Ophthal Plast Reconstr Surg, Vol. 30, No. 4, 2014
Letters to the Editor
Reply re: “Reactivation of Thyroid Eye Disease Following Extraocular Muscle Surgery” To the Editor: We thank Dr. Campbell et al.1 for their interest in our case report.2 We agree that the cumulative body of literature, albeit case reports, supports a causal relationship between periocular surgery and the development of thyroid eye disease (TED) in at-risk patients. In addition, the rate of recurrent TED—previously thought to be rare—is at least as high as 5%.3 Therefore, it does not surprise us that more cases continue to be identified. We find that the cases that Dr. Campbell reports differ from ours in 2 important ways. First, in our case, the temporal relationship between the presumed inciting surgery and active TED is extremely short (1 month on both occasions), measurably increasing the likelihood of a causal relationship. In Dr. Campbell’s cases, the interval between the presumed inciting event and their first examination of the patients was 6 and 9 months, respectively. This delay in reactivation significantly increases the possibility of unprovoked recurrent disease. Second, our case presents the interesting finding of active orbitopathy contralateral to the operated. This finding, we believed, further established the systemic immune nature of the provocation over a local traumatic event. Most importantly, we must respectfully voice our strong disagreement with Dr. Campbell’s suggestion that all patients with prior history of TED should undergo prophylactic orbital decompression before any periorbital surgery to presumably avoid compressive optic neuropathy. There is no reason to believe that the incidence of such occurrences is sufficiently high, nor the treatment of those few unfortunate enough to suffer compressive optic neuropathy sufficiently inadequate, so as to warrant exposing the large number of former TED patients to the risks attendant to orbital decompression prior to surgery as common as cataract extraction. In patients who have demonstrated risk of reactivation, such as in our case report, we will consider the use of perioperative prophylactic oral steroids. We will otherwise continue to treat all patients with TED, be they active or stable, with the same conservative, expectant management, which limits morbidity associated with both the disease and its treatment.
Luna Xu, M.D. Lora R. Dagi Glass, M.D. Michael Kazim, M.D. Correspondence: Luna Xu, M.D., Department of Ophthalmology, New York Eye and Ear Infirmary, New York, NY 10003 (luna. [email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Campbell A, Whittaker TJ, Sokol JA. Re: “Reactivation of thyroid eye disease following extraocular muscle surgery.” Ophthal Plast Reconstr Surg 2014:30:353–4. 2. Xu L, Glass LR, Kazim M. Reactivation of thyroid eye disease following extraocular muscle surgery. Ophthal Plast Reconstr Surg 2014;30:e5–6.
354
3. Selva D, Chen C, King G. Late reactivation of thyroid orbitopathy. Clin Experiment Ophthalmol 2004;32:46–50.
Re: “Medial Conjunctival Resection for Tearing Associated With Conjunctivochalasis” To the Editor: We read with interest the results of a recent article by Petris and Holds1 describing the results of medial conjunctivoplasty for the surgical treatment of symptomatic patients with conjunctivochalasis (CCh). We congratulate the authors for quantifying the severity of epiphora to judge the success of their intervention in this population. Their results reveal that the majority (80%) of CCh cases benefit from a medial conjunctival procedure and support the role of punctal occlusion in the development of epiphora in CCh. In our previous report published in Cornea, we were able to demonstrate that among 75 patients with different severity of CCh, 47 (63%) patients had punctal occlusion, 54 (72%) had delayed fluorescein clearance test (FCT), and 56 (75%) had epiphora.2 Furthermore, epiphora and delayed FCT were more frequently observed with increasing grades of CCh and were strongly correlated (r = 0.797, p
Letters to the Editor
Reply re: “Reactivation of Thyroid Eye Disease Following Extraocular Muscle Surgery” To the Editor: We thank Dr. Campbell et al.1 for their interest in our case report.2 We agree that the cumulative body of literature, albeit case reports, supports a causal relationship between periocular surgery and the development of thyroid eye disease (TED) in at-risk patients. In addition, the rate of recurrent TED—previously thought to be rare—is at least as high as 5%.3 Therefore, it does not surprise us that more cases continue to be identified. We find that the cases that Dr. Campbell reports differ from ours in 2 important ways. First, in our case, the temporal relationship between the presumed inciting surgery and active TED is extremely short (1 month on both occasions), measurably increasing the likelihood of a causal relationship. In Dr. Campbell’s cases, the interval between the presumed inciting event and their first examination of the patients was 6 and 9 months, respectively. This delay in reactivation significantly increases the possibility of unprovoked recurrent disease. Second, our case presents the interesting finding of active orbitopathy contralateral to the operated. This finding, we believed, further established the systemic immune nature of the provocation over a local traumatic event. Most importantly, we must respectfully voice our strong disagreement with Dr. Campbell’s suggestion that all patients with prior history of TED should undergo prophylactic orbital decompression before any periorbital surgery to presumably avoid compressive optic neuropathy. There is no reason to believe that the incidence of such occurrences is sufficiently high, nor the treatment of those few unfortunate enough to suffer compressive optic neuropathy sufficiently inadequate, so as to warrant exposing the large number of former TED patients to the risks attendant to orbital decompression prior to surgery as common as cataract extraction. In patients who have demonstrated risk of reactivation, such as in our case report, we will consider the use of perioperative prophylactic oral steroids. We will otherwise continue to treat all patients with TED, be they active or stable, with the same conservative, expectant management, which limits morbidity associated with both the disease and its treatment.
Luna Xu, M.D. Lora R. Dagi Glass, M.D. Michael Kazim, M.D. Correspondence: Luna Xu, M.D., Department of Ophthalmology, New York Eye and Ear Infirmary, New York, NY 10003 (luna. [email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Campbell A, Whittaker TJ, Sokol JA. Re: “Reactivation of thyroid eye disease following extraocular muscle surgery.” Ophthal Plast Reconstr Surg 2014:30:353–4. 2. Xu L, Glass LR, Kazim M. Reactivation of thyroid eye disease following extraocular muscle surgery. Ophthal Plast Reconstr Surg 2014;30:e5–6.
354
3. Selva D, Chen C, King G. Late reactivation of thyroid orbitopathy. Clin Experiment Ophthalmol 2004;32:46–50.
Re: “Medial Conjunctival Resection for Tearing Associated With Conjunctivochalasis” To the Editor: We read with interest the results of a recent article by Petris and Holds1 describing the results of medial conjunctivoplasty for the surgical treatment of symptomatic patients with conjunctivochalasis (CCh). We congratulate the authors for quantifying the severity of epiphora to judge the success of their intervention in this population. Their results reveal that the majority (80%) of CCh cases benefit from a medial conjunctival procedure and support the role of punctal occlusion in the development of epiphora in CCh. In our previous report published in Cornea, we were able to demonstrate that among 75 patients with different severity of CCh, 47 (63%) patients had punctal occlusion, 54 (72%) had delayed fluorescein clearance test (FCT), and 56 (75%) had epiphora.2 Furthermore, epiphora and delayed FCT were more frequently observed with increasing grades of CCh and were strongly correlated (r = 0.797, p
