Squint Surgery in TED - Hints and Fints, or Why Graves' Patients Are Difficult Patients

Abstract

Endocrine ophthalmopathy is the most common cause of acute onset diplopia in middle aged or older individuals. Ocular muscle involvement is characterized by myositis followed by fibrosis: this causes a stiffness and a shortening of the muscles involved with restriction of ocular movements: so the impairment of rotation is due to a mechanical obstacle and not to a paresis. Prisms are rarely useful in relieving diplopia and the majority of symptomatic patients need squint surgery. Timing of surgery is very important and two considerations are to be kept in mind: first, the systemic disease must be in remission and the ocular deviation must be stable for at least six months; second, if more than one surgical procedure is needed for the ophthalmopathy, muscle surgery has its right place after orbital surgery and before lid surgery. Obviously dealing with restrictive disorders, surgery is based on weakening procedures of the affected muscles: identifying the affected muscles is of crucial importance and may be sometime difficult for the presence of misleading signs; great advances have been made in surgical technique with the development of adjustable sutures and of topical anesthesia. Prognosis is usually good with more than 80% of patients recovering a useful field of binocular single vision with one procedure and more than 90% with two or more procedures.

Proposal of success criteria for strabismus surgery in patients with Graves' orbitopathy based on a systematic literature review

“…It was not mentioned how the abnormal head position was assessed. Twenty-two (52%) studies considered single vision in primary gaze an important aspect of the outcome of strabismus surgery (Trokel et al 1988;Mourits et al 1990;Fells et al 1992;Lueder et al 1992;Nardi et al 1992;Boergen 1993;Kraus & Bullock 1993;Flanders & Hastings 1997;Ruttum 2000;Baker & Ansons 2001;Ellerton et al 1995;Jacks & Adams 2001;Ai et al 2002;Schittkowski et al 2004;Dal Canto et al 2006;Schotthoefer & Wallace 2007;Yan & Zhang 2008;de Hoog et al 2009;Nardi 2009;Nassar et al 2009;Nicholson et al 2011;Kim et al 2013). To assess the presence of single vision in different directions of gaze, the field of BSV was used in eight studies (20%) (Maillette de Buy Wenniger- Prick et al 1986;Mourits et al 1990;Boergen 1993;Ai et al 2002;Godts et al 2002;Schittkowski et al 2004;Pitchon & Klainguti 2007;Nassar et al 2009).…”

“…Four studies specified how these directions should be measured (Godts et al 2002;Schittkowski et al 2004;Pitchon & Klainguti 2007;Nassar et al 2009). In addition to the primary gaze, the majority of studies mentioned the reading gaze as an outcome parameter (n = 22; 52%) (Trokel et al 1988;Mourits et al 1990;Fells et al 1992;Lueder et al 1992;Nardi et al 1992;Boergen 1993;Kraus & Bullock 1993;Flanders & Hastings 1997;Ruttum 2000;Baker & Ansons 2001;Ellerton et al 1995;Jacks & Adams 2001;Ai et al 2002;Schittkowski et al 2004;Dal Canto et al 2006;Schotthoefer & Wallace 2007;Yan & Zhang 2008;de Hoog et al 2009;Nardi 2009;Nassar et al 2009;Nicholson et al 2011;Kim et al 2013) of which four (9%) studies measured the reading gaze by means of the field of BSV (Mourits et al 1990;Schittkowski et al 2004;Pitchon & Klainguti 2007;Nassar et al 2009) (Table 3). Other directions of gaze were specified in eight studies (20%) (Maillette de Buy Wenniger-Prick et al 1986;Boergen 1993;Ai et al 2002;Godts et al 2002;Pitchon & Klainguti 2007;de Hoog et al 2009;<...>…”

“…In the active phase of the disease, immunosuppressive or retrobulbar radiation may improve diplopia (Mourits et al 2000;Prummel et al 2004). However, when the disease and the motility pattern have become stable, there is consensus to treat residual diplopia surgically (Prummel et al 2003;Bartalena et al 2008;Nardi 2009;Lyons & Rootman 2010). Although a full field of binocular single vision (BSV) in patients with GO is difficult to obtain due to the incomitant type of strabismus typical for patients with GO, the goal of surgery is to reach a field of BSV as large as possible (Schotthoefer & Wallace 2007;Dickinson & Perros 2009;Dagi et al 2010;Eckstein et al 2012).…”

Bilateral Inferior Rectus Muscle Recession in Patients With Graves Orbitopathy

“…10 Late overcorrections in unilateral inferior rectus recessions are widely discussed in literature, as also the other side effects such as proptosis, lower-eyelid retraction, and iatrogenic deviations in downgaze due to depression impairment. 4,[11][12][13][14][15][16][17][18][19] However, no clear data are available for bilateral inferior rectus recession patients. The assessment of the incidence of all these side effects was beyond the scope of the present study.…”

Effectiveness of Bilateral Lateral Rectus Resection for Residual Esotropia in Dysthyroid Ophthalmopathy

“…Strabismus is a common sequela of dysthyroid ophthalmopathy due to inflammation and fibrosis of the extraocular muscles 1 . The restrictive nature of the disease causes limitation of ocular movement and misalignment of the visual axes.…”