debuted with a mild Thyroid Orbitopathy, you can note bilateral exophthalmos, superior and inferior eyelid retraction and all extraocular muscles enlargement, except lateral rectum.

The postoperative images shows patient after orbital decompression surgery carried out by nasal endoscopy in the RE. It's better appreciated in right coronal views. The Müller muscle section, provoked a lid ptosis that will be repaired later on.

This patient had a restrictive strabismus This patient had a restrictive strabismus. She underwent an adjustable surgery in both eyes, after orbital decompression surgery, with a Lynch approach, the residual angle was corrected with prisms, in order to eliminate diplopia for distant and near reading vision.

This patient debuted with a slight TO This patient debuted with a slight TO. In the left picture, there is noted a 2 millimeters superior lid retraction and also an increase of orbital fat. In right picture, we see an improvement after lipectomy and Müller muscle section in OS. The VA and visual field are normal.

Click the picture in full screen view To see video of orbital decompression surgery carried out by nasal endoscopy Click the picture in full screen view

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