Improvement of Ocular Surface Disease by Lateral Tarsoconjunctival Flap in Thyroid-Associated Orbitopathy Patients with Lid Retraction

Abstract

There is a high incidence of ocular surface disease (OSD) in thyroid-associated orbitopathy (TAO) patients as a result of incomplete eyelid closure and chronic inflammatory eyelid status. This study was performed to evaluate the efficacy of a lateral tarsoconjunctival flap (LTF) in improving OSD in TAO patients from the perspective of correcting eyelid closures. As a study design, TAO patients were enrolled in this study to evaluate OSD perioperatively before they were scheduled for LTF surgery. Additional lid surgery was also recorded. The outcome was evaluated with perioperative OSD measurements and tear inflammatory mediators at baseline and one month and three months postoperatively. As a result, 42 patients (5 male, 37 female) underwent LTF surgery, and 13 patients received medial pretarsal support with collagen grafts. Eleven patients underwent blepharotomy, and 6 patients received Botox injections for upper lid retraction. The mean age of the participants was 46.4 years old, and the mean follow-up period was 10.6 months. Their clinical activity score (CAS) at the time of the operation was 2.1. Dry eye parameters, such as ocular surface disease index, tear breakup time, Schirmer’s I test score, and meibomian gland dropout were all significantly improved 3 months postoperatively. Tear osmolarity and inflammatory mediators in tear fluid, such as IL-6, IL-8, IL-18 and MCP-1, were also significantly improved after the procedures. After the surgery, all complications were mild and temporary. As a conclusion, LTF could provide TAO patients with both lid retraction correction and improvement of ocular surface disorders. Dry eye parameters significantly improved 3 months postoperatively. This method can serve as an alternative treatment option for lid correction in TAO patients.

Systematic review of ocular surface treatments in the setting of thyroid eye disease

“…This resulted in objective improvements in fluorescein staining from 2+ to trace after 3 weeks of wear as well as subjective increases in comfort. Hsu et al., performed lateral tarsoconjunctival flaps in 42 patients and showed statistically significant improvements in OSDI, TBUT, Schirmer’s test, corneal and conjunctival staining scores, and meibomian gland drop out (all p<.01) 3 months postoperatively ( 19 ). Additionally, the tear osmolarity and inflammatory markers in the tear fluid (IL-6, IL-8, IL-18 and MCP-1) were significantly improved after the lateral tarsoconjunctival flaps.…”

“…This review found lateral tarsoconjunctival flap surgery to improve dry eye parameters and decrease inflammatory markers in the tear film, but this surgical option should be reserved for patients suffering from refractory dry eye in thyroid eye disease ( 19 ). Less invasive measures focusing on tear film optimization and decreased inflammation should be trialed first, especially in patients with mild to moderate disease.…”

“…Despite the fact that ocular surface symptoms present in the majority of thyroid eye disease patients and that these patients can present with evaporative dry eye changes, more research is needed to confirm that dry eye syndrome treatments have similar efficacy in the setting of thyroid eye disease. There are significant compositional and inflammatory changes to the tear film of patients with thyroid eye disease ( 19 ). These gaps in our understanding coupled with apparent immunologic complexities represent an unaddressed opportunity for research and need for an improved treatment algorithm based on evidence.…”

Risk Factors for Ocular Surface Irritation Symptoms in Inactive Mild and Moderate-to-Severe Graves’ Orbitopathy

“…Thus, in order to decrease those symptoms, pharmacotherapy (anti-inflammatory eye drops, CsA eye drops, botulinum toxin injection, etc.) [ 16 – 20 ] or surgical intervention such as orbital decompression, correction of upper eyelid retraction, or lateral tarsoconjunctival flap surgery [ 21 – 23 ] should be implemented as soon as possible.…”