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 (po0.001), 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 (po0.05) and third (po0.05) 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 (po0.001). 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.
Purpose. To assess the agreement between the qualitative clinical method and the quantitative photographic method of evaluating normal and abnormal ocular versions in patients with inactive Graves’ orbitopathy (GO). Methods. Forty-two patients with inactive GO had their ocular versions evaluated clinically according to three categories: normal, moderate alterations (−1 or −2 hypofunction), and severe alterations (−3 or −4 hypofunction). The subjects were photographed in the 9 positions of gaze, and the extent (mm) of eye movement in each position was estimated using Photoshop® and ImageJ and converted into degrees with a well-established method. The agreement between the two methods (qualitative vs. quantitative) for classifying ocular versions as normal or abnormal was assessed. Results. The mean quantitative measurements of versions were significantly different for each clinical category (normal, moderate alterations, and severe alterations) in the following five positions: abduction, adduction, elevation in abduction, elevation, and elevation in adduction (p<0.001). No such pattern was observed for the three infraversion positions (depression in abduction, p=0.573; depression, p=0.468; depression in adduction, p=0.268). Conclusion. The agreement was strong between the quantitative photographic method and the qualitative clinical method of classifying ocular versions, especially in lateral and supraversions, which are typically affected in GO. Digital photography is recommended for the assessment of ocular versions due to its practicality, suitability for telemedicine applications, and ease of monitoring during follow-up. This trial is registered with NCT03278964.
Ao meu orientador, Professor Dr. Allan Christian Pieroni Gonçalves, pela excelente condução desta tese, com dedicação, paciência e disponibilidade para compartilhar todo seu conhecimento. Obrigada por acreditar em minha competência como pesquisadora e ter me escolhido como sua aluna da pósgraduação. Ao Professor Dr. Mário Luiz Ribeiro Monteiro, pelo exemplo de liderança, dedicação e incentivo constante à pesquisa científica no Departamento de Oftalmologia da FMUSP e neste projeto. À Secretária, Sra. Regina Ferreira de Almeida, pelo auxílio, atuação presente e dedicação constante ao serviço de pósgraduação da Disciplina de Oftalmologia da FMUSP.Às radiologistas Dra. Eloísa Maria Mello Santiago Gebrim e Dra. Cristina Hiromi Kuniyoshi pela colaboração na execução deste projeto.Aos pacientes, que possibilitaram a realização desta tese e contribuíram para a construção do conhecimento.A todos os Professores, colegas, residentes e funcionários do Departamento de Oftalmologia do HCFMUSP que contribuíram para a realização deste projeto de alguma forma.
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