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Oxidative Medicine and Cellular... 2020Surgical management of thyroid eye disease- (TED-) associated morbidity has been plagued by the complex interplay of different operative techniques. Orbital... (Review)
Review
Surgical management of thyroid eye disease- (TED-) associated morbidity has been plagued by the complex interplay of different operative techniques. Orbital decompression is the well-recognized procedure for disfiguring exophthalmos and dysthyroid optic neuropathy (DON). There are numerous published techniques described for the removal of the orbital bone, fat, or a combination. The diverse studies are noncomparative as they include different indications, stages of disease, and methods of evaluation. Thus, it is difficult to conclude the most efficient decompression technique. To obtain effective and predictable results, it is therefore important to propose a logical and acceptable clinical guideline to customize patient treatment. Herein, we developed an algorithm based on the presence of DON, preoperative existing diplopia, and severity of proptosis which were defined by patient's disabling symptoms together with a set of ocular signs reflecting visual function or cosmesis. More specifically, we aimed to assess the minimal but effective surgical technique with acceptable potential complications to achieve therapeutic efficacy. Transcaruncular or inferomedial decompressions are indicated in restoring optic nerve function in patients with DON associated with mild or moderate to severe proptosis, respectively. Inferomedial or fatty decompressions are effective to treat patients with existing diplopia associated with mild or moderate to severe proptosis, respectively. Fatty or balanced decompressions can improve disfiguring exophthalmos in patients without existing diplopia associated with mild to moderate or severe proptosis, respectively. Inferomedial or 3-wall decompressions are preferred to address facial rehabilitation in patients associated with very severe proptosis but without preoperative diplopia.
Topics: Clinical Decision-Making; Decompression, Surgical; Exophthalmos; Graves Ophthalmopathy; Humans
PubMed: 32963693
DOI: 10.1155/2020/3537675 -
Die Ophthalmologie Jul 2022
Topics: Exophthalmos; Humans
PubMed: 34842973
DOI: 10.1007/s00347-021-01534-x -
American Journal of Ophthalmology Dec 2019Improved understanding of thyroid eye disease (TED) pathogenesis has facilitated identification of a targeted molecular approach for TED treatment offering the potential... (Review)
Review
PURPOSE
Improved understanding of thyroid eye disease (TED) pathogenesis has facilitated identification of a targeted molecular approach for TED treatment offering the potential to halt or slow disease progression in a nonsurgical manner. Herein, we provide a summary of the current knowledge of TED management, followed by discussion of a novel insulin-like growth factor-1 receptor (IGF-1R) antagonist antibody and its potential to change the course of the disease.
DESIGN
Perspective.
METHODS
Review of the literature and authors' experience.
RESULTS
Many publications demonstrate IGF-1R overexpression in TED, and its activation as an autoantigen as a critical factor in TED pathogenesis. Several in vitro studies demonstrate that IGF-1R inhibition attenuates downstream molecular events including cytokine and hyaluronan production, and cellular differentiation. These observations led to the hypothesis that blocking IGF-1R may abrogate the clinical progression of TED. The recent completion of phase 2 and 3 randomized, placebo-controlled trials demonstrate the efficacy and safety of teprotumumab, a fully human monoclonal IGF-1R antagonist antibody, in patients with moderate-to-severe, active TED. Both the phase 2 and the recent phase 3 study results demonstrate that more patients with active TED receiving teprotumumab experienced a meaningful improvement in proptosis.
CONCLUSIONS
Current TED treatment strategies target inflammation and symptoms, but do not modify the disease course. Therefore, proptosis as well as strabismus and its resulting diplopia often remain, impacting patient well-being and quality of life over the long term. Targeted molecular therapy using teprotumumab demonstrates disease-modifying benefits with the potential to shift the paradigm for TED treatment.
Topics: Antibodies, Monoclonal, Humanized; Exophthalmos; Graves Ophthalmopathy; Humans; Randomized Controlled Trials as Topic; Receptor, IGF Type 1
PubMed: 31377284
DOI: 10.1016/j.ajo.2019.07.021 -
Journal of AAPOS : the Official... Aug 2018Thyroid-associated orbitopathy (TAO) is an autoimmune disorder that affects multiple periocular tissues. In TAO, an active immunologic inflammatory phase is typically... (Review)
Review
Thyroid-associated orbitopathy (TAO) is an autoimmune disorder that affects multiple periocular tissues. In TAO, an active immunologic inflammatory phase is typically followed by a cicatrizing recovery phase. Management in the inflammatory phase is supportive, and surgical rehabilitation should generally be deferred until the patient is stable. We review current treatment concepts, with a focus on the timing and sequence of surgical procedures to address proptosis, motility restriction, and eyelid malposition in patients with TAO. A stepwise surgical approach maximizes the predictability of surgical outcomes and minimizes reoperations.
Topics: Diagnosis, Differential; Exophthalmos; Graves Ophthalmopathy; Humans; Lacrimal Apparatus; Oculomotor Muscles; Orbit; Orbital Neoplasms
PubMed: 29330045
DOI: 10.1016/j.jaapos.2017.12.002 -
Eye (London, England) Nov 2023To evaluate presenting features of patients with orbital solitary fibrous tumours (SFTs), based on histological phenotype.
AIMS
To evaluate presenting features of patients with orbital solitary fibrous tumours (SFTs), based on histological phenotype.
METHODS
A retrospective case-note review was performed for demographics and presenting features for patients with orbital SFTs. The tumours were classified as "Group IA" hypocellular SFT phenotype, "Group IB" haemangiopericytoma phenotype and low mitotic activity, and high-grade "Group II" haemangiopericytoma phenotype with high mitotic activity.
RESULTS
Sixty-four patients (34 female; 53%) presented at a mean age of 42.2 years (median 38; range 19-82), with Group II patients presenting at an older age (mean 53 years). Median symptom duration was 12 months for Groups IA and IB, compared to 4 months for Group II, the commonest symptoms being proptosis (53%), diplopia (41%), periorbital swelling (31%), and altered vision (19%). Mean LogMAR was 0.17 (median 0.0; range -0.2-4), and 14% had ipsilateral optic neuropathy, with no significant difference between the three groups. Non-axial displacement was noted in 69%, a palpable mass in 45%, and reduced eye movements in 59%; choroidal folds and optic disc swelling were recorded in 12% and 9%. SFTs were mostly extraconal (59%), within the superior and superonasal quadrants (44%), with an average estimated tumour volume of 4.9 ml (median 3.6; range 0.31-14.5 ml).
CONCLUSION
SFTs may present with impaired visual function (∼15%), fundal abnormalities (a fifth), globe displacement (two-thirds), and reduced ocular motility (over a half). High-grade tumours tend to present more than a decade later, with a shorter duration of symptoms.
Topics: Humans; Female; Adult; Retrospective Studies; Severe Fever with Thrombocytopenia Syndrome; Hemangiopericytoma; Solitary Fibrous Tumors; Exophthalmos
PubMed: 37061621
DOI: 10.1038/s41433-023-02519-7 -
World Neurosurgery Jun 2022The endoscopic endonasal approach (EEA) was originally performed to treat thyroid orbitopathy and proptosis. Since then, this approach also has been used to treat other... (Review)
Review
OBJECTIVE
The endoscopic endonasal approach (EEA) was originally performed to treat thyroid orbitopathy and proptosis. Since then, this approach also has been used to treat other causes of proptosis. This review systematically identifies surgical outcome and complication rates in patients without thyroid proptosis who underwent endoscopic endonasal orbital decompression.
METHODS
Databases were searched using the following search terms: orbital disease, surgical decompression, and endoscopic endonasal approach. Two independent reviewers screened all abstracts and titles for relevance and all articles passing this screen were subjected to full-text review. To assess risk of bias, we used ROBINS-I (Risk Of Bias in Non-randomized Studies-of Interventions).
RESULTS
Eight studies with a total of 74 patients with nonthyroid proptosis were included. Pre- and postoperative eye examination was performed in all studies, but the extent of examination was varying. With a mean age of 35.7 years, most patients were adolescent, and most pathologies induced unilateral proptosis Complications to EEA for orbital decompression were transient diplopia (5 patients/6.8%), transient facial dysesthesia (2 patients/2.7%), ptosis (1 patient/1.4%), infarction (1 patient/1.4%), sinus obstruction (1 patient/1.4%), and enophtalmos (1 patient/1.4%). The authors reported successful reduction of proptosis in all but 2 patients (97.2%), and only 2 authors reported a need for secondary decompression.
CONCLUSIONS
Medial orbital decompression using EEA is a feasible approach for orbital decompression in patients with nonthyroid proptosis. While being comparable in primary outcome to transorbital approaches, the EEA seems superior in terms of complication rates.
Topics: Adolescent; Adult; Decompression, Surgical; Endoscopy; Exophthalmos; Graves Ophthalmopathy; Humans; Orbit; Retrospective Studies; Treatment Outcome
PubMed: 35331947
DOI: 10.1016/j.wneu.2022.03.075 -
The Journal of Craniofacial Surgery Jun 2021The aim of the authors' study is to show their surgical results in orbital decompression using different endonasal endoscopic techniques. These approaches are according...
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.
Topics: Decompression, Surgical; Endoscopy; Exophthalmos; Female; Graves Ophthalmopathy; Humans; Male; Middle Aged; Orbit; Retrospective Studies; Treatment Outcome
PubMed: 33170828
DOI: 10.1097/SCS.0000000000007107 -
European Journal of Ophthalmology Mar 2021We propose a new method to analyze the feasibility of calculating proptosis on the basis of simple Pythagorean theorem.
PURPOSE
We propose a new method to analyze the feasibility of calculating proptosis on the basis of simple Pythagorean theorem.
METHOD
This is a non-inferiority trial, and the registration number is ChiCTR1900026490. The absolute value of proptosis of two eyes of patients without eye injury or diseases visiting our clinic from December 2017 to June 2019 was measured by computed tomography, Hertel exophthalmometer, and by simple Pythagorean theorem. With the application of MedCalc software version 19.0.4, the differences between these methods in two eyes were showed by Bland and Altman plot.
RESULTS
A 95% limit of agreement between computed tomography and Hertel exophthalmometer is -0.7 to 0.62 mm in right eye proptosis. A total of 4.44% (4/90) points were outside 95% limit of agreement. Similarly, the same method was used to compare the proptosis between computed tomography and other ways. We also compared the proptosis measured by homolateral and heterolateral simple Pythagorean theorem method in order to find out the consistence between them. The points in all Bland and Altman plots were lower than 5%, which means that the results of comparison between any two methods had a good consistency in the measurement of proptosis of both eyes.
CONCLUSION
Pythagorean theorem can be applied to evaluate proptosis and has a good consistency comparing with computed tomography and the Hertel exophthalmometer. The method can be used for measuring proptosis of unilateral orbital, maxillofacial trauma, and dysplasia accurately. It is practical in clinical use of proptosis assessment because of its accuracy, reliability, and simplicity.
Topics: Adult; Anatomy, Regional; Exophthalmos; Feasibility Studies; Female; Humans; Male; Mathematics; Middle Aged; Reproducibility of Results; Tomography, X-Ray Computed; Young Adult
PubMed: 31986913
DOI: 10.1177/1120672120901704 -
Ophthalmic Plastic and Reconstructive...To evaluate the ophthalmic clinical features and functional outcomes for patients with malignant sinonasal tumors who initially presented with orbital symptoms.
PURPOSE
To evaluate the ophthalmic clinical features and functional outcomes for patients with malignant sinonasal tumors who initially presented with orbital symptoms.
PATIENTS AND METHODS
Retrospective chart review for patients seen at Moorfields Eye Hospital between 1997 and 2020. Patient demographics and clinical features, radiology, histology, and treatment outcomes were reviewed.
RESULTS
Forty patients (22 females; 55%) with sinonasal cancers first presented to an ophthalmologist at an average age of 53.9 years (median 56; range 8-92 years), with their having had first symptoms at 53.6 years (median 55.8; range 7.8-91.9 years). The commonest symptoms were persistent periorbital ache (19/40; 48%), periocular swelling (18; 45%), proptosis (16; 40%), and diplopia (15; 38%). All midface tumors affected only 1 orbit, and 13 of 40 (33%) eyes presented with an acuity of 20/60 or worse-5 having no perception of light-and 10 eyes (25%) had a relative afferent pupillary defect. An average of 4.5 mm relative exophthalmos was present (median 4 mm; range 0-9 mm), and a palpable mass in 19 of 40 (48%) orbits. Reduced eye movements and nonaxial displacement were recorded in 29 (73%) and 34 (85%) patients, respectively, and 9 (23%) had an abnormal optic disc or fundus. Bone erosion affected 95% of orbits, and almost a half had involvement of the neighboring extraocular muscles, orbital apex, or intracranially. The commonest tumor groups were sinonasal carcinomas (45%), sarcomas (28%), or lymphomas (11%). Of 37 globe-sparing treatments, 25 (68%) had persistence of previously impaired ophthalmic functions and 6 of 37 (16%) developed new impairment; only 6 of 37 (16%) of affected orbits retained normal function, and 6 patients lost all vision on the affected side.
CONCLUSIONS
Sinonasal malignancies that present with orbital invasion are probably at the more aggressive end of the cancer spectrum, might be expected to carry a worse prognosis, and usually arise from the ethmoid or maxillary sinuses. In our series, carcinomas and sarcomas were the commonest malignancies, with similar 5-year overall survivals (of just over 50%), and over three-quarters of patients developed permanent impairment of orbital function and/or visual loss.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Diplopia; Exophthalmos; Female; Humans; Middle Aged; Orbit; Paranasal Sinus Neoplasms; Retrospective Studies; Young Adult
PubMed: 33782330
DOI: 10.1097/IOP.0000000000001972 -
Ophthalmic Plastic and Reconstructive...Orbital amyloidosis of the extraocular muscles (EOMs) is a rare condition, and its clinicoradiological features are not well elucidated. This study describes the... (Review)
Review
PURPOSE
Orbital amyloidosis of the extraocular muscles (EOMs) is a rare condition, and its clinicoradiological features are not well elucidated. This study describes the characteristic clinical signs, MRI features, and potential treatment options.
METHODS
Retrospective multicenter case series and literature review of EOM amyloidosis.
RESULTS
Five cases were identified for inclusion. Common clinical findings were diplopia, ophthalmoplegia, and proptosis. Systemic amyloidosis was more likely to present with multiple muscle involvement, but no particular pattern was observed with localized disease. On MRI, amyloid deposition was characterized as a heterogeneous intramuscular mass with T2 hypointensity and post contrast enhancement. Management is dependent on the extent of disease and functional impairment; options include surgical debulking and radiation therapy.
CONCLUSION
EOM amyloidosis is uncommon. The combination of clinical and radiologic findings described in this study should lead to its clinical suspicion.
Topics: Amyloidosis; Diplopia; Exophthalmos; Humans; Magnetic Resonance Imaging; Multicenter Studies as Topic; Oculomotor Muscles; Retrospective Studies
PubMed: 34516528
DOI: 10.1097/IOP.0000000000002061