Intraoperative relaxed muscle positioning technique results in a tertiary Center for Thyroid Orbitopathy Related Strabismus.

BACKGROUND: Previous techniques resulted with low rates of successful fusion after the surgeries and high necessity of additional surgeries in the treatment of thyroid orbitopathy related strabismus. In this study, reviewing the results of our patients who had surgical correction with relaxed muscle positioning technique due to thyroid orbitopathy related strabismus to evaluate the effectiveness of the surgery was aimed. METHODS: The medical records of 8 patients who had surgical correction with intraoperative relaxed muscle positioning (IRMP) technique were studied retrospectively. The extent of strabismus was determined with prism cover test both at near and distance. The extent of recession was determined by marking the natural place of the released tendon during the primary position. The muscle then sutured to the globe at this precise point. RESULTS: Seven eyes (87.5%) of 8 patients had orthophoria after the surgery and they reported no diplopia in primary and reading gaze. The mean age of the patients was 51 ± 8.8 years. The mean follow-up time was 32.7 ± 18.5 months. Three patients had inferior rectus recession (IRR), 3 had bilateral medial rectus recession (MRR), 1 had only right MRR and 1 had combined MRR with IRR during the surgical correction of the strabismus. The mean amount of recession for IR was 7.5 ± 1.34 mm and it was 6.75 ± 0.95 mm for the MR muscles. The mean prism diopter before the surgery was 37.8 ± 23.3 and it was 0 after surgery except only one of the patients who had > 60 prism diopter (PD) left esotropia (ET) before surgery and had 30 PD left ET after surgery (3.3 ± 9.4). CONCLUSION: IRMP technique is a unique option for the surgical correction of thyroid orbitopathy related strabismus. By showing a dramatic increase in the quality of life of the patients, our surgical results are promising despite limited number of patients.

The effect of surgical treatment of superior oblique muscle palsy on ocular torsion.

PURPOSE: To compare the effectiveness of superior oblique tuck and inferior oblique weakening procedures on objective and subjective torsion in patients with superior oblique palsy. METHODS: Patients with unilateral superior oblique palsy evaluated between September 2007 and October 2009 were treated with one of four surgical procedures on the basis of their preoperative findings: superior oblique tuck, anterior transposition of the inferior oblique muscle, inferior oblique recession, or inferior oblique myectomy. Subjective (double Maddox rods) and objective (fundus photography) torsion were measured pre- and postoperatively. RESULTS: A total of 28 patients were evaluated (mean age, 16.4 ± 12.4 years; range, 6-51 years). In 15 (53.6%) the superior oblique palsy was congenital; in 13 (46.4%) it was acquired. The mean decrease in subjective extorsion was 6.2° ± 2.3° after superior oblique tuck, 2.3° ± 2.4° after anterior transposition of the inferior oblique, 1.3° ± 2.7° after inferior oblique recession, and 2.6° ± 4.7° after inferior oblique myectomy. Objective extorsion decreased by 5.8° ± 0.8°, 4.4° ± 1.7°, 3.1° ± 3.2°, and 3.4° ± 4.7°, respectively. CONCLUSIONS: Superior oblique tuck appears to correct extorsion more effectively than inferior oblique surgery, but this may be an artifact of performing tucks in patients with greater initial extorsion. The small amount of extorsion correction was similar for all inferior oblique procedures.

Immunohistochemical analysis of orbital connective tissue specimens of patients with active Graves ophthalmopathy.

PURPOSE: To explore the immune mechanism of Graves ophthalmopathy (GO) by analyzing infiltrating cells in orbital connective tissue (OCT) specimens of patients with active GO using immunohistochemical methods. METHODS: Five OCT specimens obtained from patients with active GO and five control specimens obtained from forensic cadavers who died from nonmedical reasons were stained with anti-CD3, CD4, CD8, CD45RO, HLA-Dr, CD25, and TNF-alpha monoclonal antibodies. Positively stained cells were counted and results were interpreted as cell counts/mm2. Four of five GO patients had never been treated with any immunomodulating therapy. Only one had received oral prednisolone prior to tissue sampling, but this treatment had ceased 5 months before surgery. RESULTS: The retro-orbital tissue specimens obtained from forensic cadavers did not show any significant positive staining for any monoclonal antibody tested. However, the specimens from GO patients showed positively stained means of 36.66 +/- 4.61 HLA-Dr+, 12.8 +/- 3.42 CD8+, 11.8 +/- 1.78 CD4+, 16.6 +/- 1.81 CD3+, 21.2 +/- 3.12 CD45RO+, 10.4 +/- 2.07 TNF-alpha+, 7.2 +/- 1.48 CD25+, 3.2 +/- 1.09 CD4+CD8+, 4.6 +/- 1.67 CD4+CD45RO+, 2.8 +/- 0.83 CD8+CD45RO+, 1.6 +/- 0.89 CD4+CD25+, and 1.8 +/- 1 0.83 CD8+CD25+ cells/mm2. CONCLUSIONS: Our study supports that most of the infiltrating lymphocytic cells in the active stage of GO are T cells, and a significant proportion of them are CD45RO+ cells. Infiltration of OCT by HLA-Dr+, CD25+, and TNF-alpha cells suggests that Th1-type immune reaction with the interference of proinflammatory cytokine(s) (TNF-alpha) may be important in the pathogenesis of disease. Further studies are needed to understand the disease pathogenesis and may provide a scientific basis for future treatment alternatives for the disease (e.g., anti-cytokine treatment).

Early surgery for dysthyroid orbitomyopathy based on magnetic resonance imaging findings.

PURPOSE: To investigate the value of magnetic resonance imaging (MRI) in the determination of the fibrotic phase in dysthyroid orbitopathy, which may be an indication for early surgery. PATIENTS AND METHODS: Thirteen patients with dysthyroid orbitopathy who had vertical deviation in excess of 20 PD and associated diplopia in the primary position that did not respond to medical treatment were included in the study. On MRI, the absence of high-intensity foci in the T2 sequence, especially in the coronal planes, indicated that the extraocular muscles were not edematous. These muscles were evaluated as being in the fibrotic phase, and surgery was performed without waiting the recommended 6 months for the stabilization of the angle of deviation. RESULTS: The complaint of diplopia disappeared after a single operation in 8 patients, and after a second operation in 4. Thus, success was obtained in 12 of the 13 patients. One patient with persistent vertical diplopia refused a second operation. CONCLUSION: Our results indicate that MRI is an effective and reliable method for the determination of the fibrotic phase in patients with dysthyroid orbitopathy who have diplopia in the primary position, and that MRI results have an important role in determining whether early surgery is appropriate.

Consecutive exotropia following strabismus surgery.

We investigated the clinical factors affecting the development of consecutive exotropia following esotropia surgery. The development period of consecutive exotropia, amblyopia and limitation of adduction were evaluated in 89 patients with primary esotropia that changed to consecutive exotropia after surgery. In the presence of deep amblyopia, consecutive exotropia developed earlier. When two horizontal muscles were operated, limitation of adduction was more frequent in symmetrical rather than asymmetrical surgical procedure. Since consecutive exotropia may develop many years after esotropia surgery, a long-term follow-up period in patients without consecutive exotropia in the early postoperative period is advised.

Extraocular muscle surgery in dysthyroid orbitomyopathy: influence of previous conditions on surgical results.

PURPOSE: To determine the influence of previous treatments other than the surgical treatment of restrictive myopathy resulting from dysthyroid orbitomyopathy. METHODS: The outcome of 23 cases with dysthyroid orbitomyopathy was evaluated after extraocular muscle surgery. RESULTS: It has been observed that the duration of the orbitomyopathy, severity of myopathy of the deviation angle, and the modality of treatment prior to surgery (radiotherapy and corticotherapy) did not influence surgical outcome. Binocular single vision was achieved in primary and reading positions in 14 of 23 cases (60.9%) after surgery while prisms were required to achieve the same result in 5 cases (21.7%). CONCLUSION: It is concluded that previous treatment does not influence the results of extraocular muscle surgery in patients with dysthyroid orbitomyopathy.