Thyroid Orbitopathy is caused by an inflammation that affects the orbit, the space behind the eye, that involves fat and extra-ocular muscles.
The eyelids are also affected by an excessive opening (eyelid retraction) that adds to the excessive protrusion of the eye and determines a significant dryness with burning and eye irritation.
Thyroid orbitopathy is the most frequent cause of exophthalmos (mono or bilateral), affecting women more frequently than men between 40 and 60 years old.
The onset of symptoms is often gradual. Patients cannot identify the onset. The progression is variable, often associated with thyroid disease, and smoking is a common risk factor.
Exophthalmos is bilateral, although it often manifests itself asymmetrically.
The appearance of patients with thyroid exophthalmos is significantly altered compared to before the onset of the disease. We can only restore the standard shape and position of the eyes concerning the protrusion and changes of the eyelids thanks to rehabilitative surgery.
Figure: Extremely enlarged extra-ocular muscles visible on CT scan;
the increase in muscle thickness is typical of thyroid orbitopathy.
In addition to eyelid exophthalmos and retraction, other changes induced by thyroid dysfunction include swelling of the eyelids, with appearance or worsening of eyelid bags.
In most patients, the clinical signs and symptoms described occurring in varying associations from case to case.
It is also important to remember that thyroid orbitopathy typically has two phases:
- Active inflammatory phase: lasts from 6 to 18 months, and resolution is often spontaneous. In this phase, it is necessary to monitor the ocular surface’s visual functions and manage the phenomena related to inflammation (swelling, redness, and periocular pain) with cortisone. It can be administered intravenously or, as we happen to recommend more and more often, at least in the initial phase, locally with cortisone injections (peri-bulbar) near the eye to reduce systemic complications and maximize the ocular therapeutic effect.
This treatment is indicated only in the active, inflammatory phase. It is beneficial for controlling the disease around the eyes, improving irritation and pain disorders, reducing swelling, and in many cases, also improving any doubling of vision.
The advantage of injection treatment near or to the eye compared to intravenous is that the injection treatment, to be done exclusively with a dedicated ophthalmologist, eliminates or dramatically reduces all the side effects of systemic cortisone at high doses. It maximizes the impact of cortisone where it is useful, that is, at the peri-ocular level.
It involves making a simple puncture in the clinic and to be repeated.
The orbital inflammation that caused double vision, strabismus, and swelling visible in the left photo was treated with peri-bulbar cortisone.
The treatment avoided the need for strabismus surgery by returning the eyes to the correct position and significantly reducing the eyelid swelling typical of this active phase.
- Quiescent, chronic, fibrotic phase: characterized by a complete stabilization of ocular signs and symptoms wherein the eye is white, with no edema, and hyperemia but the damage that occurred previously and that has not improved spontaneously with cortisone is permanent. The medical treatment is ineffective at this point, and after stabilization of 6-12 months, it is possible to intervene surgically for an aesthetic-functional rehabilitation.
Surgical Therapy of Exophthalmos
Orbital decompression is a surgery performed to correct the excessive protrusion of the eyeballs (exophthalmos) using minimally invasive techniques, no visible scars, and in day surgery.
The technique involves widening the bone orbital space by removing the two thinner orbital walls that border the sinuses. There is no visible incision for orbital decompression. Surgery is under general anesthesia with only one night of hospitalization (night hospital).
The pain is minimal, and you can typically return to light activities in 48 hours and regular ones in 10-15 days.
First of all, the surgical procedure involves the correction of exophthalmos through orbital decompression, the correction of the upper and lower eyelid retraction, and on the fat, through a blepharoplasty to offer the patient a complete and adequate aesthetic and functional rehabilitation.
We perform all aesthetic corrective interventions that also affect both the lower and upper eyelids, associating decompression with the correction of eyelid retraction and aesthetic blepharoplasty.
The advantage of a single intervention in a single session is a solution that only we, at Oculoplastica Bernardini, offer, is evident in savings, reduction in the number of interventions, and satisfaction with complete aesthetic impact.
At the end of the surgical phase, the patient should be similar to the pre-disease state.
The Technique of Orbital Decompression
Through a small cut in the pink part between the eye and the nose, the medial and lower walls of the orbit are reached, which are incredibly fragile walls and give considerable decompression capacity:
The intra-operative aspect with the view from behind demonstrates the return of the decompressed right eye compared to the left that is still to be operated on. The exophthalmos in the two eyes was symmetrical. The re-entry effect of the eyeball is immediate:
The CT scan of the orbits demonstrates the effect of removing the medial wall with expansion towards the ethmoidal sinuses that were previously occupied by air on both sides and consequently, the enlargement of the orbital volume with considerable re-entry of the eyeballs:
The CT scan of the orbits demonstrates the removal effect of the lower wall (orbital floor) with expansion towards the maxillary sinuses that were previously occupied by air on both sides and consequently, the enlargement of the orbital volume with considerable re-entry of the eyeballs:
Aesthetic Results: Before and After