Thyroid eye disease surgery requires planning, customization
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CHICAGO — Management of thyroid eye disease requires a carefully planned, personalized approach, according to Michael Kazim, MD, speaking at the American Academy of Ophthalmology meeting.
“In the acute phase, I never treat patients surgically, with the exception of those who don’t tolerate medicines or don’t respond to them,” he said.
In the chronic phase, when patients have had at least 6 months of stable thyroid eye disease and have not improved spontaneously, the classic surgical interventions are decompression followed by strabismus surgery and lid surgery.
These procedures, when possible, should be combined, but some points must be considered.
“Don’t combine medial decompression with horizontal strabismus surgery or fat decompression with small-angle strabismus repair. Normal levator function in the upper eyelid should not be combined with decompression, and don’t do any upper or lower lid retraction if you are going to do a vertical strabismus surgery,” Kazim said.
When performing orbital decompression, take into account that all cases of proptosis are different, he said. Normative averages are of no value, and pre-disease photos should be reviewed to define the amount of ptosis reduction needed.
“Plan the surgery according to the effect you want to achieve, taking into account that, on average, you can have 3 mm ptosis reduction from fat decompression, 3 mm from lateral bone decompression, and 3 mm to 4 mm from medial and floor bone decompression. With fat decompression, you can improve motility in about 10% of cases, and in special cases, you can improve optic nerve function,” he said.
Kazim prefers endoscopic medial/anterior floor decompression for better visualization and better management of sinus outflow. He also recommended not over-pushing the operation and avoiding the anterior 1 cm floor to prevent hypoglobus or vertical strabismus.
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Kazim M. Surgery for thyroid eye disease. Presented at: American Academy of Ophthalmology meeting; Sept. 30-Oct. 3, 2022; Chicago.
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