Netherlands Ophthalmological Society, 168th Meeting, Rotterdam 1973 Ophthalmologica, Basel 173: 171-179 (1976)
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy R. C. A pers and J. J. M. B ierlaagh Department of Ophthalmology, University of Leiden, Leiden
The motility disturbances in thyroid disease are said to be due to fibrosis of the extraocular muscles [M iller et al., 1965; P ratt-J ohnson et al., 1972], This means that when for example the inferior rectus is fibrosed it leads to a limitation of elevation. In other words the deviation is maximum in the opposite direction of action of the affected muscle. Therefore, when planning surgery we operate on the affected muscle. Selection of Cases Our indications for eye muscle surgery are: (1) singular limitation of eye movements with diplopia in the primary position; (2) multiple limita tions with a large angle of deviation in the primary position, making bin ocular single vision practically impossible. Before considering eye surgery we wait 6 months for the deviation to remain static. The patient should also have been evaluated endocrinologically by the endocrinologist and should be euthyroid.
So far we have operated 10 patients with horizontal and vertical diplo pia due to thyroid ophthalmoplegia. In 3 patients we operated on only one muscle. If there was only a limitation of elevation we performed a recession of the inferior rectus. If there was an abduction limitation we performed a recession of the medial rectus. In the other patients, more eye muscles had to be operated on because of combined limitations of elevation, depression and/or abduction.
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Material
172
A pf.rs/B ierlaagh
Fig. 1. a Limitation of elevation of the left eye. b Same patient after recession of left inferior rectus of 6 mm.
Surgery During the operation we always do a forced duction test to evaluate the mechan ical limitations in the various fields of gaze. As said before, the principle of surgery in those cases is to recess the muscle that is most fibrosed and interferes with the eye movements. We prefer to recess the affected muscle, rather than resect the pseudo-paralysed muscle, because the affected muscle cannot relax and this causes the limitation of action of the antagonist. When we recess, i.e. weaken the affected muscle, it allows better movement of the antagonist. During the operation we could demonstrate that the limitation of movement was due to fibrosis of the muscles as they were inelastic and would not relax, as is frequently mentioned in the literature [Chamberlain, 1971; H ugonnier and M agnard, 1967; M iller and The operation itself may cause difficulties because the forced duction remains obstructed until the muscle is severed from the globe. It is useful to place the sutures far enough back so that they will not detach. The check ligaments also need to be cut as far back as possible before cutting the muscle as there is a considerable amount of bleeding when cutting the ciliary vessels.
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S mith ],
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 173 / / o 3 - 3 jo Left Eye
Rlfht Eye
Fig. 2. a Hess chart of the patient in figure 1. pre-operativcly. b Hess chart of the same patient post-operatively.
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S.V.Ç .
174
A pers /B ierlaagh
Fig. 3. a A patient with multiple limitations of eye movements and a large devia tion in the primary position pre-operatively. b Same patient post-operatively.
In the first group of 3 patients where we operated only on one muscle we obtained a restitutio ad integrum, except for the extreme fields of gaze where some diplopia was still experienced. Figure 1 shows a patient with a limitation of elevation pre- and post-operatively. This was the patient who had to stop the prednisone treatment because of a stomach haemor rhage. Figure 2 shows Fless charts of the same patient pre- and postoperatively (recession of the left inferior rectus of 6 mm). It is clear that the depression of that eye remains good. A large recession of the inferior rectus has, however, also some disadvantages: (a) the lower eyelid drops, and (b) the protrusion of the eyeball increases, and when it may not be demonstrable with the Hertel, it may show by signs of keratitis, due to dehydration. The second group of patients with horizontal and vertical limitations of eye movements had double vision in all directions. Post-operatively
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R esults
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 175
A.V.
Right Eye
Fig. 4. a Hess chart of patient of figure 3 pre-operatively. b Hess chart of same patient post-operatively after recession of left inferior and medial rectus and reces sion of right superior rectus.
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Left Eye
176
A pers/B ieri.aagh
they all had a large field of binocular single vision with an average di ameter of 50-60 . Figure 3 is a characteristic example of a patient in the primary posi tion pre- and post-operatively. This patient had a limitation of elevation and abduction of the left eye and a depression limitation of the right eye. We performed a recession of the left inferior rectus, the left medial rectus and the right superior rectus. Figure 4 shows the improvement of the motility on the Hess charts pre- and post operatively. Figure 5 shows the field of binocular single vision post-operatively, which was absent preoperativcly. Another patient showed a limitation of elevation of the left eye with an eso-deviation. We performed a large recession of the inferior rectus of the left eye and a recession of the right medial rectus with a recession of the right inferior oblique. Figure 6 shows the Hess charts preand post-operatively. The elevation is much improved but not normalised. This can perhaps be further compensated by prisms. Figure 7 demon strates the field of binocular single vision of the same patient post-opera tively which again was absent pre-operatively.
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Fig. 5. Field of binocular single vision post-operatively of patient of figure 3.
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 177
Left if
Right Ex«
Left if
Right Ey«
Fig. 6. a Hess chart of another patient pre-operatively. b Post-operative Hess chart of same patient.
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h. s.
178
A pkrs/B irri .aagii
Fig. 7. Field of binocular single vision post-operatively of patient of figure 6.
When contemplating surgery we should remember the following im portant points: (1) From the endocrine point of view the patient should be fully controled, i.c. euthyroid. (2) The motility disturbances should have been the same for about 6 months. (3) Eye muscle surgery should take place after a decompression operation if necessary, but before eyelid surgery. (4) Pre-operatively a forced duction test should be performed to evaluate local mechanical limitations in the various directions of gaze. (5) The antagonist of the pseudo-paralytic muscle should be recessed as this muscle is fibrotic and the cause of the limitation. (6) From experience we can say that the recession of the inferior rectus may be large, even 8-10 mm! [P ratt-J ohnson et al., 1972], We never saw an underacting muscle post-operatively. The recession of the medial rectus was always 5 mm. (7) To prevent limitation of movement of the operated muscle the check ligaments should always be cut. (8) The patient is told that possibly more operations may be necessary and that the lower eyelid will drop.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
Comment
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 179
References C hamberlain, W.: Strabismus in thyroid dysfunction. Orthoptic Proc. 2nd Int. Orth.
Orth. Congr., pp. 287-295, 1971. H anscombe, M. C.: Some aspects of surgery of the vertically-acting extraocular
muscles. Brit. Orthop. J. 22: 23-34 (1965). H ugonnier, R. et M agnard, P.: La diplopie au cours de la maladie de Basedow.
Bull. Soc. fr. Ophtal. 80: 437-459 (1967). L yle , T. K.: The management of hormonal exophthalmos. Ocular deviation and de
fects of ocular movement (and some cases showing visual field defects). Trans, ophthal. Soc. U.K. 80: 107-130 (1960). M iller , J. E.; van H euven , W„ and W ard, R.: Surgical correction of hypotropias associated with thyroid dysfunction. Archs Ophthal., Chicago 74: 509-515 (1965). N u it , A. B.: Ocular complications in thyroid disease. Br. Orthop. J. 17: 55-65 (1960). P ratt-J ohnson , J. A.; Stephen , M., and D rance, M. D.: Surgical treatment of dysthyroid restriction syndromes. Can. J. Ophthal. 7: 405-412 (1972). Byron-S mith and Soll, D. B.: Strabismus associated with thyroid disease. Am. J. Ophthal. 50: 473-478 (1960). Dr. R. C. A pers , Department of Ophthalmology, University of Leiden, Leiden (The Netherlands)
Discussion H orst : Did all patients from your first paper who were treated with Prednisone receive any other medical therapy? A pers : All patients were treated with thyroid inhibitors with 50-70 mg thyroxin added to prevent development of a hyperthyroidism which could have been detri mental to the eye deviation. At the same time care has been taken of a sufficient potassium supply and medicinal stomach protection.
A pers : A normal person will blink about 15 times a minute, the frequency can be measured best by observing the patient in the ocular of the Goldman perimeter. If the patient has not been informed and if the illumination is normal, the frequency will not artificially be influenced. The imperfect closure can be observed best with the slit-lamp, attending specially to the incomplete refreshment of the pre-corneal tear film.
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W inkelman: The diminished frequency of blinking and imperfect closure to gether with exophthalmos are always mentioned as Stcllwag’s sign. What ought to be the frequency of the blinking and has this been measured by the speaker and in what way?
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy R. C. A pers and J. J. M. B ierlaagh Department of Ophthalmology, University of Leiden, Leiden
The motility disturbances in thyroid disease are said to be due to fibrosis of the extraocular muscles [M iller et al., 1965; P ratt-J ohnson et al., 1972], This means that when for example the inferior rectus is fibrosed it leads to a limitation of elevation. In other words the deviation is maximum in the opposite direction of action of the affected muscle. Therefore, when planning surgery we operate on the affected muscle. Selection of Cases Our indications for eye muscle surgery are: (1) singular limitation of eye movements with diplopia in the primary position; (2) multiple limita tions with a large angle of deviation in the primary position, making bin ocular single vision practically impossible. Before considering eye surgery we wait 6 months for the deviation to remain static. The patient should also have been evaluated endocrinologically by the endocrinologist and should be euthyroid.
So far we have operated 10 patients with horizontal and vertical diplo pia due to thyroid ophthalmoplegia. In 3 patients we operated on only one muscle. If there was only a limitation of elevation we performed a recession of the inferior rectus. If there was an abduction limitation we performed a recession of the medial rectus. In the other patients, more eye muscles had to be operated on because of combined limitations of elevation, depression and/or abduction.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
Material
172
A pf.rs/B ierlaagh
Fig. 1. a Limitation of elevation of the left eye. b Same patient after recession of left inferior rectus of 6 mm.
Surgery During the operation we always do a forced duction test to evaluate the mechan ical limitations in the various fields of gaze. As said before, the principle of surgery in those cases is to recess the muscle that is most fibrosed and interferes with the eye movements. We prefer to recess the affected muscle, rather than resect the pseudo-paralysed muscle, because the affected muscle cannot relax and this causes the limitation of action of the antagonist. When we recess, i.e. weaken the affected muscle, it allows better movement of the antagonist. During the operation we could demonstrate that the limitation of movement was due to fibrosis of the muscles as they were inelastic and would not relax, as is frequently mentioned in the literature [Chamberlain, 1971; H ugonnier and M agnard, 1967; M iller and The operation itself may cause difficulties because the forced duction remains obstructed until the muscle is severed from the globe. It is useful to place the sutures far enough back so that they will not detach. The check ligaments also need to be cut as far back as possible before cutting the muscle as there is a considerable amount of bleeding when cutting the ciliary vessels.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
S mith ],
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 173 / / o 3 - 3 jo Left Eye
Rlfht Eye
Fig. 2. a Hess chart of the patient in figure 1. pre-operativcly. b Hess chart of the same patient post-operatively.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
S.V.Ç .
174
A pers /B ierlaagh
Fig. 3. a A patient with multiple limitations of eye movements and a large devia tion in the primary position pre-operatively. b Same patient post-operatively.
In the first group of 3 patients where we operated only on one muscle we obtained a restitutio ad integrum, except for the extreme fields of gaze where some diplopia was still experienced. Figure 1 shows a patient with a limitation of elevation pre- and post-operatively. This was the patient who had to stop the prednisone treatment because of a stomach haemor rhage. Figure 2 shows Fless charts of the same patient pre- and postoperatively (recession of the left inferior rectus of 6 mm). It is clear that the depression of that eye remains good. A large recession of the inferior rectus has, however, also some disadvantages: (a) the lower eyelid drops, and (b) the protrusion of the eyeball increases, and when it may not be demonstrable with the Hertel, it may show by signs of keratitis, due to dehydration. The second group of patients with horizontal and vertical limitations of eye movements had double vision in all directions. Post-operatively
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
R esults
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 175
A.V.
Right Eye
Fig. 4. a Hess chart of patient of figure 3 pre-operatively. b Hess chart of same patient post-operatively after recession of left inferior and medial rectus and reces sion of right superior rectus.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
Left Eye
176
A pers/B ieri.aagh
they all had a large field of binocular single vision with an average di ameter of 50-60 . Figure 3 is a characteristic example of a patient in the primary posi tion pre- and post-operatively. This patient had a limitation of elevation and abduction of the left eye and a depression limitation of the right eye. We performed a recession of the left inferior rectus, the left medial rectus and the right superior rectus. Figure 4 shows the improvement of the motility on the Hess charts pre- and post operatively. Figure 5 shows the field of binocular single vision post-operatively, which was absent preoperativcly. Another patient showed a limitation of elevation of the left eye with an eso-deviation. We performed a large recession of the inferior rectus of the left eye and a recession of the right medial rectus with a recession of the right inferior oblique. Figure 6 shows the Hess charts preand post-operatively. The elevation is much improved but not normalised. This can perhaps be further compensated by prisms. Figure 7 demon strates the field of binocular single vision of the same patient post-opera tively which again was absent pre-operatively.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
Fig. 5. Field of binocular single vision post-operatively of patient of figure 3.
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 177
Left if
Right Ex«
Left if
Right Ey«
Fig. 6. a Hess chart of another patient pre-operatively. b Post-operative Hess chart of same patient.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
h. s.
178
A pkrs/B irri .aagii
Fig. 7. Field of binocular single vision post-operatively of patient of figure 6.
When contemplating surgery we should remember the following im portant points: (1) From the endocrine point of view the patient should be fully controled, i.c. euthyroid. (2) The motility disturbances should have been the same for about 6 months. (3) Eye muscle surgery should take place after a decompression operation if necessary, but before eyelid surgery. (4) Pre-operatively a forced duction test should be performed to evaluate local mechanical limitations in the various directions of gaze. (5) The antagonist of the pseudo-paralytic muscle should be recessed as this muscle is fibrotic and the cause of the limitation. (6) From experience we can say that the recession of the inferior rectus may be large, even 8-10 mm! [P ratt-J ohnson et al., 1972], We never saw an underacting muscle post-operatively. The recession of the medial rectus was always 5 mm. (7) To prevent limitation of movement of the operated muscle the check ligaments should always be cut. (8) The patient is told that possibly more operations may be necessary and that the lower eyelid will drop.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
Comment
Indications and Results of Eye Muscle Surgery in Thyroid Ophthalmopathy 179
References C hamberlain, W.: Strabismus in thyroid dysfunction. Orthoptic Proc. 2nd Int. Orth.
Orth. Congr., pp. 287-295, 1971. H anscombe, M. C.: Some aspects of surgery of the vertically-acting extraocular
muscles. Brit. Orthop. J. 22: 23-34 (1965). H ugonnier, R. et M agnard, P.: La diplopie au cours de la maladie de Basedow.
Bull. Soc. fr. Ophtal. 80: 437-459 (1967). L yle , T. K.: The management of hormonal exophthalmos. Ocular deviation and de
fects of ocular movement (and some cases showing visual field defects). Trans, ophthal. Soc. U.K. 80: 107-130 (1960). M iller , J. E.; van H euven , W„ and W ard, R.: Surgical correction of hypotropias associated with thyroid dysfunction. Archs Ophthal., Chicago 74: 509-515 (1965). N u it , A. B.: Ocular complications in thyroid disease. Br. Orthop. J. 17: 55-65 (1960). P ratt-J ohnson , J. A.; Stephen , M., and D rance, M. D.: Surgical treatment of dysthyroid restriction syndromes. Can. J. Ophthal. 7: 405-412 (1972). Byron-S mith and Soll, D. B.: Strabismus associated with thyroid disease. Am. J. Ophthal. 50: 473-478 (1960). Dr. R. C. A pers , Department of Ophthalmology, University of Leiden, Leiden (The Netherlands)
Discussion H orst : Did all patients from your first paper who were treated with Prednisone receive any other medical therapy? A pers : All patients were treated with thyroid inhibitors with 50-70 mg thyroxin added to prevent development of a hyperthyroidism which could have been detri mental to the eye deviation. At the same time care has been taken of a sufficient potassium supply and medicinal stomach protection.
A pers : A normal person will blink about 15 times a minute, the frequency can be measured best by observing the patient in the ocular of the Goldman perimeter. If the patient has not been informed and if the illumination is normal, the frequency will not artificially be influenced. The imperfect closure can be observed best with the slit-lamp, attending specially to the incomplete refreshment of the pre-corneal tear film.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 4:38:06 PM
W inkelman: The diminished frequency of blinking and imperfect closure to gether with exophthalmos are always mentioned as Stcllwag’s sign. What ought to be the frequency of the blinking and has this been measured by the speaker and in what way?
