Diagnosis and Management of Thyroid Orbitopathy

Department of Ophthalmology and Visual Sciences, University of Wisconsin–Madison, Madison, Wisconsin, United States
Otolaryngologic Clinics of North America (Impact Factor: 1.49). 11/2005; 38(5):1043-74. DOI: 10.1016/j.otc.2005.03.015
Source: PubMed


Thyroid orbitopathy, also known as Graves' orbitopathy, is an autoimmune orbital disease characterized by abnormal percentages of peripheral blood suppressor/cytotoxic T8+ lymphocytes, and a depressed T4/T8 ratio. Environmental and genetic factors, such as HLA-DR histocompatibility loci, may play a role in developing thyroid orbitopathy, although a specific cause has not yet been undetermined. Both cellular and humoral immune mechanisms contribute to the disorder.

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    ABSTRACT: The aim of this study was to present the authors' experience with identifi cation and classifi cation of thyroid ophtalmopathy activity. A total of 46 orbits from 23 patients with thyroid ophthalmopathy symptoms were evaluated on computed tomography images in terms of diameters and density of extraocular muscles, muscular index, proptosis, width of the optic nerve, width of superior ophthalmic vein and lacrimal gland position. Radiological symptoms of proptosis were present in 78.3% patients, while 80% cases of diagnosed proptosis were bilateral. The most frequently aff ected eye muscle was the inferior (61%) and medial (54%) rectus prior to superior (39%), lateral rectus (37%) and superior oblique (26%). The highest correlation between muscle enlargement and proptosis was noted in the case of inferior rectus (77%) and medial rectus (70%). 78% of muscle enlargement was bilateral. Anterior displacement of the lacrimal gland was observed in 58% of cases. Width of the superior ophthalmic vein and the optic nerve (sheath complex) did not diff er signifi cantly from normal population ranges. All muscles measured in the study had a lower density when compared to reference data; the density of the thickened muscles was lower than the density of muscles with an unmodifi ed diameter.
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    ABSTRACT: To examine the outcomes of orbital surgical decompression in patients affected by thyroid orbitopathy with mild-to-severe proptosis. The surgical procedures included fat removal alone or combined with orbital bone walls fracture. An analysis of a retrospective case series of 56 patients (115 orbits) who underwent orbital decompression for Graves' orbitopathy between July 1997 and September 2006 using different surgical techniques: orbital fat decompression alone or combined with bone decompression via coronal, trans-palpebral or trans-nasal access; the endoscopic trans-nasal access for medial orbital wall decompression associated with fat removal has been the procedure of choice in the last 5 years. The mean proptosis reduction was 3.40 mm (0-8 mm) by fat removal and 5.40 mm (1-10 mm) by fat removal and bone decompression combined. The association of both procedures reduces the amount of fat to be removed, avoiding enophthalmos and thus decreasing the number of orbital walls to be fractured. The incidence of new-onset primary-gaze diplopia was 38%. Most of the patients subsequently underwent eyelid surgery to reduce retraction and to achieve symmetry. Orbital decompression is effective in reducing proptosis, exposure keratopathy and congestive apex symptoms, and in improving cosmesis. Endoscopic nasal decompression combined with orbital fat removal allows a precise and gradual medial and infero-medial wall decompression; it permits a less aggressive approach to the bone orbital decompression on the whole. In any case, surgical procedures need to be tailored to the individual patient, knowing that further operations are essential to improve cosmetic results after proptosis correction.
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