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Rationale: Thyroid eye disease (TED) is the most common orbital disorder in adults and significantly affects patient health. Orbital decompression surgery is an important treatment option. Central retinal artery occlusion (CRAO) after orbital medial wall decompression is rare in patients with TED. Therefore, the earlier the identification and treatment, the more likely it is to reduce visual impairment., Patient Concerns: This paper examines a case of CRAO occurring postoperatively in a patient who underwent medial wall orbital decompression for TED., Diagnoses: Central retinal artery occlusion., Interventions: During the operation, the pupil was dilated, and eye massage and peribulbal injection of atropine were performed immediately. Fundus fluorescein angiography suggested the possibility of CRAO. Intravenous methylprednisolone 1000 mg, mannitol 50 g, ginkgo biloba extract 20 mL, nimodipine 20 mg tid, cobamamide 0.5 mg tid, and oral citicoline 0.2 g tid, along with periocular injection of atropine and hyperbaric oxygen therapy were also administered., Outcomes: Fifteen days after onset, the patient's retinal edema and retinal blood perfusion greatly improved. The patient's visual acuity recovered from counting fingers to 0.6., Lessons: Retinal vascular obstruction is a serious threat to vision; therefore, early detection and treatment are very important., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: To report a unique case of corneal ulcer perforation associated with a severe manifestation of Graves' ophthalmopathy that was treated with unilateral transnasal endoscopic orbital inner wall decompression combined with penetrating keratoplasty., Patient Concerns: A 66-year-old male with Graves' disease experiencing unilateral corneal ulcer perforation, a rarity in medical literature. He presented with a 9-month history of bilateral exophthalmos accompanied by decreased vision, and over the past month, he experienced loss of vision and painful swelling in the right eye (RE)., Diagnoses: After a series of examinations, he was diagnosed with Graves' ophthalmopathy., Interventions: Through local anti-infective treatment, the RE corneal ulcer showed no signs of infection. Once the patient's thyroid function and heart rate were stable and his overall condition was stable, he underwent RE unilateral transnasal endoscopic orbital inner wall decompression combined with penetrating keratoplasty under general anesthesia., Outcomes: The patient underwent successful unilateral transnasal endoscopic orbital inner wall decompression combined with penetrating keratoplasty, resulting in a significant 4 mm reduction in orbital proptosis and it improved the vision and saved the eyes., Lessons: Transnasal endoscopic orbital inner wall decompression combined with penetrating keratoplasty is an effective method for treating corneal ulcer perforation caused by Graves' ophthalmopathy. This method can not only greatly improve the appearance but also save the patient's eyeball and improve visual function., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Graves-Basedow's disease (GBD) is an autoimmune pathology that affects the thyroid and is characterized by the presence of goiter, hyperthyroidism, ophthalmopathy, and dermopathy. Graves-Basedow ophthalmopathy (GBO) is a set of inflammatory and infiltrative alterations of the orbital tissue that affects 40-90% of subjects suffering from GBD. Our study aims to investigate the differences in the clinical outcomes of patients treated with two different techniques: the classic open and the more modern endoscopic. A retrospective clinical study was carried out from the year 2011 until the year 2020 to evaluate the clinical outcomes of two different surgical techniques for the treatment of GBO. Eighteen patients were given surgical indications, 12 males and 6 females aged between 37 and 69 years (average age 48.5 years), for a total of 36 orbits. From the year 2011 to the year 2014, all patients were treated with the open orbital decompression technique; from 2015 onwards, patients were subjected to orbital decompression with the endoscopic transnasal approach. Pre- and postoperative ophthalmometry, reduction of proptosis, and reduction of oculo-orbital index were compared for the two techniques. As evidenced by the statistical analysis carried out on the sample before and after surgical treatment, there is a statistically significant difference between ophthalmometry and the Oculo-Orbital Index (IOO) values; this indicates that surgical orbital decompression with two walls (floor and medial wall) is effective in reducing exophthalmos. The positive result is also confirmed by the reduction of proptosis, measured in millimeters, averaging 1.7 mm. In the analysis of data relating to the two different patient groups, treated respectively with endoscopic orbital decompression (Technique 1) and classical open orbital decompression (Technique 2), the results obtained show that there is no statistically significant difference between the results of the two techniques. Therefore, the choice of surgical approach is at the discretion of the surgeon. It is our opinion that orbital decompression with the endoscopic transnasal technique should be an absolute indication in all patients who have clinical and radiographic signs of involvement of the optic nerve at the orbital apex (crowded apex syndrome) thanks to the ability of this technique to add and decompress the optical channel at the apex. For all other patients with GBO, the endoscopic technique of orbital decompression can be indicated as a first-line surgical approach considering the absence of skin scars and the best aesthetic results., Competing Interests: Declaration of competing interest Authors declare that there are no relevant conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: To compare outcome, complications and surgical time of blepharotomy versus levator recession with adjustable sutures (LRWAS) for correction of upper eyelid retraction in thyroid eye disease., Methods: In the period 2019-2023, we performed a prospective randomized comparative study between blepharotomy and LRWAS. We examined patients, recorded time consumption, and obtained photographs preoperatively, 1 day, 1 week, 3 months, and 6 months after surgery. Outcome was categorized according to Mourits and Sasim`s classification from 1999 (perfect-acceptable-unacceptable)., Results: A total of 30 patients (25 women) with a median (range) age of 51.5 (34-74) years at surgery were included. A significant different ( p < 0.01) median operation time was found between blepharotomy (41.5 (17-105) minutes) and LRWAS (68 (35-101) minutes). Median time from operation to last examination was 6 (6-18) months. Fifteen patients (24 eyelids) were operated with blepharotomy and 15 patients (25 eyelids) with LRWAS. Preoperative median margin reflex distance 1 was 6.5 (5-8) mm, and at final visit, median margin reflex distance 1 was 3.5 (3-4) mm after blepharotomy and 3.5 (2-5.5) mm after LRWAS. Reoperation was performed in 11 eyelids, 10 due to overcorrection and 1 because of a residual retraction. Significantly more eyelids needed reoperation after LRWAS (n = 9) compared with blepharotomy (n = 2). At final examination, a perfect or acceptable result was found in 14 (93%) patients after both procedures. Significantly shorter total duration of all visits was observed after treatment with blepharotomy (50 (35-70) minutes) compared with LRWAS (65 (40-115) minutes). Wound dehiscence occurred in 1 patient after blepharotomy, and 1 postoperative infection was observed after LRWAS., Conclusion: We demonstrate equally high success rates after blepharotomy and LRWAS for correcting upper eyelid retraction in thyroid eye disease, but blepharotomy is less time-consuming and implies fewer reoperations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Although urgent orbital decompression surgery for sight-threatening Graves' orbitopathy unresponsive to available medical treatments continues to evolve, post-operative new-onset or worsened pre-operative strabismus or diplopia remains a significant complication. At present, the optimal surgical technique remains debatable. Here, we sought to compare long-term outcomes after balanced medial-lateral wall versus selective 3-wall decompression as an urgent treatment for unresponsive sight-threatening GO., Methods: This retrospective study examined the post-operative outcome of 102 eyes (57 patients) that underwent urgent orbital decompression for sight-threatening GO. Treatment effectiveness was measured by visual acuity, proptosis, perimetry, and strabismus/diplopia, while fundus findings were detected by fundus color photography and optical coherence tomography and followed up for more than 12 months., Results: Fifty-seven patients (102 orbits) with an average age of 52.7 ± 10.2 years were evaluated. Balanced medial-lateral wall (BMLW-OD) or selective 3-wall decompression(S3W-OD) were performed in 54 and 48 eyes, respectively. Twelve months after orbital decompression, all parameters significantly improved in both groups, including best-corrected visual acuity (BCVA), mean defect of visual field (VF-MD), pattern standard deviation of visual field (VF-PSD), and proptosis (all P < 0.01). However, new-onset esotropia occurred in 25.8% and 3.8% of patients who underwent BMLW-OD surgery or S3W-OD, respectively. Moreover, 6.5% and 38.5% of patients improved after decompression in the medial-lateral wall decompression group and the selective 3-wall decompression group, respectively., Conclusions: We demonstrated that S3W-OD provides a lower rate of new-onset strabismus/diplopia as compared with BMLW-OD surgery, while still allowing for satisfactory visual outcomes., Trial Registration Number:  : NCT05627401. Date of registration: November 25, 2022., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Key Points: Utilization of orbital decompressions (ODS) increased (CAGR: +3.2%) from 2000 to 2019. FDA approved teprotumumab in January 2020; ODS utilization decreased (CAGR: -14.9%) from 2019 to 2022. In 2022, total spending was substantially higher for teprotumumab ($325 million) than surgery ($580,000)., (© 2024 ARS‐AAOA, LLC.)

Purpose: To compare inferomedial wall orbital decompression to balanced medial plus lateral wall orbital decompression in patients with Graves' orbitopathy in the inactive phase with regard to exophthalmos reduction and the effects on quality of life., Methods: Forty-two patients with inactive Graves' orbitopathy were randomly divided into two groups and submitted to one of two orbital decompression techniques: inferomedial wall orbital decompression or medial plus lateral wall orbital decompression. Preoperative and postoperative assessments included Hertel's exophthalmometry and a validated Graves' orbitopathy quality of life questionnaire. The results of the two groups were compared., Results: Compared to preoperative measurement, exophthalmos reduction was statistically significant in both groups (p<0.001) but more so in patients undergoing medial plus lateral wall orbital decompression (p=0.010). Neither orbital decompression techniques increased the visual functioning subscale score on the Graves' orbitopathy quality of life questionnaire (inferomedial wall orbital decompression p=0.362 and medial plus lateral wall orbital decompression p=0.727), but a statistically significant difference was observed in the score of the appearance subscale in patients submitted to medial plus lateral wall orbital decompression (p=0.006)., Conclusions: Inferomedial wall orbital decompression is a good alternative for patients who do not require large exophthalmos reduction. However, medial plus lateral wall orbital decompression offers greater exophthalmos reduction and greater improvement in appearance (higher Graves' orbitopathy quality of life questionnaire scores), making it a suitable option for esthetic-functional rehabilitation.

Graves'-associated upper eyelid retraction (GAUER) is the commonest manifestation of orbitopathy in adults. Surgical management typically follows a 3-step staged approach commencing with orbital decompression. The rationale behind this is that certain surgical interventions can influence the parameters and outcomes of subsequent procedures. We performed a systematic review and meta-analysis evaluating the effects of orbital decompression on GAUER in adult patients with Graves' orbitopathy. All original English, non-pediatric studies meeting the study inclusion criteria from the last 20 years were included. The characteristics of margin reflex distance 1 (MRD-1) pre- and post-orbital decompression of 688 orbits were collected, and a meta-analysis of 472 orbits was performed. The average reduction in MRD-1 across 688 orbits was found to be 0.40 mm. Meta-analysis of 6 applicable articles demonstrated that orbital decompression decreases MRD-1 by an average of 0.35 mm ( n  = 472, p  = .007, 95% CI = [0.08, 0.63]). This study demonstrates that although statistically significant, orbital decompression does not appear to have a clinically significant effect on GAUER . This has implications for clinical practice, namely the likely requirement of eyelid surgery following or in combination with orbital decompression, and the importance of counselling patients on this preoperatively.

Purpose: The superior orbital fissure contains cranial nerves III, IV, VI, and V1 with their three branches: frontal, lacrimal, and nasociliary. Superior orbital fissure syndrome (SOFS) is rare and can occur as a result of compression of these nerves due to trauma, bleeding, or inflammation in the retrobulbar space, but no cases of SOFS after deep lateral orbital wall decompression (DLOWD) have been reported. The aim of this paper is to describe this pathology, its possible causes, management, and outcome., Methods: Retrospective study of 575 DLOWD in patients with disfiguring exophthalmos due to Graves' ophthalmopathy performed in our hospital between 2010 and 2023. Three cases of postoperative SOFS were identified based on clinical presentation, history, physical examination, and radiological study. All patients were observed for a minimum of 12 months., Results: SOFS was diagnosed with the presence of ophthalmoplegia, ptosis, fixed and dilated pupils, hypo/anesthesia of the upper eyelid and forehead, loss of corneal reflex, and no loss of vision after DLOWD. Fractures, edema, and hemorrhages were excluded. They were treated with high-dose intravenous steroids and the patients recovered completely., Conclusions: DLOWD challenges orbital surgeons because it requires removing bones near the globe or neurovascular structures. SOFS may occur due to the proximity and increased pressure on these structures.

Background: Orbital decompression is commonly performed to correct proptosis in patients with Graves' orbitopathy (GO). In literature, the incidence of new-onset constant diplopia after orbital decompression varies. Few studies have evaluated changes in duction and cyclodeviation after orbital decompression. We evaluated the changes in duction, cyclodeviation, eye position and degree of diplopia after orbital decompression., Methods: We retrospectively analysed data from patients who underwent orbital decompression at our hospital between January 2016 and July 2020. Data regarding the type of decompression, eye position, duction, cyclodeviation and level of diplopia according to the Gorman score were recorded., Results: Data from 281 eyes/orbits of 156 patients were analysed. Proptosis decreased from 23.8±2.5 to 20.9±2.5 mm. Horizontal and vertical duction range decreased (horizontal d=0.40 and vertical 0.30; p=0.000) after surgery; however, the change was not clinically significant (≤5°). Horizontal deviation changed towards esodeviation (d=-0.45; p=0.000), whereas vertical deviation remained stable (d=0.15; p=0.161). Preoperative cyclotorsion in the primary and downgaze positions changed towards incyclodeviation (primary: d=0.30, p=0.021; downgaze d=0.30, p=0.039). Diplopia improved in 22% (18 patients), whereas new-onset constant diplopia developed in 11% (12 patients). Elevation has an excellent predictive value of causing new-onset constant diplopia when measured preoperatively as <19°, sensitivity 88.0%, specificity 41.7% (area under the curve 0.812 (95% CI 0.660 to 0.963); p=0.000)., Conclusion: After orbital decompression, incidence of new-onset constant diplopia was 11% and 22% of the patients had partial or complete improvement of their diplopia. The changes in duction, cyclodeviation and horizontal deviation showed a statistical but not clinical difference. Patients with GO and a preoperatively restricted elevation of <19° are at risk of developing new-onset constant diplopia. In addition, preoperative incyclodeviation may worsen after decompression surgery., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

This study aims to investigate the changes in ocular biomechanical factors in patients with inactive thyroid eye disease (TED) who undergo orbital decompression surgery. This observational prospective study include 46 eyes of 31 patients with inactive TED undergoing orbital decompression at a tertiary university hospital from October 2021 to September 2023. All participants underwent a full ophthalmic examination, and a biomechanical examination was performed using corvis ST at baseline, 1 month, and 3 months postoperatively. The study participants had a mean age of 45 ± 11.6 years, and 58.1% of them were female. The second applanation time (A2T) increased from baseline to postoperative month 1 and continued to increase to postoperative month 3 (P < 0.001). The first applanation velocity (A1V), highest concavity (HC) peak distance, and pachymetry parameters also increased from postoperative month 1 to postoperative month 3 (P = 0.035, P = 0.005, and P = 0.031, respectively). The HC time increased from baseline to postoperative month 3 (P = 0.027). Other changes were statistically insignificant. The P-values were adjusted according to biomechanically corrected intraocular pressure (bIOP). Baseline Hertel significantly influenced A2 time (P < 0.001). Our findings suggest that ocular biomechanical parameters may change following decompression surgery in patients with inactive TED. Specifically, an increase in A2T, A1V, and HC peak distance suggests a decrease in corneal stiffness, although the increased HC time contradicts this. It is recommended to postpone keratorefractive or intraocular lens implantation surgeries until corneal biomechanics stabilize after decompression surgery for optimal results., (© 2024. The Author(s).)

Purpose: Thyroid eye disease (TED) is characterized by a variety of disfiguring periocular changes. Vertical globe changes affecting the relative position of the eyelids are not well understood in patients with TED. This study seeks to determine the effect of orbital decompression on vertical globe displacement in patients with TED, without TED, and with intraconal tumor (ICT)., Methods: For this cross-sectional study, a clinical database was used to identify patients with TED. Comparison groups were drawn from separate anonymized databases. Vertical position and interpupillary distance (IPD) were measured from photographs and exophthalmos was measured via Hertel's exophthalmometer. Primary outcomes were vertical globe position at baseline and postoperatively in patients with TED and ICT. Secondary outcomes included the relationship between vertical globe position, exophthalmos, and IPD., Results: Among 269 participants meeting the inclusion criteria, mean vertical globe position was significantly lower in patients with TED following lateral decompression surgery compared to controls, after accounting for race, age, and sex. While patients with ICT had a significant difference in preoperative and postoperative IPD, patients with TED did not. Medial or inferior decompression did not significantly change globe position and lateral decompression did not cause lateral canthal dystopia in patients with TED. No association between postoperative changes in exophthalmometry, IPD, and globe position was found in patients with TED., Conclusions: Patients with TED experience hypoglobus that does not improve following decompression surgery. There was no correlation between change in vertical globe position and exophthalmos or IPD among patients with TED. Surgeons should discuss the possibility of hypoglobus as a persistent finding for patients with TED undergoing decompression surgery., Competing Interests: D.B.R. is a consultant for Horizon Therapeutics. The remaining authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

This study aimed to investigate the effect of orbital wall decompression surgery and reduction of proptosis on the choroidal vascularity index (CVI) and subfoveal choroidal thickness (SFCT) in patients with thyroid eye disease (TED). Fifty-one eyes from 38 patients with controlled TED and proptosis were enrolled in this study. The majority of the patients (50.9%) had a clinical activity score (CAS) of zero, and none had a CAS greater than 2. The patients underwent a complete baseline ophthalmologic examination, and their choroidal profile alterations were monitored using enhanced depth imaging optical coherence tomography (EDI-OCT) before and during the three months after surgery. Changes in SFCT, luminance area (LA), total choroidal area (TCA), and the choroidal vascularity index (CVI) were measured as the ratio of LA to TCA in EDI-OCT images. The participants had an average age of 46.47 years, and 22 were female (57.9%). The SFCT of the patients exhibited a significant reduction over the follow-up period, decreasing from 388 ± 103 to 355 ± 95 µm in the first month (p < 0.001) and further decreasing to 342 ± 109 µm by the third month compared to baseline (p < 0.001). The CVI exhibited a drop from 0.685 ± 0.037 at baseline to 0.682 ± 0.035 and 0.675 ± 0.030 at 1 and 3 months post-surgery, respectively. However, these changes were not statistically significant, indicating comparable decreases in both LA and TCA. There was a significant correlation between improved proptosis and reduction in SFCT (p < 0.001) but not with CVI (p = 0.171). In conclusion, during the three months of follow-up following orbital wall decompression, CVI did not change, while SFCT reduced significantly. Additionally, SFCT was significantly correlated with proptosis reduction, whereas CVI was not., (© 2024. The Author(s).)

Purpose: Strabismus reoperation in Graves' ophthalmopathy (GO) is complicated and challenging. The purpose of this study was to evaluate the various surgical strategies of strabismus reoperation and their outcomes in patients with GO., Methods: A retrospective study was conducted on strabismus reoperations performed at the Zhongshan Ophthalmic Center of Sun Yat-sen University, Guangzhou, China from 2008 to 2018. Data collected included sex, age at surgery, duration of deviation, ocular alignment, ocular motility, various surgical procedures performed and surgical outcomes. Surgical methods included rectus recession for newly developed strabismus, rectus resection for undercorrection and anterior advancement of a previously recessed rectus for overcorrection. Surgical success was defined as an absence of diplopia, a horizontal deviation of ≤ 10 prism diopters (PD) and a vertical deviation of ≤ 5 PD at distance in primary and reading positions., Results: Of the 153 GO patients receiving strabismus surgery, 27 cases (20 males, 7 females) underwent reoperation for strabismus, with a reoperation rate of 17.6%. Success rates of reoperation in patients with a previous undercorrection and overcorrection were 45% and 71.4%, respectively. Success rates of rectus recession, rectus resection and anterior advancement were 47.1%, 66.7% and 50%, respectively. Two patients underwent the third surgery. The overall success rate was 51.9%., Conclusions: Rectus recession is an effective method for GO patients with newly-developed strabismus. Rectus resection may benefit some patients with undercorrection who underwent a maximal degree of rectus recession. Anterior advancement of a previously recessed rectus is effective for cases with overcorrection., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Thyroid eye disease (TED) is a common ophthalmologic manifestation of thyroid dysfunction. Despite various imaging techniques available, there hasn't been a widely adopted method for assessing the anterior segment vasculature in TED patients. Our study aimed to evaluate alterations in ocular surface circulation following orbital decompression surgery in TED patients and investigate factors influencing these changes. Using anterior segment optical coherence tomography-angiography (AS-OCTA), we measured ocular surface vascularity features, including vessel density (VD), vessel diameter index (VDI), and vessel length density (VLD), both before and after decompression surgery, alongside standard ophthalmic examinations. Our AS-OCTA analysis revealed a significant decrease in most of the temporal vasculature measurements six weeks post-surgery (p < 0.05). However, differences in the nasal region were not statistically significant. These findings indicate notable changes in ocular surface circulation following orbital decompression in TED patients, which may have implications for intraocular pressure (IOP) control and ocular surface symptoms management. AS-OCTA holds promise as a tool for evaluating the effectiveness of decompression surgery and assessing the need for further interventions., (© 2024. The Author(s).)

Purpose: Dysthyroid optic neuropathy (DON) leads to vision loss. This study aimed to investigate a new method that can directly evaluate the change in muscle cone inner volume (MCIV) and distinguish DON orbits from non-DONs., Materials and Methods: This study included 54 patients (108 orbits) who were diagnosed with thyroid eye disease and treated at the Beijing Tongren Hospital between December 2019 and September 2021. The extraocular muscle volume (EOMV), orbital fat volume (OFV), and bony orbit volume (BOV) of the patients were measured using three-dimensional reconstruction. MCIV was measured using artificially defined boundaries. The associations between these volumes and clinical indicators were studied, and the diagnostic efficacy of these volumes for DON was described using receiver operating characteristic (ROC) curves., Results: The ROC curve showed that the area under the curve of MCIV/BOV (%) combined with EOMV/BOV (%) reached 0.862 (p < 0.001), with a sensitivity of 85.7% and a specificity of 76.1%., Conclusion: The combination of MCIV/BOV (%) and EOMV/BOV (%) is a good indicator for the diagnosis of DON, which aids in the early detection and intervention of DON., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To investigate the results of patients undergoing surgical treatment for strabismic diplopia in thyroid eye disease (TED) following teprotumumab., Design: Multicenter, retrospective, case series., Methods: We report 28 patients who underwent extraocular muscle surgery for strabismic diplopia after treatment with teprotumumab at 7 different academic centers. Elapsed time from last teprotumumab dose to the date of surgery, previous orbital decompression, primary preoperative horizontal and vertical deviation, surgical procedure, and 2-month postoperative results were collected from the patient records., Results: Sixteen (57%) patients were diplopia-free after 1 surgery. Three (11%) chose prism spectacles to correct residual diplopia, 2 (7%) used compensatory head posture to resolve diplopia, and 1 (4%) had intermittent diplopia and was functionally improved (choosing no prisms or further surgery). These were considered treatment successes. Three (11%) patients required reoperation, and all were diplopia-free after their second procedure., Conclusions: Most patients requiring surgery for strabismic diplopia following teprotumumab achieve good outcomes with success rates comparable to series published before the availability of teprotumumab., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence., Methods: Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects., Results: One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up ( p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone., Conclusions: Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone., Competing Interests: D.B.R. is a consultant for Horizon Therapeutics. The other authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Incomitant hypotropia in thyroid eye disease can be difficult to manage, especially in the presence of orthotropia with fusion in down gaze and reading position. Recessing the affected ipsilateral inferior rectus muscle may result in an undesirable downgaze diplopia secondary to a hypertropia in downgaze. Various surgical techniques have been described to manage this potential complication including asymmetric recession of both inferior rectus muscles, posterior myoscleropexy operation, and the Scott recess/resect procedure of the contralateral inferior rectus. In 2004, Hoerantner et al. introduced the y-split recession of the medial rectus muscle for near esotropic deviations. The anterior portion of muscle is split and secured in a y-shaped configuration, which reduces the muscle lever arm and helps minimize incomitance and muscle slippage. Unlike the traditional Cüppers Faden, a y-split recession results in torque reduction in all gaze positions. In addition, a y-split recession does not involve scleral passes posteriorly reducing the risk of globe perforation. We report a patient with incomitant strabismus secondary to thyroid eye disease who underwent a combination of traditional recession and y-splitting recession of the contralateral inferior rectus muscle, resulting in good functional alignment in primary gaze and in the reading position.

Backgrounds: To report the long-term surgical outcomes and the impact on daily life activities of strabismus surgery in patients with Thyroid Associated Orbitopathy (TAO) with and without previous orbital decompression., Methods: Patients who underwent strabismus surgery for TAO were retrospectively reviewed. The primary outcome was to evaluate the influence of orbital decompression on the outcomes of TAO related strabismus surgery. Surgical success was defined by the resolution of diplopia and a post-operative deviation < 10 prism diopters (PD). The secondary outcomes were the clinical features, surgical approaches, and impact on daily life activities., Results: A total of 45 patients were included in the study. The decompression surgery group (DS) included 21 patients (46.7%), whereas the non-decompression surgery group (NDS) patients were 24 (53.3%). The mean follow-up time from the last strabismus surgery was 2,8 years (range 8-200 months). Successful surgical outcome was achieved in 57,1% of patients in the DS, and 75% of patients in the NDS (p = 0,226). DS patients required almost twice the number of surgical interventions for strabismus compared to the NDS (1,95 vs. 1,16 respectively, p = 0,006), a higher number of extraocular muscles recessed in the first surgery (2,67 vs. 1,08 respectively, p < 0.001), and a lower rate of unidirectional surgery compared to NDS (23% vs. 95%, p < 0,001). At the pre-operative assessment, 71.4% of DS patients had eso-hypotropia, while no patients had this type of strabismus in the NDS group (p < 0.001). On the other hand, the hypotropia rate was 79.2% in NDS patients and only 4.8% in DS patients (p < 0.001). Moreover, 21,8% of NDS patients used prism lenses in daily life activities, compared to 42.9% of patients that used prism lenses to reduce the impairment in their daily life activities (p = 0.016)., Conclusions: The results of our study showed that DS patients required almost twice the number of strabismus surgical procedures, a higher number of extraocular muscles recessed in the first surgery, and an increased need for prism lenses to correct the residual deviation compared to the NDS, but with similar long-term surgical outcomes., (© 2024. The Author(s).)

Purpose: To explore if orbital fat-to-muscle ratio (FMR) is predictive of whether surgical decompression or teprotumumab leads to greater proptosis reduction in thyroid eye disease (TED)., Methods: A single-center retrospective cohort study comparing surgical decompression with teprotumumab according to FMR. All TED patients completing an 8-dose course of teprotumumab between January 2020 and September 2022 and all patients undergoing bony orbital decompression from January 2017 to December 2019 were included. Subjects were excluded if they were <18 years, received both surgical decompression and teprotumumab, or lacked orbital imaging. The primary exposure variable was teprotumumab or surgical decompression. The secondary exposure variable was baseline FMR. The primary outcome measure was change in proptosis (mm)., Results: Thirty-eight patients, mean age 53.5 years (±11.4), were included in the teprotumumab group and 160 patients, mean age 48 years (±11.1), in the surgical group. Average proptosis reduction after teprotumumab and surgical decompression was 3 mm (±1.44) and 5 mm (±1.75), respectively. The FMR was stratified at the median of 1.80. In subjects with FMR < 1.80, teprotumumab showed equivalent proptosis reduction compared to surgical decompression, -0.33 mm (SE 1.32) p  = .802. In subjects with FMR ≥ 1.80, surgical decompression led to significantly more proptosis reduction than teprotumumab, 3.01 mm (SE 0.54), p  < .001., Conclusions: Baseline FMR can be used to counsel patients as to proptosis reduction with teprotumumab versus surgery. Subjects with low FMR obtain comparable proptosis reduction with teprotumumab or surgery, whereas high FMR is associated with more significant proptosis reduction following surgery over teprotumumab.

This study aimed to assess the feasibility of utilizing a surgical guide, designed through digital medical technology, in lateral orbital decompression surgery. METHODS: In total, 18 patients with thyroid-associated ophthalmopathy (TAO), who underwent orbital balance decompression surgery at the Affiliated Eye Hospital of Nanchang University between September 2018 and August 2022, were included. Orbital CT scanning was performed on all patients with TAO, and Mimics 21.0 software was used to reconstruct a three-dimensional model of the orbit based on the CT data. The osteotomy guide plate for lateral orbital decompression surgery was designed using 3-matic 13.0 software, adhering to the criteria of surgical effectiveness and safety. The surgical positioning guide was designed using Geomagic Wrap 21.0. Once printed, the surgical guide was sterilized with low-temperature plasma and applied during surgery. Of the nine patients treated using a surgical navigation system, three cases experienced cerebrospinal fluid leakage complications during the procedure, and two exhibited inadequate bone removal along the lateral wall. In contrast, among the nine patients treated with surgical guides, no intraoperative cerebrospinal fluid leakage or evidence of insufficient lateral wall bone removal was observed, highlighting a statistically significant distinction between the two cohorts (p = 0.046). Postoperative improvements were notable in best-corrected visual acuity (BCVA) and exophthalmos for patients afflicted with extremely severe TAO. The surgical guide, designed with digital medical technology, has been shown to be an effective and secure auxiliary tool in lateral orbital decompression surgery. It not only aids in reducing the incidence of intraoperative complications, but also enhances the accuracy and safety of surgery. These improvements offer robust support for continued exploration in this field within clinical practice., Competing Interests: Declaration of competing interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To assess the association of optic nerve sheath (ONS) infiltration, fat infiltration, and scleral enhancement with active thyroid eye disease (TED) and dysthyroid optic neuropathy (DON)., Methods: Thyroid eye disease patients who had axial and coronal fat-suppressed contrast enhanced T1-weighted magnetic resonance imaging (MRI) imaging performed were included. Optic nerve sheath infiltration was defined by the presence of thickening and circumferential enhancement of the optic nerve sheath. Clinical assessments were performed by orbital surgeons or neuro-ophthalmologists and the disease activity (active/inactive) and presence or absence of dysthyroid optic neuropathy were recorded., Results: The study population consisted of 76 orbits from 38 patients with a mean age of 53 ± 15 years, with 25 (66%) being female. Optic nerve sheath infiltration was present in 28 (37%) orbits, fat infiltration in 37 (49%) and scleral enhancement in 14 (18%) orbits. ONS infiltration (OR 19.8, p < 0.01), fat infiltration (OR 5.2, p < 0.01) and scleral enhancement (OR 12.2, p = 0.01) were all significantly associated with active clinical disease. Patients with ONS infiltration had a significantly higher odds of dysthyroid optic neuropathy (OR 3.4, p < 0.05). Fat infiltration (OR 2.8, p = 0.1) and scleral enhancement (OR 2.3, p = 0.23) were not significantly associated with DON., Conclusions: Optic nerve sheath infiltration may be a predictor of dysthyroid optic neuropathy. Intraorbital fat infiltration and scleral enhancement may be used to detect active TED. These radiological findings may serve as useful diagnostic and stratification tools in evaluating TED patients., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background: To retrospectively review lateral wall orbital decompression for thyroid eye disease (TED) and to evaluate pre-operative CT scans to analyse the variation in proptosis reduction., Methods: Consecutive lateral wall orbital decompressions performed by a single surgeon were retrospectively reviewed. Pre-operative CT scan features and post-operative proptosis reduction were analysed. The sphenoid trigone cross-sectional areas were summed and multiplied by the slice thickness to yield bone volume. Cumulative extraocular muscle thickness was calculated by combining the maximum thickness of the four recti. "Trigone volume" and "cumulative muscle thickness" were correlated with proptosis reduction at 3 months post-surgery., Results: Out of 73 consecutive lateral wall orbital decompressions, 17 orbits had prior endonasal medial wall orbital decompression. In the remaining 56 orbits, the mean pre-operative and post-operative proptosis were 24.3 ± 1.6 mm and 20.9 ± 2.3 mm respectively. The proptosis reduction ranged from 1 to 7 mm (mean of 3.5 mm ± 1.3 (p < 0.001)). Mean sphenoid trigone volume was 895 ± 434.4 mm 3 . The mean cumulative muscle thickness was 20.4 ± 5 mm. The correlation coefficient between muscle thickness and proptosis reduction was - 0.3 and was statistically significant (p = 0.043). The correlation coefficient between sphenoidal trigone volume and proptosis reduction was 0.2 (p = 0.068). With a multivariate analysis, the coefficient of efficient of regression for muscle thickness was - 0.007 (p = 0.42) and the coefficient of regression for trigone volume was 0.0 (p = 0.046)., Conclusion: Proptosis reduction following lateral wall orbital decompression can be variable. Extraocular muscle thickness had a significant correlation with the outcome, with greater proptosis reduction in orbits with thin muscles. The sphenoidal trigone size had a weak correlation with decompression outcome., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The main treatment for the symptoms of proptosis and optic nerve compression caused by thyroid-associated ophthalmopathy is orbital decompression surgery. Medial inferior wall decompression and balanced decompression are two frequently used surgical procedures. However, there is no unified consensus on how to choose different surgical options for orbital decompression in clinical practice., Aims: To compare the effects of medial inferior wall decompression and balanced decompression surgery through meta-analysis and to provide reference for clinical optimal decision making., Methods: Databases, including PubMed, Web of Science, Ovid, Cochrane Library, and ClinicalTrials.gov, were searched for randomized controlled trials and cohort studies on decompression surgery for thyroid-associated ophthalmopathy published from inception to March 21, 2023. Using RevMan 5.3 software, a meta-analysis was conducted based on the following outcome indicators: proptosis, diplopia rate, intraocular pressure, visual acuity, and complication rate., Results: Two randomized controlled trials and five cohort studies with a total of 377 patients were included in this analysis. After balanced decompression surgery, patients with thyroid-associated ophthalmopathy experienced a significant decrease in proptosis [MD = 4.92, 95% CI (4.26, 5.58), P < 0.0001]. Balanced decompression can improve postoperative visual acuity [MD = - 0.35, 95% CI (- 0.56, - 0.13), P = 0.001] and intraocular pressure [MD = 5.33, 95% CI (3.34, 7.32), P < 0.0001]. The rates of proptosis [MD = 0.33, 95% CI (- 1.80, 2.46), P = 0.76] and diplopia [OR = 1.20, 95% CI (0.38, 3.76), P = 0.76] did not differ between patients who underwent medial inferior wall decompression and those who underwent balanced decompression., Conclusion: Balanced decompression and medial inferior wall decompression are both effective options for surgical treatment of thyroid-associated ophthalmopathy in clinical practice., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: This study aims to evaluate the long-term outcomes of inferomedial orbital wall decompression (IMOD) in Graves' ophthalmopathy (GO)., Methods: A retrospective review of 422 eyes of 226 patients with GO-related cosmetically disfiguring proptosis (COS), dysthyroid optic neuropathy (DON), or exposure keratopathy (EXP) who received IMOD from 1989 to 2020 was conducted. Hertel value (HE) and corrected visual acuity (CVA) were evaluated at baseline and regularly thereafter. Proptosis recurrence, diplopia, and adjuvant surgeries were assessed. Complete success was defined as proptosis reduction over 2 mm without recurrence and improved diplopia. Partial success was defined as proptosis reduction without recurrence but with persistent or new-onset diplopia, and failure as proptosis recurrence., Results: After follow-up for 40.1 ± 39.6 months (range, 6-239 months), 236 eyes (55.9%) achieved complete success, 175 eyes (41.5%) achieved partial success, and 11 eyes (2.6%) had failure. Significant CVA improvement was observed in both DON and COS groups (P < 0.001 and P = 0.045, respectively). Average proptosis reduction was 5.2 ± 2.2 mm, with a significant increase of 0.5 mm after long-term follow-up (P < 0.001). Incidence of proptosis recurrence was 2.6%. Surgical success rate of COS group was positively correlated with preoperative HE., Conclusion: IMOD demonstrated excellent success rate in all three subgroups with a low proptosis recurrence rate and improved visual outcome in both DON and COS groups. Delayed proptosis reduction effect of IMOD may result in delayed-onset asymmetry, especially in the unilateral group., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Objective: There is currently no recommendation on the optimal surgical management for dysthyroid optic neuropathy (DON). The aim of this study is to systematically review the surgical management of DON and its outcome on visual acuity (VA)., Data Sources: MEDLINE, Cochrane Library, and clinicaltrials.gov REVIEW METHODS: A systematic review of studies about the surgical management of DON was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles were included if preoperative and postoperative VA in logMAR (Logarithm of the Minimum Angle of Resolution) were available., Results: Fifteen articles were included in the study accounting for 669 orbits. The mean VA improvement was of 0.44 logMAR overall, 0.41 logMAR for 1-wall, 0.41 logMAR for 2-wall, and 0.55 logMAR for 3-wall decompressions. The mean reduction in exophthalmos was 4.9 mm overall, 4.3 mm for 1-wall, 4.54 mm for 2-wall, and 6.02 for 3-wall decompressions. The mean new onset diplopia (NOD) rate was 19.84% overall, 19,12% for 1-wall, 20.75% for 2-wall, and 19.83% for 3-wall decompressions., Conclusion: The results are limited due to the high number of biases in the included studies. It seems that 3-wall decompression offers the best VA improvement and proptosis reduction although also the highest NOD and complications rate. Two-wall balanced decompression or 1-wall inferomedial decompression seems to be effective with less morbidity., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: To report outcomes of strabismus surgery in thyroid eye disease using intraoperative bow-knot adjustable sutures under topical anaesthesia and calculate prediction models for surgical correction and postoperative drift depending on surgical dose-response., Methods: We retrospectively reviewed patients operated on from 2016 to 2021. A satisfactory outcome was defined as no diplopia with maintenance of vertical (<5 PD) and horizontal (<10 PD) stable alignment at primary gaze. Subjective diplopia corrected with prisms within successful motor alignment was defined as a fair result. Otherwise, the result was considered to be poor., Results: A total of 73 patients were included (60 females, 82%). Mean preoperative horizontal and vertical deviations were 26.9 PD (19.1 SD), and 11.8 PD (7.6 SD), respectively. Mean horizontal drift was -3.2 PD (5.2 SD), whereas mean vertical drift was -3.4 PD (3.3 SD). A linear regression established a dose-response of 2.37 PD/mm for each medial rectus recession (p < 0.0001; r 2  = 0.777) and 3.75 PD/mm for unilateral inferior rectus recession (p < 0.0001; r 2  = 0.922). Final success rate was satisfactory in 62 patients (85%), fair in 7 patients (10%), and poor in 4 patients (5%)., Conclusions: Muscle recession with intraoperative adjustable sutures is effective for the treatment of thyroid eye disease strabismus. Predictable dose-responses could be achieved with a drift toward overcorrection. Undercorrection proportional to the planned surgical dose should be the immediate postoperative target of choice. Other variables such as orbital decompression and concurrent vertical and horizontal surgery do not correlate with dose-response and postoperative drift. However, further studies are necessary to validate our findings., (Copyright © 2022 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Rehabilitative orbital decompression treats disfiguring exophthalmos in patients with Graves' orbitopathy (GO). This study aimed to identify risk factors associated with the postoperative recurrence of proptosis after orbital decompression., Design: Retrospective, case-control study., Methods: This retrospective review included patients with GO who underwent rehabilitative orbital decompression for disfiguring proptosis in an inactive state with a low clinical activity score (0-2) between January 2017 and December 2020 by a single surgeon. Exophthalmos was measured using a Hertel exophthalmometer, and recurrence was defined as an increase of 2 mm or more after decompression during the follow-up period. The association between preoperative variables and proptosis recurrence was analyzed using multivariable logistic regression., Results: Of the total 217 patients, 11 (5.1%) developed recurrence of proptosis during the follow-up period (range, 3-30; mean, 15.6 months). Univariate logistic regression analysis identified thyroid-stimulating hormone receptor antibody (TRAb) and thyroid-stimulating immunoglobulin (TSI) as significant factors for recurrence, with age, sex, smoking, disease duration, orbital radiotherapy, and total thyroidectomy history being nonsignificant. TRAb remained significant in a multivariate logistic regression analysis (odds ratio, 1.06; P = .014). Receiver operating characteristic curve analysis revealed an area under the curve of 0.86 with a sensitivity of 90.9% and specificity of 82.0% at a TRAb level of 7.96 IU/L., Conclusion: Preoperative TRAb and TSI are valuable markers to predict proptosis recurrence after orbital decompression. These results may help surgeons to decide the optimal timing for orbital decompression to lessen the risk of postoperative recurrence of proptosis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This article summarizes the results of research on the morphological and functional features of different types of orbital bone decompression in thyroid eye disease (TED) and presents an analysis of surgical anatomy of the lateral orbital wall in the context of performing deep lateral bone decompression of the orbit was carried out. The study includes an analysis of the results of orbital bone decompression with resection of the greater wing of the sphenoid bone using ultrasound osteodestructor in comparison with osteodestruction using a high-speed drill, description of transethmoidal orbital decompression with endonasal access both as a single method of surgical treatment of TED and in combination with lateral bone decompression of the orbit, including the advantages and disadvantages of the method, and presents a morphological description of the pathological changes in the medial orbital wall bone fragments obtained during endonasal transethmoidal orbital decompression in patients with TED.

Introduction: The aim of the study was to standardize the endoscopic deep medial orbital decompression surgery for better relief of optic nerve compression in dysthyroid optic neuropathy (DON)., Methods: A total of 128 eyes from patients received the standardized endoscopic deep medial orbital decompression surgery were recruited in this study. The efficacy of the procedure was assessed at a 1-month follow-up by the best-corrected visual acuity (VA), visual field (VF), and visual evoked potential (VEP). Clinical data were collected to explore the factors that affected visual recovery. Oxygen saturation of retinal blood vessels, retinal thickness, and vessel density were measured to demonstrate the potential recovery mechanisms., Results: After surgery, the ratio of extraocular muscle volume in the orbital apex to orbital apex volume significantly decreased from 44.32 ± 22.31% to 36.82 ± 12.02% (p &lt; 0.001). 96.87% of eyes' final VA improved; average VA improved from 0.93 ± 0.73 to 0.50 ± 0.60 at 1 week (p &lt; 0.001) and 0.40 ± 0.53 at 1 month (p &lt; 0.001). Postoperatively, VF and VEP also improved, the oxygen saturation of retinal arteries increased, and the retinal thickness was reduced. Preoperative VA, visual impairment duration, and clinical activity score evaluation were associated with visual recovery., Conclusion: In this study, we standardized the endoscopic deep medial orbital decompression, of which key point was to relieve pressure in the orbital apex and achieved satisfactory visual recovery in DON patients., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Purpose: To evaluate the effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy., Methods: This retrospective study enrolled 55 eyes of 33 patients treated in our hospital for restrictive strabismus caused by thyroid-associated ophthalmopathy. We performed muscle recession for the obviously restricted extraocular muscles, with 6 weeks of follow-up. Surgical outcomes were compared between the orbital decompression group (DG, n=15) and non-orbital decompression group (NDG, n=18)., Results: A total of 33 patients with Graves' ophthalmopathy who underwent rectus muscle recession surgery were included. Of these, 15 patients had undergone orbital decompression prior to strabismus surgery, and 18 had not. The two groups did not differ in terms of the preoperative horizontal or vertical ocular deviation, degree of restriction of eye movement, degree of diplopia, or mean number of muscles that underwent surgery (P>0.05). There was no significant difference in the preoperative horizontal or vertical ocular deviation, level of eye movement restriction, degree of diplopia and the success rate of the surgery (P>0.05)., Conclusion: Rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy during the quiescent period could improve the ocular deviation and diplopia, and orbital decompression performed before strabismus surgery had no significant effect on surgical technique or outcomes of rectus muscle recession surgery., (Copyright © 2023. Published by Elsevier Masson SAS.)

Purpose: To evaluate and compare the changes in orbital soft tissue volume and visual function after endoscopic transnasal medial orbital decompression in patients with active and inactive dysthyroid optic neuropathy (DON)., Methods: This prospective, cohort study recruited 112 patients (112 eyes) with DON who were divided into an active and inactive DON group (56 eyes each) by clinical activity scores. All patients underwent endoscopic transnasal medial orbital decompression. The pre- and post-operative orbital soft tissue volumes were measured with high-resolution computed tomography (CT) using Mimics software. Visual function, including best-corrected visual acuity (BCVA), visual field (VF), and visual evoked potential (VEP), was recorded before and after surgery., Results: Preoperatively, compared with the inactive DON group, the active DON group had greater extraocular muscle volume (EMV) and EMV/orbital volume (OV) ratio, but worse BCVA, VF, and exophthalmos. Postoperatively, although the EMV slightly increased, with the enlarged medial rectus muscle contributing dramatically, the EMV/OV ratio decreased in patients with DON. Besides, visual function including BCVA, VF, VEP and exophthalmos was also improved in both groups after surgery. There were no significant differences in postoperative OV; EMV; EMV/OV ratio; and the BCVA, VF, and VEP parameters between both groups (all P > 0.05)., Conclusion: Patients with DON who did not respond well to steroids, regardless of disease activity, may benefit from orbital decompression via the decrease in the proportion of EMV in OV, especially patients with active DON, who showed more improved visual function than patients with inactive DON., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The intraoperative relaxed muscle positioning (IRMP) technique for strabismus surgery in thyroid eye disease (TED) involves recessing muscles' insertions to positions where they rest without tension. We evaluate the long-term outcomes of patients who underwent surgery using this technique., Methods: The medical records of patients with TED and diplopia who underwent strabismus surgery with IRMP between 1999 and 2021 were reviewed retrospectively. Excellent outcomes were defined as no diplopia in primary and reading gazes without the use of prisms; good outcomes, as residual deviation of <10 Δ with diplopia in primary and reading gazes. Good or excellent outcomes were considered successes. Poor outcomes were defined as residual deviation >10 Δ with diplopia in primary and reading gazes or the inability of patients to tolerate prismatic correction., Results: A total of 129 patients were followed for an average of 4.24 ± 5.13 years (longest follow-up 20 years): 96 (73.6%) underwent a single surgery, and 33 (26.4%) underwent additional interventions. Seven of these had been planned as staged procedures, and all were successful. Five patients experienced disease reactivation and underwent additional surgery, with successful outcomes in 4 (80%). Of the remaining 21 patients, 6 underwent a third procedure, and a single patient underwent a fourth. Overall, 93.6% of patients had a successful outcome: 77.5% excellent and 16.3% good., Conclusions: In our study cohort, the IRMP approach resulted in durable relief from large-angle strabismus and diplopia in a large majority of patients., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To review and summarize a comprehensive synopsis of surgery of the eyelid in thyroid eye disease (TED)., Methods: A PubMed search for specific eyelid manifestations of TED was performed. Studies reporting surgical management of these were reviewed, along with the author's own experience., Results: The most common eyelid manifestations of TED include eyelid retraction, blepharoptosis, entropion, and epiblepharon, with most of them requiring surgical intervention. The correction of eyelid retraction has received maximum attention, with several surgical techniques that have stood the test of time. Blepharoptosis in TED that requires surgical intervention is usually aponeurotic. Entropion and Epiblepharon are rare in TED, and may resolve spontaneously, or following orbital decompression., Conclusions: Retraction is the commonest eyelid manifestation of TED, with multiple surgical options available for its correction. Blepharoptosis, entropion, and epiblepharon are rare eyelid findings in TED, that may occasionally require surgical correction., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To evaluate the optical coherence tomography angiogram changes in non-active severe thyroid-related ophthalmopathy patients after cosmetic bone decompression., Methods: Eighteen patients (25 eyes) with severe not active not compressive (NANC) TED who were candidates for decompression surgery for cosmetic reasons were included in this study, and a 3 × 3 mm macular scan was used to measure vessel density and RNFL thickness. Whole macular vessel density in its superficial, deep and choriocapillaris layers was evaluated. The following data were extracted for each of layers: superior and inferior hemispheres, fovea, parafoveal vessel density, its superior and inferior hemispheres, and temporal, superior, nasal and inferior quadrant., Results: The mean RPC increased postoperatively, which was statistically significant in small vessels of peripapillary area (p-value = 0.045). The mean RNFL thickness decreased after surgery and it was statistically significant in the peripapillary (p-value = 0.032) and Inferior-Hemifield area (p-value = 0.036). The choriocapillaris changes were significant in Superior-Hemifield (p-value = 0.031) and Fovea (p-value = 0.03)., Conclusion: Thyroid-associated orbitopathy patients have a tendency to decrease vascular density and correlated with disease activity more than stage of orbitopathy. There was not a strong and even discrepant result in linkage of RNFL thickness and other optic nerve function tests and TED patient status and it is needed to do studies with more epidemiologic power and same methodology of study to be more comparable., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To study the orbital perfusion parameters of ophthalmic artery (OA) and central retinal artery (CRA) in inactive TED and the changes following surgical decompression., Methods: Non-randomised clinical trial. 24 inactive moderate-to-severe TED orbits of 24 euthyroid cases underwent surgical decompression and examined again at 3 months. The peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) of OA and CRA were evaluated using colour doppler imaging and normative database was established using 18 healthy controls., Results: The mean age was 39.38 ± 12.56 years and male: female ratio was 1: 1.18. Intraocular pressure was higher, and CRA-PSV, CRA-RI, OA-PSV, and OA-EDV were lower in TED in comparison to heathy orbits. The CRA-PSV, CRA-EDV, OA-PSV, and OA-EDV negatively correlated with proptosis and duration of thyroid disease. The area under curve of OA-PSV (95% CI:0.964-1.000, p < 0.001) and OA-EDV (95% CI:0.699-0.905, p < 0.001) helped in differentiating TED orbits from HC, and in predicting the severity of disease. Post decompression, CRA-PSV, CRA-EDV, OA-PSV, and OA-EDV improved, with decrease in CRA-RI and OA-RI in both lipogenic and MO., Conclusions: The orbital perfusion is reduced in inactive TED. The changes in OA flow velocities can help in differentiating inactive TED from healthy orbits and progression of TED. Sequential orbital CDI of OA and CRA can serve as an objective tool for case selection and monitoring response to surgical decompression., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Competing Interests: The authors have no financial or conflicts of interest to disclose.

Competing Interests: The authors have no financial or conflicts of interest to disclose.

Purpose: The purpose of the study was to measure the effect of rim-off deep lateral decompression for Graves orbitopathy on the lateral rectus muscle path and oculomotor balance., Methods: Retrospective analysis of the medical records and pre- and postoperative computed tomography scans of 34 orbits of 23 patients who underwent deep lateral decompression alone. The oculomotor balance of these 23 patients was measured with the alternate cover test and prisms before and after surgery. Bezier functions were used to measure the postoperative path of the lateral rectus in all decompressed orbits., Results: Deep lateral decompression induced a curvilinear deformation of the lateral rectus. There was no significant correlation between the position of the point of maximum muscle displacement and the size of the residual lateral wall. The changes in the lateral rectus path had no adverse effects on the oculomotor balance of the patients., Conclusions: The location of the curvilinear deformation of the lateral rectus does not depend on the residual segment of the lateral wall. The changes of the lateral rectus path have no deleterious effect on the oculomotor balance., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: Saturday night retinopathy, the term coined by Jayam et al . in 1974, is a rare condition in which external compression of the orbit during a drug and alcohol stupor causes a unilateral orbitopathy with ophthalmoplegia and ischemic retinopathy. This condition has been increasingly reported in the last decade, correlating with an increasing burden of substance use. This condition mirrors a similar entity typically reported in patients following spinal surgery, where a headrest supporting the patient's face compresses the orbit. The current authors combine these 2 entities, entitled external compressive ischemic orbitopathy, and present a comprehensive literature review describing this entity., Methods: A systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All related publications of vision loss in the setting of orbital compression were reviewed. Data collected included patient demographics, precipitating circumstances of vision loss, presenting ocular symptoms, outcomes, and ancillary imaging., Results: In total 31 articles were selected for inclusion, yielding 46 patients. A total of 10 patients suffered orbitopathy in the setting of a drug stupor, and 36 following prone-positioned surgery. However, 79% of patients presented with visual acuity of light perception or worse. Also, 86% of patients presented with ophthalmoplegia, 92% with proptosis and orbital edema, and 86% with varying degrees of retinal ischemia. When compared with iatrogenic cases, self-induced stuporous cases demonstrated worse presenting visual acuity, ophthalmoplegia, retinal and choroidal filling, and worse final outcomes., Conclusion: External compressive ischemic orbitopathy is a severe vision-threatening condition that has been increasingly reported in the last decade., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background: TSH receptor autoantibodies (TRAbs) are pathognomonic for Graves' disease and are thought to also underly the pathogenesis of Graves' ophthalmopathy (GO). A decline in TRAb levels has been documented post-total thyroidectomy (TTx) in GO, however with conflicting correlations with disease outcomes. The aim of the study was to compare the effectiveness of TTx to other treatment modalities of Graves' disease and examine whether the lowering of TRAbs is associated with GO improvements., Method: We searched electronic databases including Medline, Embase, Scopus, and Web of Science until 31 September 2022 using a broad range of keywords. Patients with GO undergoing TTx with measurements of both TRAbs and progression of the disease using a validated GO scoring system were included. Fourteen studies encompassing data from 1047 patients with GO met our eligibility criteria. The PRISMA guidelines were followed, and five studies had comparable data that were suitable for a meta-analysis., Results: The Cochrane Risk of Bias tool for RCTs showed low risk of bias across most domains. The pooled odds ratio showed that more patients significantly had normalized TRAb levels post-TTx as compared to other interventions (OR: 1.36, 95% CI: 1.02-1.81, p = 0.035). But, there was no significant difference in GO improvement post-TTx as compared with other intervention groups., Conclusions: This meta-analysis shows that TRAb levels may decline largely post-TTx, but may not predict added improvements to the progression of GO. Thus, future studies with uniform designs are required to assess the minimal significant GO improvements., (© 2023. The Author(s).)

We report a woman, 45th year old with Graves' disease treated with anti-thyroid drug (thiamazole). She came to our clinic with severe and active Graves' orbitopathy. We treated her with high dose intravenous methylprednisolone weekly (0.5 g weekly/ 6 weeks) and mycophenolate sodium 0.72 g daily/ 6 weeks. Because of her longterm consumption but not successful to achieve remission of anti-thyroid drugs and the size of her goiter, we decided to do total thyroidectomy. Only one week after thyroidectomy, her eye inflammation grade was reduced, but still bulging. We continue with the intravenous methylprednisolone weekly. Because of the partial response, we continue with another dose of methylprednisolone (0.25 g weekly for another 6 weeks).After 12 weeks of intravenous methylprednisolone (maximum dose for 1st course 4.5 g), there is a partial response make it to moderate to severe grade but still active inflammation. Our team decided to give her second-line treatment and we give her intravenous tocilizumab monthly for 4 weeks. After three tocilizumab infusion, the inflammation is reduced remarkably. Her overall appearance is getting better. But, because of her sight was not improved much as the inflammation reduced, we done orbital MRI and we decided to do another intravenous methylprednisolone 1 g for three days followed by orbital decompresion surgery. Shortly after the orbital decompresion, her sight was improved very well. She can now doing activities she can do previously. After recovery, we plan to give her the fourth (last) tocilizumab infusion. Overall, tocilizumab improves clinical outcome in patient with active corticosteroid-resistant moderate to severe Graves' orbitopathy. Patient's quality of life also improved.

Key Points: 10% of patients undergoing MAI decompression for TED developed new-onset diplopia MAI decompression remains an excellent option for orbital decompression for TED., (© 2023 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Graves orbitopathy is both disabling and disfiguring. Medical therapies to reduce inflammation are widely used, but there is limited trial data beyond 18 months of follow-up., Methods: Three-year follow-up of a subset of the CIRTED trial (N = 68), which randomized patients to receive high-dose oral steroid with azathioprine/placebo and radiotherapy/sham radiotherapy., Results: Data were available at 3 years from 68 of 126 randomized subjects (54%). No additional benefit was seen at 3 years for patients randomized to azathioprine or radiotherapy with regard to a binary clinical composite outcome measure (BCCOM), modified European Group on Graves' Orbitopathy score, or Ophthalmopathy Index.Clinical Activity Score (CAS), Ophthalmopathy Index, and Total Eye Score improved over 3 years (P < .001). However, quality of life at 3 years remained poor. Of 64 individuals with available surgical outcome data, 24 of 64 (37.5%) required surgical intervention. Disease duration of greater than 6 months before treatment was associated with increased need for surgery [odds ratio (OR) 16.8; 95% CI 2.95, 95.0; P = .001]. Higher baseline levels of CAS, Ophthalmopathy Index, and Total Eye Score but not early improvement in CAS were associated with increased requirement for surgery., Conclusion: In this long-term follow-up from a clinical trial, 3-year outcomes remained suboptimal with ongoing poor quality of life and high numbers requiring surgery. Importantly, reduction in CAS in the first year, a commonly used surrogate outcome measure, was not associated with improved long-term outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society.)

Context: The level of evidence is low for the treatment of patients with dysthyroid optic neuropathy (DON) and there is no consensus on the treatment of DON with intravenous high-dose glucocorticoids (ivGC) or direct surgical decompression., Objective: To compare the efficacy of glucocorticoid treatment and orbital decompression (OD) in DON., Data Sources: PubMed, EMBASE, and Cochrane Library were searched along with other sources., Study Selection: A total of 17 studies met the inclusion criteria., Data Extraction: Standard methodological guidance of the Cochrane Handbook was used and data were independently extracted by multiple observers. The primary outcomes were the improvement of best corrected visual acuity (ΔBCVA). Secondary outcomes were proptosis reduction, change in diplopia, visual field defects, and intraocular pressure (IOP)., Data Synthesis: The ΔBCVA in the ivGC + OD group was improved 0.26 LogMAR more than in the ivGC group (P = .007). The ΔBCVA in the OD group was better than in the ivGC group (P = .008). Posttreatment proptosis in the ivGC + OD and OD groups were improved further by 3.54 mm and 3.00 mm, respectively, than in the ivGC group (P < .01). The mean deviation (MD) in the ivGC + OD group was improved by an additional 5.33 dB than in the ivGC group (P = .002). The IOP in the ivGC + OD group was improved further than in the ivGC group (P = .03)., Conclusions: Based on the results of the present meta-analysis, OD or ivGC + OD may be more effective in improving BCVA and MD and reducing proptosis compared with ivGC. Compared with ivGC alone, ivGC + OD is more effective in improving IOP than ivGC. Although this study improves the hierarchy of evidence in the treatment of DON, additional randomized controlled trials are needed to confirm this conclusion., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Thyroid-associated ophthalmopathy (TAO) is an autoimmune disease involving the ocular tissues that may require strabismus surgery treatment. Presently, little is known about the impact of strabismus surgery on the quality of life of such patients. Consequently, the aim of the present study was to explore the effect of strabismus surgery on the quality of life of strabismus patients with quiescent TAO. This was a prospective case-series study. Strabismus patients with TAO who were admitted to the First Affiliated Hospital of Guangxi Medical University for strabismus surgery from October 2011 to April 2016 were included in this study. The included patients were asked to complete the Graves' ophthalmopathy quality of life questionnaire (GO-QOL) before strabismus surgery and 6 weeks after the surgery, respectively. Preoperative and postoperative GO-QOL scores were compared using the paired samples t-test. The correlation between strabismus surgery and the quality of life was analyzed using Spearman correlation analysis. In total, 23 patients, with a mean age of 49.04 years old, were included in the study. Compared to the preoperative GO-QOL scores, the postoperative scores of these patients for visual function (43.04 vs 73.50, P < .001) and psychosocial function (40.13 vs 72.93, P < .001) were both significantly increased. The greater the preoperative angle of misalignment of the eyes, the worse the psychosocial function (r = -0.433, P = .039). Strabismus surgery can significantly improve the quality of life of strabismus patients with quiescent TAO., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Thyroid eye disease (TED) is the most frequent orbital disease in adults and is characterized by the accumulation of orbital adipose tissue (OAT). It can lead to eyelid retraction or even vision loss. Orbital decompression surgery serves as the primary treatment for inactive TED by removing the excess OAT. However, there is a lack of alternative treatments to surgery due to the unclear understanding of the pathogenesis, particularly the metabolic features. Accordingly, our study was implemented to explore the content and features of metabolites of OATs from TED patients., Method: The OATs used in the current study were obtained from the orbital decompression surgery of seven patients with inactive TED. We also collected control OATs from eye surgical samples of five individuals with no history of autoimmune thyroid diseases, TED, or under non-inflammatory conditions. The liquid chromatography mass spectrometer was used for the measurements of the targeted metabolites. Afterwards, we performed differential metabolite assay analysis and related pathway enrichment analysis., Results: In our study, a total of 149 metabolite profiles were detected in all participants. There were significant differences in several metabolite profiles between the TED group and the control group, mainly including uric acid, oxidized glutathione, taurine, dGMP, oxidized glutathione 2, uracil, hexose-phosphate, 1-methylnicotinamide, D-sedoheptulose 1,7-bisphosphate, and uridine 5'-monophosphate (all p -value < 0.05). The TED-related pathways identified included purine metabolism, beta-alanine metabolism, glutathione metabolism ( p -values < 0.05). Our study found overlaps and differences including uric acid and uracil, which are in accordance with metabolites found in blood of patients with TED from previous study and several newly discovered metabolite by our study such as hexose-phosphate, 1-methylnicotinamide, D-sedoheptulose 1,7-bisphosphate, compared to those tested from blood, OAT, or urine samples reported in previous studies., Conclusion: The findings of our study shed light on the metabolic features of OAT in individuals with TED. These results may help identify new treatment targets for TED, providing potential avenues for developing alternative treatments beyond ophthalmic surgery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Du, Wang, Yang, Hu, Liu, Jian, Wang, Zhang, Chen, Wang and Zhang.)

Purpose: To evaluate the role of hyaluronic acid (HA) filler injection in the management of upper eyelid retraction (UER) in thyroid eye disease (TED)., Methods: Retrospective interventional series of all patients with TED who had undergone HA injection, from February 2011 to April 2013 by a single surgeon (Y-DK) in a tertiary medical institution. Outcome measures: Mean margin reflex distance 1 (MRD1) pre- and post-filler., Results: There was a total of 13 patients and 17 eyes included in the study. The injection dosage for 15 eyes was 0.5 ml, one patient had 0.35cc on the right eye and 0.65cc on the left eye. Mean MRD1 at presentation was 6.21 mm. There was a mean decrease in MRD1 of 2.01 mm ( p  < .001) at 1 month post filler, 2.06 mm ( p  < .001) at 6 months post filler and 2.61 mm ( p  < .001) at 1 year post filler. There was no correlation between pre-filler MRD1 and change in MRD1 at various time points post-filler, nor any correlation between pre-filler upper scleral show (USS) and change in USS post-filler. There was also no correlation found between clinical activity score (CAS) and change in MRD1, as well as duration of thyroid eye disease (TED) and change in MRD1. Complications included mild upper lid lumpiness on downgaze (n = 4, 23.5%) which improved but persisted with time. There were no untoward intravascular or vision-threatening complications., Conclusion: Transconjunctival HA injection is an effective treatment option for TED-related UER in both active and inactive TED patients in an East Asian population, with a potentially long-lasting effect.