Ophthal Plast Reconstr Surg, Vol. 30, No. 4, 2014
Letters to the Editor
of a decompressed floor. Thyroid function was grossly normal, but her thyroid stimulating immunoglobulin (TSI) was elevated. She underwent emergent bilateral medial wall and deep lateral wall decompression and IV steroid therapy. At 3 months postoperatively, her APD had resolved, corrected vision returned to 20/20 OU, and her visual field scotoma and proptosis resolved.
CASE REPORT NO. 2
Endoscopic view of a right nasal cavity showing a progressively near total cicatrized ostium following silicone intubation alone for 3 months.
REFERENCES 1. Lee A, Ali MJ, Li EY, et al. Balloon dacryoplasty in internal ostium stenosis after endoscopic dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2014;30:7–10. 2. Ali MJ, Naik MN, Honavar SG. Balloon dacryoplasty: ushering the new and routine era in minimally invasive lacrimal surgeries. Int Ophthalmol 2013;33:203–10. 3. Ali MJ, Naik MN, Honavar SG. Minimally invasive lacrimal surgery: balloon dacryoplasty. In: Isloor S, ed. Lacrimal Drainage Surgery. New Delhi, India: Jaypee Brothers Medical Publishers, 2014:79–85. 4. Ali MJ, Naik MN. Efficacy of endoscopic guided anterograde 3 mm balloon dacryoplasty with silicone intubation in treatment of acquired partial nasolacrimal duct obstruction in adults. Saudi J Ophthalmol 2014;28:40–3.
Re: “Reactivation of Thyroid Eye Disease Following Extraocular Muscle Surgery” To the Editor: We read with great interest the case report from Dr. Xu et al.1 reporting a single patient with stable, bilateral thyroid eye disease (TED), which reactivated unilaterally 1 month after strabismus surgery. Then, after an 18-month period of quiescence, a second strabismus surgery again reactivated his TED within 1 month. This suggested that surgical manipulation provoked reactivation of TED. We would like to report 2 patients whose inactive TED reactivated bilaterally—1 after cataract surgery and the other after strabismus surgery.
Our second patient was a 59-year-old male smoker with Type II Graves disease who presented with bilateral compressive optic neuropathy. He was treated with I131 15 years earlier. Two years ago, he had medial wall and fat decompression at another institution for proptosis, followed 1 year later by uncomplicated cataract surgery. Six months after cataract surgery, the patient underwent strabismus surgery. Three months later, the patient was referred to our clinic with bilateral compressive optic neuropathy. On examination, his VA was OD 20/80 and OS 20/60, with a left APD, bilateral restrictive myopathy, proptosis, eyelid retraction, disc edema, and visual field loss. CT imaging confirmed bilateral compression with an intact lateral wall, orbital floor, and some residual ethmoid bone. He underwent emergent bilateral 3-wall decompression and steroid therapy. Two months post operatively his vision had returned to normal with resolution of his APD and disc edema, but persistent visual field loss. His thyroid level had been stable since 2011 and remained so throughout his postoperative course.
DISCUSSION Both our patients experienced reactivation of thyroid ophthalmopathy following ocular surgery. Patient no. 1’s cataract surgeries did not involve retrobulbar blocks, which are commonly a confounding factor for reactivation due to hypothesized direct needle trauma or anesthetic myotoxicity. However, her reactivation correlates to the bimodal age distribution of TED and may have been coincidental. Patient no. 2 had partial orbital decompression 1 year prior to strabismus surgery but still experienced reactivation of his TED after muscle surgery, which led to visual acuity and visual field loss. His continued smoking status is an additional factor that may have led to reactivation. Both our patients with Graves TED had received bilateral, partial orbital decompressions and had quiescent thyroid ophthalmopathy, which reactivated following ocular surgery, similar to Dr. Xu’s single patient case report. Although our first patient recovered to baseline visual acuity and visual fields, the second patient experienced permanent visual field loss. It may be prudent to consider a prophylactic, full orbital decompression prior to any ophthalmic surgery that may reincite orbital inflammation.
Anita Campbell, M.D. Thomas J. Whittaker, J.D., M.D. Jason A. Sokol, M.D.
CASE REPORT NO. 1 Our first patient was a 70-year-old woman with Type II Graves disease, who had undergone orbital floor decompression 30 years ago for severe proptosis. She presented to our institution with profound visual field loss, bilateral vision loss worse in the OS (VA: OD 20/100, OS 20/40), a right afferent pupillary defect (APD), proptosis (Hertel base 103, OD 27 mm, OS 27 mm), restrictive myopathy, and optic nerve pallor. Six months prior to presentation, she underwent uncomplicated cataract surgery under topical anesthesia. CT Scan was consistent with bilateral apical crowding in the setting
Correspondence: Anita Campbell, M.D., Department of Ophthalmology, University of Kansas, 7400 State Line Road, Prairie Village, KS 66208 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Xu L, Glass LR, Kazim M. Reactivation of thyroid eye disease following extraocular muscle surgery. Ophthal Plast Reconstr Surg 2014;30:e5–6.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
353
Letters to the Editor
of a decompressed floor. Thyroid function was grossly normal, but her thyroid stimulating immunoglobulin (TSI) was elevated. She underwent emergent bilateral medial wall and deep lateral wall decompression and IV steroid therapy. At 3 months postoperatively, her APD had resolved, corrected vision returned to 20/20 OU, and her visual field scotoma and proptosis resolved.
CASE REPORT NO. 2
Endoscopic view of a right nasal cavity showing a progressively near total cicatrized ostium following silicone intubation alone for 3 months.
REFERENCES 1. Lee A, Ali MJ, Li EY, et al. Balloon dacryoplasty in internal ostium stenosis after endoscopic dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2014;30:7–10. 2. Ali MJ, Naik MN, Honavar SG. Balloon dacryoplasty: ushering the new and routine era in minimally invasive lacrimal surgeries. Int Ophthalmol 2013;33:203–10. 3. Ali MJ, Naik MN, Honavar SG. Minimally invasive lacrimal surgery: balloon dacryoplasty. In: Isloor S, ed. Lacrimal Drainage Surgery. New Delhi, India: Jaypee Brothers Medical Publishers, 2014:79–85. 4. Ali MJ, Naik MN. Efficacy of endoscopic guided anterograde 3 mm balloon dacryoplasty with silicone intubation in treatment of acquired partial nasolacrimal duct obstruction in adults. Saudi J Ophthalmol 2014;28:40–3.
Re: “Reactivation of Thyroid Eye Disease Following Extraocular Muscle Surgery” To the Editor: We read with great interest the case report from Dr. Xu et al.1 reporting a single patient with stable, bilateral thyroid eye disease (TED), which reactivated unilaterally 1 month after strabismus surgery. Then, after an 18-month period of quiescence, a second strabismus surgery again reactivated his TED within 1 month. This suggested that surgical manipulation provoked reactivation of TED. We would like to report 2 patients whose inactive TED reactivated bilaterally—1 after cataract surgery and the other after strabismus surgery.
Our second patient was a 59-year-old male smoker with Type II Graves disease who presented with bilateral compressive optic neuropathy. He was treated with I131 15 years earlier. Two years ago, he had medial wall and fat decompression at another institution for proptosis, followed 1 year later by uncomplicated cataract surgery. Six months after cataract surgery, the patient underwent strabismus surgery. Three months later, the patient was referred to our clinic with bilateral compressive optic neuropathy. On examination, his VA was OD 20/80 and OS 20/60, with a left APD, bilateral restrictive myopathy, proptosis, eyelid retraction, disc edema, and visual field loss. CT imaging confirmed bilateral compression with an intact lateral wall, orbital floor, and some residual ethmoid bone. He underwent emergent bilateral 3-wall decompression and steroid therapy. Two months post operatively his vision had returned to normal with resolution of his APD and disc edema, but persistent visual field loss. His thyroid level had been stable since 2011 and remained so throughout his postoperative course.
DISCUSSION Both our patients experienced reactivation of thyroid ophthalmopathy following ocular surgery. Patient no. 1’s cataract surgeries did not involve retrobulbar blocks, which are commonly a confounding factor for reactivation due to hypothesized direct needle trauma or anesthetic myotoxicity. However, her reactivation correlates to the bimodal age distribution of TED and may have been coincidental. Patient no. 2 had partial orbital decompression 1 year prior to strabismus surgery but still experienced reactivation of his TED after muscle surgery, which led to visual acuity and visual field loss. His continued smoking status is an additional factor that may have led to reactivation. Both our patients with Graves TED had received bilateral, partial orbital decompressions and had quiescent thyroid ophthalmopathy, which reactivated following ocular surgery, similar to Dr. Xu’s single patient case report. Although our first patient recovered to baseline visual acuity and visual fields, the second patient experienced permanent visual field loss. It may be prudent to consider a prophylactic, full orbital decompression prior to any ophthalmic surgery that may reincite orbital inflammation.
Anita Campbell, M.D. Thomas J. Whittaker, J.D., M.D. Jason A. Sokol, M.D.
CASE REPORT NO. 1 Our first patient was a 70-year-old woman with Type II Graves disease, who had undergone orbital floor decompression 30 years ago for severe proptosis. She presented to our institution with profound visual field loss, bilateral vision loss worse in the OS (VA: OD 20/100, OS 20/40), a right afferent pupillary defect (APD), proptosis (Hertel base 103, OD 27 mm, OS 27 mm), restrictive myopathy, and optic nerve pallor. Six months prior to presentation, she underwent uncomplicated cataract surgery under topical anesthesia. CT Scan was consistent with bilateral apical crowding in the setting
Correspondence: Anita Campbell, M.D., Department of Ophthalmology, University of Kansas, 7400 State Line Road, Prairie Village, KS 66208 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Xu L, Glass LR, Kazim M. Reactivation of thyroid eye disease following extraocular muscle surgery. Ophthal Plast Reconstr Surg 2014;30:e5–6.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
353
