University of Medicine and Pharmacy Gr. T.

Popa Iasi Faculty of Medicine Discipline of Endocrinology

Surgery for Graves' Ophthalmopathy: when and what for? The experience of Iasi
Coordinators: M.D.PhD Dumitru Branisteanu M.D.Victor Costan

Author: Iftime Ionica-Lidia

Co-authors: Costinescu NicoletaRamona, Gorgan Lavinia-Andreea, Luca Irina

Introduction:

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DD Brniteanu MD PhD (KU Leuven)

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Introduction:
Ophthalmopathy is a common extrathyroidal feature of Graves disease. Graves orbitopathy could be classified into three types:

Type I - with prevalence of fat tissue,

Type II - with muscle involvement Type III - a combination of the two previous types

Introduction:
Early symptoms and signs: a sense of irritation in the eyes; excessive tearing; the conjunctivae injected; exophthalmos; lagophthalmos; periorbital edema; blurred vision and easy tiring of the eyes; double vision.

Introduction:
Severe cases:

color vision and visual acuity decreased or lost;

the corneas may ulcerate or become infected.

Extreme orbitopathy: subluxation of the globe; blindness; visual field defects.

Introduction:
Indications for orbital decompression: if glucocorticoid therapy or external radiation (or both) does not halt progression of the disease

if loss of vision is threatened by: -ulceration

-infection of the cornea -changes in the retina or optic nerve

at patients request (in some patients, desire for a nearly complete cosmetic correction may be such that decompression surgery is the only satisfactory route)

Material and method:

18 patients Phase of ophthalmopathy: -one of this patients was an emergency case (malignant exophtalmos) -the other 17 were operated in the chronic phase of ophthalmopathy

Forms of ophthalmopathy: -13 patients were operated for proptosis -5 patients were operated for diplopia

Material and method:

Approach for orbital decompression:

- 15 patients- Inferior and superior transpalpebral approach

- 3 patients -Transconjunctival approach Lipectomy:

- 5 patients-removal of both intraconal and extraconal fat

- 13 patients -only extraconal fat

All patients with the entire floor of the orbit removed were submitted to anaesthesia of the infraorbitary nerve territory.

Results:
Proptosis: was decreased in all patients with at least 1 mm by Hertels exophtalmometry.
Diplopia: patients without initial diplopia described transient diplopia in the first postoperatory week; patients who presented diplopia before surgery have noticed significant improvement or even disappearance after decompression.

Clinical case no. 1:

Emergency intervention in a patient with right malignant ophthalmopathy and zero visual acuity in the acute phase.

c. Four Before after a. months removal b. One year the surgery. wall removal of after external of the inferior and internal and more extraconal fat. orbital walls and extraconal fat in the affected eye.

Dr. V Costan

Clinical case no. 2:

Patient thyroidectomized for Graves disease and thyroid papillary carcinoma having bilateral exophthalmos in the stable chronic phase, accompanied by mild diplopia and palpebral incompetence (left panel). Patient was submitted to bilateral surgical decompression (removal of extraconal fat tissue through inferior and superior transpalpebral intervention, and removal of the orbit floor.) One year after surgery, the patient had diminished bilateral exophthalmos, with the disappearance of diplopia and of palpebral incompetence (right panel).

Clinical case no. 3:

Two yearsophthalmopathytoxin diplopia with after surgery, The injection of botulinic diplopia disappeared Bilateral orbit decompression through removal Graves - in the superior andthe levator floor and superiorand superior eyelidthe intervention scars becamebilateral of restriction of completely normalized inferior orbit eye movements and almost invisible, but a certain of after injection eyelid positionsremovaldegree of superior eyelid transpalpebral one week extraconal fat. superior eyelid retraction retraction persisted. Dr. V Costan

Clinical case no. 4:

Patient with bilateral Graves ophthalmopathy and shortening of the right inferior eyelid 16 months after decompression surgery (upper image), submitted to eyelid lengthening with hard palate mucosal graft (lower image).

Discussion:

The experience of Iasi suggests that the combination between lipectomy and orbital wall removal adapted to the clinical modifications and radiological features lead to better results, since it allows a more efficient individual adaptation.

Conclusions:
From the experience of Iasi we conclude that orbit surgery in the chronic phase of Graves ophthalmopathy is preferred for: Its predictable results
Its reduced rate of complications The improvement of the quality of life

Thank you!