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© Borgis - New Medicine 1/2016, s. 12-14 | DOI: 10.5604/14270994.1197170
*Robert Brodowski1, Bogumił Lewandowski1, 2, Mateusz Dymek1, Iwona Gawron3, Hanna Hartman-Ksycińska2
The application of surgical decompression in relieving the symptoms of thyroid-associated ophthalmopathy
1Department of Maxillofacial Surgery, Frederic Chopin Clinical Hospital No.1 in Rzeszów, Poland
Head of Department: Bogumił Lewandowski, MD, PhD, Ass. Prof.
2Department of Emergency Medicine, Faculty of Medicine, University of Rzeszów, Poland
Head of Department: Bogumił Lewandowski, MD, PhD, Ass. Prof.
3Podkarpackie Oncology Centre in Rzeszów, Poland
Head of Department: Jan Gawełko, MD, PhD
Summary
Introduction: Thyroid-associated ophthalmopathy (TAO) is characterized, among others, by exophthalmos in patients with hyperthyroidism. It occurs in approximately 15% of patients with Graves' disease. The incidence rate of women to men is 4.5:1. The eyeballs protrude outside the bony edges of the eye sockets, causing eyelid retraction, dryness of the conjunctival sac, leading to formation of erosions and ulceration of the cornea, and bulbar conjunctiva. Untreated, the condition can lead to serious damage of the eye, including loss of vision.
Case report: The paper presents a case of a 56-year-old female with ophthalmological complications in the form of exophthalmos in the course of Graves' disease. The patient complained of mild pain in and behind the eyeballs increasing upon eyeball movement, the sensation of eye protrusion, difficulty in closing the eyelids causing dryness of the conjunctiva, and photophobia. The severity of the ophthalmic symptoms posed a serious risk of blindness. Surgical decompression of the orbit was performed by removing the medial wall and the floor of the orbit bone in order to protect the patient’s vision. Post-surgical improvement was observed not only in the local condition, but also in the cosmetic effect.
Introduction
Severe thyroid-associated ophthalmopathy (TAO), also known as severe orbitopathy, infiltrative oedematous exophthalmos, or malignant exophthalmos, is one of a triad of ophthalmologic symptoms of thyrotoxicosis, observed in approximately 15% of cases in Graves’ disease. The incidence rate of women to men is 4.5:1 (1-3). The eyeballs protrude outside the bony edges of the eye sockets, causing eyelid retraction, dryness of the conjunctival sac, formation of erosions and ulceration of the cornea, and bulbar conjunctiva. Swelling and infiltration of the muscles interferes with eye movement, potentially leading to double vision and impaired visual acuity including loss of vision. TAO significantly reduces the patients’ quality of life. Benign changes in the eyesight occur in most patients with hyperthyroidism, impairing the ability to see, yet causing no threat of vision loss as they resolve with the relief of hyperthyroidism symptoms. They do not require special treatment and are limited to being an aesthetic defect (4, 5).
The development of the disease is determined by genetic, environmental and endogenous factors. These include: gender, age, with the peak of incidence falling between 50 and 70 years of age, smoking, thyroid disorders, both hyperthyroidism and hypothyroidism, and radioiodine therapy (1).
The pathogenesis of TAO is the presence of THS receptor (TSHR) antigen in the follicular epithelial cells of the thyroid and fibroblasts of the orbits, skin and orbital preadipocytes. It is assumed that T cells are directed against a common antigen, and triggered by the influence of circulating adhesion retrobulbar proteins infiltrate extraocular tissues and oculomotor muscles. The pathogenesis of infiltrative oedematous exophthalmos includes three processes: infiltration, swelling, and subsequent fibrosis (1, 2).
The extraorbital tissue is infiltrated by mononuclear cells, lymphocytes, and activated fibroblasts, cytokines are released (interferon-gamma, tumor necrosis factor, inerleukin-6), production of glycosaminoglycans is increased, and immunomodulatory proteins are released. This process also indirectly affects extraocular muscles. What results is substantially increased content of interstitial tissue and nerve fibers as compared to skeletal muscles. Histopathological changes in oculomotor muscles involve interstitial connective tissue. The process of inflammation in the connective tissue results in a significant change in the volume and function of extraocular muscles. The orbital contents increase as a result of infiltration and tissue oedema, which hinders the venous and lymphatic outflow from the orbit. The intraocular pressure and the pressure on the optic nerve increase. It is the active phase of ocular lesions, leading to a disproportion between the capacity of the orbit and its contents. This results in protrusion of the eyeballs and the impairment of their mobility. The next step is the process of fibrosis, which indicates the transition to the inactive phase (1, 3, 6).
Mangement of infiltrative oedematous exophthalmos is in the first place symptomatically-pharmacological treatment intended to reduce infiltration and swelling of the tissues filling the orbit. A three-stage method of treatment is required: immunosuppressive therapy combined with corticosteroids are recommended in the first stage. Radiotherapy is used in the second stage of treatment. Another method of reducing the pressure on the optic nerve, and increasing the capacity of the orbit is a surgical removal of the wall of the orbit and intraorbital fat called orbital decompression (3, 6). Surgical orbital decompression is applied both in the active and inactive phase, and is used in emergency situations threatening with loss of vision (6, 7). Adjunctive therapy is helpful, which involves the use of topical anti-inflammatory drops and ointments and, where appropriate, drops reducing intraocular pressure, diuretics, higher position of the head during night, darkened or prismatic glasses, and cornea protection. In any case of thyroid dysfunction, treatment aimed at balancing the thyroid function is necessary: thyreostatics in the phase of hyperthyroidism and thyroxine in hypothyroidism (1, 2, 6).
Case report
A 56-year-old female was referred to the Clinical Department of Maxillofacial Surgery from the Ophthalmology Department of Provincial Specialist Hospital in Rzeszów for a surgical decompression of the orbits in the course of severe infiltrative oedematous ophthalmopathy posing a serious risk of blindness. The patient had a 28-year history of Graves’ disease, hypertension, and following strumectomy in 2014 underwent adjuvant therapy.

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Piśmiennictwo
1. Sewerynek E: Rozpoznanie i leczenie objawów ocznych w przebiegu chorób tarczycy o podłożu autoimmunologicznym. Forum Med Rodz 2007; 1: 143-151. 2. Baldeschi L, Wakelkamp MJ, Lindeboom R et al.: Early versus late orbital decompression in Graves’ orbitopathy. A retrospective study in 125 patients. Ophthalmology 2006; 113: 874-878. 3. Babiński D, Skorek A, Nałęcz A, Stankiewicz C: Dekompresja oczodołu w przypadku orbitopatii tarczycowej. Otolaryngol Pol 2011; 65(4): 262-265. 4. Goldberg RA: The evolving paradigm of orbital decompression surgery. Arch Ophthalmol 1998; 116: 95-98. 5. Bałdys-Waligórska A, Gołkowski F, Kusnierz-Cabala B et al.: Graves’ ophthalmopathy in patients treated with radioiodine 131-I. Endokrynol Pol 2011; 62: 214-219. 6. Sellari-Franceschini S, Berrettini S, Santoro A et al.: Orbital decompression in Graves’ ophthalmopathy by medial and lateral wall removal. Otolarymgol Head and Neck Surg 2005; 133: 185-189. 7. Pecold K, Krawczyński M: Chirurgia oczodołu. [W:] Pecold K, Krawczyński M (red.): Oczodół, powieki i układ łzowy. Urban & Partner, Wrocław 2005: 115-123.
otrzymano: 2015-11-02
zaakceptowano do druku: 2016-01-04

Adres do korespondencji:
*Robert Brodowski
Department of Maxillofacial Surgery Frederic Chopin Clinical Hospital No.1 in Rzeszów
2 Chopina Str., 2 35-055 Rzeszów, Poland
tel.: +48 (17) 866-62-62
e-mail: robert.brodowski@wp.pl

New Medicine 1/2016
Strona internetowa czasopisma New Medicine