ULTRASOUND EXAMINATION OF THE ORBIT IN PATIENTS WITH THYROIDASSOCIATED ORBITOPATHY - EXAMINATION GUIDE AND RECOMMENDATIONS FOR EVERYDAY PRACTICE. A REVIEW.

The purpose of this study is to present the possibilities and benefits of ultrasonography (US) of the orbit in the diagnosis and treatment of thyroidassociated orbitopathy (TAO). Methods: US examination of the orbit is an essential addition to clinical and laboratory examination in TAO patients. Nevertheless, it is often neglected in clinical practice or indicated with delay. Based on previously published studies and our experience with the diagnosis and treatment of TAO patients, we aim to highlight the clear benefit of US examination of the orbit and oculomotor muscles, not only for correct TAO diagnosis but also in the monitoring of the disease over time. However, knowledge of the drawbacks and limitations of this method is also essential, as we shall point out. It is always necessary to remember that US examination must be evaluated in connection with the clinical findings. A detailed recommendation for US examination of the extraocular muscles and the orbit based on our experiences with diagnosing and treating TAO patients in daily practice is also included. Conclusion: According to our experience, US examination of the orbit is an excellent and irreplaceable tool for timely TAO diagnosis and further disease monitoring. However, considerable examiner experience and detailed knowledge of the clinical and ultrasound manifestations of TAO are essential.

Computed tomography and magnetic resonance imaging of the orbit in the diagnosis and treatment of thyroid-associated orbitopathy - experience from practice. A Review.

The purpose is to acquaint readers with the contribution of imaging methods (IMs) of the orbit, specifically computed tomography (CT) and magnetic resonance imaging (MRI), in the diagnosis of thyroid-associated orbitopathy (TAO). Methods: IMs of the orbit are an indispensable accessory in the clinical and laboratory examination of TAO patients. The most frequently used and probably most accessible method is an ultrasound examination of the orbit (US), which, however, has a number of limitations. Other methods are CT and MRI. Based on the published knowledge implemented in our practice and several years of experience with the diagnosis and treatment of TAO patients, we would like to point out the benefits of CT and MRI in the given indications: visualisation of the extraocular muscles, assessment of disease activity, diagnosis of dysthyroid optic neuropathy and differential diagnosis of other pathologies in the orbit. Our recommendation for an ideal MRI protocol for disease activity evaluation is also included.  Conclusion: IMs play an irreplaceable role not only in the early diagnosis of TAO, but also in the monitoring of the disease and the response to the applied treatment. When choosing a suitable IM for this diagnosis, a number of factors must always be taken into account; not only availability, cost and burden for the patient, but especially the sensitivity and specificity of the given method for the diagnosis of TAO.

Comparison of Three Methods of Tonometry in Patients with Inactive Thyroid-Associated Orbitopathy.

INTRODUCTION: Intraocular pressure (IOP) measurement in patients with thyroid-associated orbitopathy (TAO) can be difficult and misleading, particularly in patients with diplopia and eye deviation (esotropia or hypotropia). However, when measuring IOP, it is also necessary to pay sufficient attention to TAO patients without diplopia in primary gaze direction and without motility disorder that might not be readily apparent. PURPOSE: The aim of this study was to evaluate the accuracy of measurement of intraocular pressure (IOP) using three different types of tonometers: the rebound tonometer (iCARE), the Goldmann applanation tonometer (GAT) and the non-contact airpuff tonometer (NCT) in patients with inactive TAO.  Materials and Methods: A total of 98 eyes of 49 adult patients with TAO were examined. The study group included 36 females and 13 males, with an age range of 19-70 years and a median age of 55.0. All the patients had evidence of thyroid disease,  a history of mild to moderate TAO, no clinical signs or symptoms of active disease, and no diplopia in direct gaze direction. In addition to a comprehensive eye examination, all the patients underwent measurement of intraocular pressure with three tonometers: NCT, iCARE, and GAT. The measurements with these three devices were compared. RESULTS: The mean IOP was 18.1 ± 2.4 mmHg (range 13-25 mmHg) with GAT, 22.3 ±5.0 mmHg (range 13-35 mmHg) with NCT, and 18.0 ±2.4 mmHg (range 13.3-26 mmHg) with iCARE. The mean difference between the GAT and iCARE measurements (using the Bland-Altman analysis) was -0.1 ±1.16 mmHg (limits of agreement -2.4 to 2.1). The mean difference between the GAT and NCT measurements was 4.2 ±3.6 mmHg (limits of agreement -2.8 to 11.2). The mean difference between the iCARE and NCT measurements was -4.3 ±3.7 mmHg (limits of agreement -11.6 to 2.9). No significant difference was found between GAT and iCARE (p = 1.000). However, there was a significant difference between GAT and NCT (p < 0.0001), as well as between iCARE and NCT (p < 0.0001).  Conclusions: In patients with TAO, NCT significantly overestimates IOP values compared to the GAT and ICare. By contrast, the iCARE rebound tonometer provides IOP measurements comparable to the gold standard GAT in these patients.

COMPUTER TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING OF THE ORBIT IN THE DIAGNOSIS AND TREATMENT OF THYROID-ASSOCIATED ORBITOPATHY - EXPERIENCE FROM PRACTICE. A REVIEW.

The purpose is to acquaint readers with the contribution of imaging methods (IMs) of the orbit, specifically computer tomography (CT) and magnetic resonance imaging (MRI), in the diagnosis of thyroid-associated orbitopathy (TAO). Methods: IMs of the orbit are an indispensable accessory in the clinical and laboratory examination of TAO patients. The most frequently used and probably most accessible method is an ultrasound examination of the orbit (US), which, however, has a number of limitations. Other methods are CT and MRI. Based on the published knowledge implemented in our practice and several years of experience with the diagnosis and treatment of TAO patients, we would like to point out the benefits of CT and MRI in the given indications: visualisation of the extraocular muscles, assessment of disease activity, diagnosis of dysthyroid optic neuropathy and differential diagnosis of other pathologies in the orbit. Our recommendation for an ideal MRI protocol for disease activity evaluation is also included. Conclusion: IMs play an irreplaceable role not only in the early diagnosis of TAO, but also in the monitoring of the disease and the response to the applied treatment. When choosing a suitable IM for this diagnosis, a number of factors must always be taken into account; not only availability, cost and burden for the patient, but especially the sensitivity and specificity of the given method for the diagnosis of TAO.

[Conservative management options for thyroid disease induced diplopia]. / Konzervativní moznosti resení diplopie u pacientu s endokrinní orbitopatií

AIM: To focus on the conservative management options for diplopia in patients with thyroid ophthalmopathy in the active and in the "wait-for-operation" stage of the disease. To evaluate the degree of patient knowledge about the treatment options for diplopia and about different types of occlusion. To identify patient preferences when selecting from various management options. MATERIALS AND METHODS: This prospective study included patients with thyroid ophthalmopathy and disturbing diplopia in the primary gaze position who were referred for further treatment at the Department of Ophthalmology from January 2010 to June 2012. Twenty five patients (16 women and 9 men) were included for this study during the observation period. At the beginning, the degree of patient knowledge about the treatment options for diplopia and about different types of occlusion was assessed. Subsequently, all patients were informed in detail about different types of black and semi-translucent occlusion. After stabilization of diplopia, Fresnel prism and prism spectacle glasses were tested. At follow-up visits, patient preferences were evaluated. RESULTS: Twenty patients were initially informed about monocular patching options by their doctor. Only twelve patients received more specific recommendations on how to cover the eye; in all cases non-translucent plastic or tape patch was recommended. Only one patient used non-translucent occlusion in daily life; ten patients used it occasionally during static activities. None of the patients was informed about semi-translucent occlusion possibilities. At follow-up after two to four months, 19 patients used semi-translucent occlusion in daily life (18 used semi-translucent tape, one used frosted lens). Only one patient continued to use non-translucent occlusion. Five patients used no occlusion and closed one eye when necessary. CONCLUSION: Strabismus surgery in patients with thyroid ophthalmopathy is recommended in the inactive phase of the disease. For patients with diplopia it could be very difficult to overcome the active phase of the disease. In our study, the vast majority of patients in this phase preferred semi-translucent occlusion to non-translucent one.

[The ultrasound findings in posttraumatic endophthalmitis]. / Ultrazvukové nálezy u poúrazových endoftalmitid.

The aim of this study was to evaluate the ultrasound findings in eyes with endophthalmitis following penetrating injury and to establish unfavorable predictive signs of this serious disease. In a retrospective study we evaluated findings in 7 eyes of 7 patients followed up because of posttraumatic endophthalmitis at the Department of Ophthalmology, School of Medicine, in Olomouc, Czech Republic, EU, during the period September 1999-December 2004. The mean age of the patients was 37.3 years (range 22-49 years). The mean duration of the period between the injury and the formation of the endophthalmitis was 8.4 days (range 1-21 days). The visual acuity at the time of admittance was very low; it ranged between light perception and 1/60 (0,016 or 20/1200). All patients underwent diagnostic-therapeutic pars plana vitrectomy with vitreous samples taken for microbiological examination and intravitreal antibiotic application. The final visual acuity (VA) ranged from 1/60 (0,016 or 20/1200) to 6/12 (0.5 or 20/40), so it was very variable and that gave us the possibility to follow the connection between the final VA and seriousness of the penetrating injury, and also with the interval between the emergence of the endophthalmitis and beginning of its treatment. During the ultrasound examination, the presence of membranes in the vitreous body, posterior vitreous detachment, thickening of the choroid, detachment of the choroid and detachment of the retina were of concern to us. Membranes were present in the vitreous in 5 eyes. Without membranes detected by the ultrasound, there were 2 eyes; in both of them the final VA was better than 6/36 (0,1667 or 20/120). The posterior vitreous detachment was detected in 3 eyes, and not detected in four eyes. We didn't find any connection between the final VA and posterior vitreous detachment. The thickening of the choroid was present at the ultrasound examination in all seven eyes. The detachment of the choroid was not found in any eye. The retina was detached in two eyes. In three eyes only, the final central VA was better than 6/36 (0.1667 or 20/120). In two of them, the intraocular foreign body was found and in both the bacteria Staphylococcus epidermidis was detected. In the third eye, the soil bacteria Enterococcus and Klebsiela were cultivated. The ultrasound findings in these three eyes are identical only in the term of thickening of the choroid, similar to other eyes. In two of them no membranes were detected by ultrasound and no posterior vitreous detachment was found. The ultrasound examination in eyes with endophthalmitis after penetrating injury is specific in particular because of the mechanism of the injury. In contrast to the cases of the postoperative endophthalmitis, no prognostic unfavorable sings in the ultrasound examination can be strictly identified.