Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study.

OBJECTIVES: To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS: Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS: Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS: IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES: To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS: Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS: Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS: IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Evaluation of Ocular Versions in Graves' Orbitopathy: Correlation between the Qualitative Clinical Method and the Quantitative Photographic Method.

PURPOSE: To assess the agreement between the qualitative clinical method and the quantitative photographic method of evaluating normal and abnormal ocular versions in patients with inactive Graves' orbitopathy (GO). METHODS: Forty-two patients with inactive GO had their ocular versions evaluated clinically according to three categories: normal, moderate alterations (-1 or -2 hypofunction), and severe alterations (-3 or -4 hypofunction). The subjects were photographed in the 9 positions of gaze, and the extent (mm) of eye movement in each position was estimated using Photoshop® and ImageJ and converted into degrees with a well-established method. The agreement between the two methods (qualitative vs. quantitative) for classifying ocular versions as normal or abnormal was assessed. RESULTS: The mean quantitative measurements of versions were significantly different for each clinical category (normal, moderate alterations, and severe alterations) in the following five positions: abduction, adduction, elevation in abduction, elevation, and elevation in adduction (p < 0.001). No such pattern was observed for the three infraversion positions (depression in abduction, p=0.573; depression, p=0.468; depression in adduction, p=0.268). CONCLUSION: The agreement was strong between the quantitative photographic method and the qualitative clinical method of classifying ocular versions, especially in lateral and supraversions, which are typically affected in GO. Digital photography is recommended for the assessment of ocular versions due to its practicality, suitability for telemedicine applications, and ease of monitoring during follow-up. This trial is registered with NCT03278964.

[Exudative bilateral retinal detachment and behavior changes in a patient with neurosyphilis: case report]. / Descolamento de retina exsudativo bilateral associado a alterações de comportamento em paciente com diagnóstico de neurossífilis: relato de caso.

PURPOSE: To report a case of bilateral retinal detachment associated with behavior changes. RESULTS: A 62-year-old, female patient presented agitated, complaining of progressive bilateral low vision for the 3 past months, along with anxiety and behavior changes. On examination, she had visual acuity of light perception in the right eye and conting fingers at 30 cm in the left eye; anterior chamber reaction; bilateral hyperemic and edematous optic disc and bilateral serous retinal detachment, yellow-white subretinal peripapillary plaques and subretinal and intraretinal exudation. On laboratory work-up, the patient had positive VDRL and FTA-Abs tests. Lumbar puncture was done; she had positive FTA-Abs and hemagglutination treponemal test on spinal fluid analysis. Neurosyphilis diagnosis was established, and the patient was admitted to the hospital for an intravenous penicillin course associated with oral prednisone (0.5 mg/kg). After 2 weeks, the patient showed marked improvement of her retinal findings, with reatachment of the retina and also an improvement of visual acuity. CONCLUSION: Syphilis is a pleomorphical disease, and may present as diffuse uveitis associated with bilateral exudative retinal detachment. Central nervous system involvement must always be evaluated and discarded; proper treatment may lead to visual function improvement and diminished sequelae.

Descolamento de retina exsudativo bilateral associado a alteracões de comportamento em paciente com diagnóstico de neurossífilis: relato de caso / Exudative bilateral retinal detachment and behavior changes in a patient with neurosyphilis: case report

OBJETIVO: Descrever caso de descolamento de retina bilateral associado a alteracões de comportamento. RESULTADO: Paciente de 62 anos, sexo feminino, apresentou-se com baixa de visão bilateral, progressiva, de 3 meses de duracão, associada a alteracões de comportamento e agitacão psicomotora. Ao exame oftalmológico apresentava acuidade visual de percepcão luminosa em olho direito; e conta dedos a 30 cm em olho esquerdo. A biomicroscopia evidenciou reacão de câmara anterior; à fundoscopia, apresentava edema e hiperemia do disco óptico bilateralmente, áreas extensas de descolamento de retina seroso, placas sub-retinianas amareladas peripapilares e exsudacão sub-retiniana e intra-retiniana em ambos os olhos. O exame sorológico para sífilis foi positivo (FTA-Abs e VDRL). A análise liquórica revelou FTA-Abs e teste de hemaglutinacão indireta positivos. Foi feito, então, diagnóstico de neurossífilis, e a paciente foi internada para antibioticoterapia endovenosa, e prednisona oral 40 mg/dia (0,5 mg/kg). Após 2 semanas, a paciente passou a apresentar melhora importante do quadro ocular com reabsorcão da exsudacão e melhora da acuidade visual. CONCLUSAO: A sífilis é doenca pleomórfica, podendo ter como manifestacão ocular uma uveíte difusa associada a descolamento de retina exsudativo bilateral. O envolvimento do sistema nervoso central deve sempre ser considerado e descartado, e o tratamento eficaz da doenca pode promover melhora da funcão visual e diminuir suas seqüelas.