Surgical Treatment of Diplopia in Graves Orbitopathy Patients

PURPOSE: To review the authors' current understanding of motility dysfunction in patients with thyroid eye disease and to summarize appropriate evaluation and available management options

Incidence of A pattern strabismus after inferior rectus recession in patients with Graves' orbitopathy: A retrospective multicentre study

Introduction and purpose: Patients with Graves' orbitopathy (GO) may develop restricted elevation; this can lead to hypotropia, sometimes in combination with an abnormal head posture. Recession of one or both inferior rectus muscles is the first line surgery to restore eye motility in these patients. However, this may result in A pattern strabismus. This study was performed to determine the rate of occurrence of this type of incomitant strabismus and potential predictive factors. Methods: All patients undergoing surgery on one or two inferior rectus muscles over a 10-year period were screened retrospectively for the A pattern, defined as a ≥5° difference in squint angle between the primary gaze and downgaze. The extraocular muscle thickness in patients with acquired A pattern was determined by computed tomography (CT) and compared with a control group consisting of patients randomly selected from the total cohort. Results: In a total of 590 patients, surgery was performed on the inferior rectus muscle(s) during the study period; the A pattern was identified in 59 patients. Simultaneous surgery was performed on one or both medial rectus muscles in 32% of the patients. This group had significant incyclotorsion (p = 0.000) and less depression (p = 0.000) postoperatively. The mean amount of recession was 4.38 ± 1.53 mm in the A pattern group and 3.91 ± 1.37 mm in the control group (p = 0.032). The amount of depression was 50.2° ± 7.4° in the A pattern group and 57.3° ± 4.4° in the control group (p = 0.045). The inferior rectus muscle was significantly thicker in the A pattern than in the control group (p = 0.027), while there was no significant difference in the thickness of the superior oblique muscle between the two groups (p = 0.870). Of all patients with the A pattern, 47% required further surgery to achieve adequate binocular single vision. Conclusion: Increased preoperative inferior rectus muscle thickness and relatively limited depression could be predictors of postoperative A pattern inferior rectus recession in patients with GO. Step-by-step procedures are preferable in this surgically challenging group of patients

Bilateral Inferior Rectus Muscle Recession in Patients With Graves Orbitopathy: Is It Effective?

Purpose: To evaluate the effect of bilateral inferior rectus recession regarding improvement of elevation, reduction of abnormal head tilt and vertical squint angle in patients with Graves orbitopathy. Method: Retrospective case series. Patients with Graves orbitopathy who underwent symmetric or asymmetric bilateral inferior rectus recession were selected for this study. Effect on change of elevation, depression cyclodeviation, and vertical squint angle was calculated 3 months and 6 to 12 months postoperatively. Results: Forty-three patients could be included, who underwent a recession of both inferior recti by 1 of the 5 surgeons. Three months postoperatively, the elevation changed from 12 degrees +/- 6.9 degrees preoperatively to 19 degrees +/- 6.7 degrees postoperatively (p = 0.000) and the depression from 54 degrees +/- 6.2 degrees preoperatively to 48 degrees +/- 9.2 degrees postoperatively (p = 0.005). Total duction range remained stable (p = 0.728). Three months after surgery, motility did not change significantly anymore. The dose effect response on elevation was 1.7 degrees +/- 1.7 degrees/mm, and was higher in case of severe preoperative elevation restriction (r = -0.405). Three months postoperatively, the excyclodeviation changed from 6.4 degrees +/- 6.0 degrees to 0.4 degrees +/- 6.0 degrees in primary position (p = 0.000). However, in downgaze 4 patients developed a significant incyclodeviation of > 5 degrees. Muscle volume, prior decompression surgery, or performing surgeon did not influence the outcome. Conclusion: Bilateral recession of the inferior rectus muscles in patients with Graves orbitopathy results in a shift of vertical duction range toward upgaze and a significant decrease of excyclodeviation. Overcorrection of cyclodeviation in downgaze has to be considered before planning this type of surgery. Poor preoperative elevation contributes to higher dose-effect responses. Considering all variables, the orthoptic picture does not change after 3 months of surgery. (Ophthal Plast Reconstr Surg 2012;28:268-272

Outcome of inferior and superior rectus recession in Graves' orbitopathy patients

PURPOSE: To evaluate the surgical effect of unilateral inferior rectus recession (IR-group) with or without a recession of contralateral superior rectus (IR-SR-group) on squint angle and motility restrictions in Graves' Orbitopathy (GO) patients. DESIGN: Retrospective case series. MATERIALS AND METHODS: Primary outcome parameters were the changes of squint angle 3 months and 6-12 months postoperatively. As in a previous study, success was defined as a postoperative vertical squint angle of ≤3° in primary position and on downgaze. Secondary outcome parameters were the influence of surgery on duction range and influence of muscle size on dose-effect response. RESULTS: Fifty-six patients were included in the study; 31 patients in the IR-group and 25 patients in the IR-SR-group. The amount of (fixed suture) recession ranged from 2 mm to 7 mm. Vertical deviations in primary position changed from 8.0° [95% CI 6.6-9.7°] to 1.0° [95% CI -0.4-6.5°] in the IR-group and from 17.0° [95% CI 15.7-20.0°] to 1.5° [95% CI 0.8-2.9°] in the IR-SR-group. The success rate was 74% in the IR-group and 64% in the IR-SR-group. Elevation significantly improved in both groups (IR-group p = 0.007; IR-SR- group p = 0.000). The volume of vertical rectus muscles as assessed on CT-scans did not influence the dose-effect response. CONCLUSIONS: The highest success rate and highest reduction of depression was found in the IR-group. The total duction range remained stable after strabismus surgery (IR-group) or improved (IR-SR-group). Both squint angle and cyclodeviation remained stable during long time follow-up (6-12 months after surgery)

Quality of life improves after strabismus surgery in patients with Graves' orbitopathy

Objective: To evaluate the influence of strabismus surgery on quality of life (QoL) in Graves' orbitopathy (GO) patients. Design: Prospective study of case series. Methods: Consecutive GO-patients who were scheduled for their first strabismus surgery were included in the study. The patients completed the GO-QoL questionnaire within 3 months before the surgery and 2-4 months after the surgery. A complete orthoptic examination, including the field of binocular single vision (BSV), was performed. Clinically relevant response (CRR) in the QoL was also evaluated. Results: In this study, 28 patients were included. The GO-QoL score for visual functioning was 46.3 +/- 24.2 before surgery and 65.7 +/- 30.5 after surgery (P=0.009). The GO-QoL score for appearance changed from 60.6 +/- 25.9 to 69.5 +/- 24.2 (P=0.005). After surgery, the field of BSV increased from 24.3 +/- 34.8 to 68.5 +/- 36.0 points (P=0.000). A weak correlation was found between the field of BSV and the visual functioning score after surgery (r=0.417; P=0.034). CRR was found in 20 (71%) patients. Those with a CRR showed a larger field of BSV (P=0.002) and better GO-QoL scores (P=0.008). Conclusions: GO-QoL score increases significantly for both visual functioning and appearance after the first strabismus surgery in GO-patients, showing the highest improvement for the visual functioning questions. Both the GO-QoL and field of BSV outcomes correlate well with the CR

Unilateral and bilateral medial rectus recession in Graves' Orbitopathy patients

To evaluate the effect of uni- and bilateral medial rectus recession on squint angle and ductions in Graves' Orbitopathy (GO) patients. Retrospective case series. Consecutive GO patients seen between January 2000 and March 2012 who were operated on one or both medial rectus muscles were selected for the study. Data regarding squint angle, abduction, and adduction were collected starting 3 months before surgery and 3 and 6-12 months after surgery. 102 patients were eligible for inclusion. Of these, 24 patients were operated on one medial rectus and 78 on two medial rectus muscles. The dose-effect response was 1.0 [-0.6-3.8]°/mm in the unilateral and 1.4 [0.2-3.0]°/mm in the bilateral group (p=0.000). In the bilateral group, the maximal abduction and adduction changed significantly (p=0.000). However, the total duction range remained unchanged (unilateral: p=0.525; bilateral: p=0.137). The extent of the preoperative abduction did not influence the dose-effect response (r=-0.234; p=0.040), nor did the muscle volume (unilateral p=0.989; bilateral p=0.397). Twenty-three patients (23%) needed additional horizontal squint surgery. In this large series of medial rectus recessions in patients with Graves' disease we found significantly lower dose-effect response ratios as compared to other studies. The amount of abduction deficit does not influence outcom

Comparison of cyclodeviation and duction measurement in Graves' orbitopathy patients using different devices

To compare measurement outcomes of different devices measuring cyclodeviation and ductions in Graves' orbitopathy (GO) patients. Cyclodeviation in GO patients was measured using the Harms tangent screen (HTS), the cycloforometer of Franceschetti, and the synoptometer. Ductions were measured using the modified perimeter, the Goldmann perimeter and the Maddox tangent scale (MTS). In 13 patients, cyclodeviation in primary position, up-, and downgaze was measured with the above-mentioned devices. The mean differences ranged from 0.3º to 3.1º and were smallest between the HTS and the cycloforometer (89% of all measurements within 2º difference). Measurement of abduction, adduction, elevation, and depression using the modified perimeter, Goldmann perimeter, and MTS were obtained in another 13 patients. The mean differences ranged from 1.2º to 12.9º and were smallest between the modified perimeter and the Goldmann perimeter (92% of all measurements ≤ 8º). The HTS and cycloforometer produce interchangeable measurement outcomes. The modified perimeter and the Goldmann perimeter are interchangeable as well. However, the synoptometer and the MTS are not suitable for comparative analysi

Primary and secondary superior rectus recessions to correct vertical deviations in Graves’ orbitopathy patients

Purpose: Patients with vertical strabismus and consecutive diplopia due to Graves’ orbitopathy (GO) might need recession of the rectus superior muscle. The aim of this retrospective analysis is to provide dose–effect values and motility analysis for these patients. Methods: Dose–effect relations (deviation reduction in primary position per amount of recession in mm), monocular excursions and size of the field of binocular single vision (BSV) were evaluated in three different groups of patients. Group 1 (n = 33) patients with primary fibrosis of superior rectus muscle undergoing recession of the ipsilateral rectus superior, Group 2 (n = 14) superior rectus muscle recession after recession of inferior rectus on the contralateral eye and Group 3 (n = 15) simultaneous ipsilateral superior rectus recession and contralateral inferior rectus muscle recession. Surgery was performed using the dose–effect for inferior rectus recession of 4 prism dioptre (PD, Δ) reduction/per mm recession and the intraoperative traction test. Results: Restoration of BSV in the central 20° of gaze could be reached in 88%, 79% and 67% of patients in the three groups, respectively. Restoration of BSV in downgaze (up to 30°) was a little less successful, 79%, 57% and 53%, respectively. The median dose–effect was 3.2 Δ reduction/mm recession in Group 1 (Spearman correlation r = 0.75, p < 0.0001) and 3.3 Δ/mm in Group 2 (n.s.) and 4 Δ/mm in Group 3 (r = 0.67, p = 0.016). The basis for the improvement was the symmetrization of ductions. Conclusion: If superior rectus recession is necessary in GO, higher dosing around 3 Δ reduction/per mm recession should be applied. In case of large deviations, combined vertical surgery (inferior rectus and superior rectus contralateral) is required and reasonable (low cyclotorsion). Single-step or two-step procedures lead to similar results

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

Proposal of success criteria for strabismus surgery for patients with Graves' orbitopathy (GO) based on a systematic review of the literature. We performed a systematic search of OVID MEDLINE, OVID Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and the publisher subset of PubMed, to identify studies reporting on success criteria of strabismus surgery in GO. In addition, we handsearched several orthoptic journals and proceedings of strabismological congresses. Of the 789 articles retrieved, 42 articles described success criteria for strabismus surgery in GO. Most studies defined success in terms of a subjective diplopia-free field in primary and down gaze. Almost half of the studies used a graded scale (excellent, good, acceptable and failure) to describe the outcome of surgery. Three of the eligible studies described a tool to quantify the field of single vision in detail. Quality of life was not reported as an outcome measure in any of the published studies. In conclusion, success criteria for strabismus surgery in patients with GO are poorly defined and no consensus is available. The lack of standardization hampers comparative studies and thus the search for the best surgical treatment for diplopia in patients with GO. Therefore, we propose strict success criteria including a tool for quantification of remaining diplopia plus a disease-specific quality of life questionnaire (the GO-QoL

The Pulfrich phenomenon: Practical implications of the assessment of cases and effectiveness of treatment

The Pulfrich phenomenon, originally described in normal observers, is a treatable disorder of the perception of movement in depth in cases of unilateral or asymmetric optic neuropathy. Treatment is highly bespoke and factors influencing treatment response and failure remain unclear. We assessed 25 adults with suspected Pulfrich phenomenon due to a range of conditions in two tertiary referral centres. Monocularly tinted spectacles were successful in reducing symptoms of the Pulfrich phenomenon under daylight conditions in nine subjects, eight of whom had optic neuritis. These spectacles were not effective at night and in patients with visual field defects due to ischaemic optic neuropathy, glaucoma, optic disc drusen or severe peripapillary retinal nerve fibre loss on optical coherence tomography