Compressive Optic Neuropathy and Repeat Orbital Decompression

Abstract

Purpose To characterize the presenting characteristics, pre-operative clinical activity score (CAS), surgical approach, and visual outcomes in patients with thyroid eye disease undergoing repeat orbital decompression for recurrent or recalcitrant compressive optic neuropathy. Methods The medical records of patients with recurrent or recalcitrant compressive optic neuropathy (CON) undergoing repeat orbital decompressions were retrospectively reviewed. The primary outcome measures included pre- and post-operative Humphrey visual field mean deviation, visual acuity measured in logarithm of the minimal angle of resolution, color vision measured by Ishihara plates, and presence of relative afferent pupillary defect. Details of the surgical procedure and each patient’s CAS at presentation were also recorded. Results Six patients, 9 orbits, with a mean pre-operative CAS of 3.8 were included in this review. The mean time between initial decompression and presentation to our center for recurrent or persistent CON symptoms was 8.6 years (range, 1–15 years). At presentation, the average HVF mean deviation was −16.5 (standard deviation (SD): 8.8), improving to −3.8 (2.4) post-operatively with a mean of 9.3 months follow-up (mean improvement of 75%). Pre-operative visual acuity was 0.34 (0.23) LogMAR, improving to 0.05 (0.10) logMAR with a mean follow up of 10.4 months. Pre- to post-operative comparisons of clinical measures all showed statistically significant improvement (p<0.05). Eight eyes presented with decreased visual acuity (any VA < 20/20), 4 with decreased color vision (any color vision < 11), and 1 with a relative afferent pupillary defect and all of these patients demonstrated improvement following repeat orbital decompression. Conclusions In patients with thyroid eye disease, symptoms of recurrent compressive optic neuropathy occurred up to 15 years following initial orbital decompression underscoring the smoldering, progressive nature of the disease. Repeat decompression which focused on the orbital apex resulted in visual improvement in all 6 patients. Despite clinical evidence of compressive optic neuropathy, the mean CAS of these patients at presentation was only 3.8, highlighting the importance of close monitoring of patients with thyroid eye disease following decompression regardless of the external manifestations of disease activity.

Early efficacy of teprotumumab for the treatment of dysthyroid optic neuropathy: A multicenter study

“… 8 Despite the widespread use of these modalities over decades for TED, the literature is mostly comprised of retrospective studies, Case reports and small case series which now guide practice patterns in the treatment of DON. 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 There has only been one prospective, randomized controlled trial (RCT) to compare corticosteroids versus corticosteroids and surgical decompression for DON. 12 In this study, Wakelkamp et al reported similar initial outcomes after medical decompression and surgical decompression, and found that immediate surgical decompression did not result in better visual outcomes nor did it preclude the use of corticosteroids.…”

Retrobulbar Optic Neuropathy: “Neither the Patient nor the Doctor Can See”

“…VF defects occur as concordance with the localization of the lesion. [1][2][3][4][5][6]18,[28][29][30] Stage 0 papilledema Papilledema is optic disc swelling due to elevated intracranial pressure. Optic nerve damage develops due to intraneuronal ischemia secondary to the stasis in the axoplasmic flow.…”

Thyroid Eye Disease

“…A variety of treatment strategies have been described for DON including oral or intravenous (IV) corticosteroids, surgical decompression, and orbital radiation. 10,[28][29][30][31] Most current treatment strategies initially use high-dose corticosteroids as a first-line therapy for optic neuropathy and reserve decompression surgery for persistent defects. Orbital radiation is occasionally used as an adjunct to corticosteroids.…”