David B Granet MD, MHCM,
FACS, FAAP, FAAO
Treating a patient with an immobile eye due to thyroid disease requires a multidisciplinary approach that takes into account the entire spectrum of the disease and its impact on the eye, reports David B Granet MD, MHCM, FACS, FAAP, FAAO, Shiley Eye Centre, University of California, San Diego, US.
“Thyroid disease may be difficult, but with careful planning and understanding and working with your colleagues in oculoplastics you can change these patients lives and make them smile again,” Dr Granet told the 2020 WSPOS Virtual Meeting.
The physician needs to understand the condition from the patient’s point of view. Often they will experience frustration because they don’t understand that they have to wait for the disease to get better and stabilised. Also confusing is the fact that the systemic effects of thyroid disease sometimes don’t become manifest until after they have developed the associated eye problems.
“Perhaps the first and foremost is the psychological impact of the disease; the disfigurement that we have is more impactful than the double vision, which is astonishing to people. So, if you don’t take care of the psychological burden then you are not helping your patients,” Dr Granet explained.
He noted that thyroid eye disease has two stages of development. There is the active inflammatory phase, which is characterised by sore, red eyes and cosmetic problems. It usually resolves within three years (many much sooner). However, 10% develop serious long-term ocular complications. Then there is the quiescent stage where a much less inflamed orbit and motility defect may be present. Severity at this stage may range from being a nuisance to blindness from exposure keratopathy or optic neuropathy.
There are also two different clinical spectrums of disease. Type I, where there is largely fat infiltration and associated proptosis and type II, where there is extraocular muscle involvement.
Five-step approach
In 1997, Dr Granet and Don Kikkawa MD established the Thyroid Eye Center at UCSD, and they have developed a five-step approach to treating thyroid eye disease. The first step is medical treatment, the second is Botox, the third is orbital decompression, the fourth is strabismus repair and the fifth is lid repair.
He noted that research conducted by Dr Kikkawa at their centre has shown that it is possible to grade the amount of orbital decompression required based on the degree of proptosis present. In addition, they have shown that if you inject Botox at the time of decompression you can affect the strabismus and sometimes actually prevent strabismus.
Moreover, their research also shows that in correctly selected patients, outpatient administration of Botox chosen can correct small strabismus deviations, completely eliminating the need for strabismus surgery in up to one-third of cases, Dr Granet pointed out.
The goal in strabismus surgery is to get the patient to primary position and, if possible, reading position. It is possible to accomplish both by aiming just below the primary and allowing the patient to obtain a small chin-up position. Under-correcting the vertical alignment will help compensate for late changes and asymmetric surgery is needed in asymmetric problems.
“While most have inferior rectus contraction/over-action problems, many have superior rectus inferior oblique or even superior oblique type patterns. Look carefully, before you start,” he cautioned.
“Our group uses delayed adjustable sutures. Delaying the suture adjustment by five-to-seven days decreases risk of infection, decreases splinting and provides the patient with a better chance for binocular recovery.”
