Management of Diplopia in Thyroid Eye Disease

Educational Objectives

The goal of this program is to improve the management of patients with thyroid eye disease-associated diplopia. After hearing and assimilating this program, the clinician will better be able to:

1. Select appropriate surgical options for patients with diplopia secondary to thyroid eye disease.

Summary

Strabismus: seen in ≈15% of patients with Graves disease; only ≈5% require surgery; inferior rectus most commonly involved muscle; causes limitation of eye movement and positive forced ductions; develops ≈5 yr after onset of thyroid disease

Diplopia: orbitopathy usually present for ≈2 yr before onset; experienced by ≤30% of patients after orbital decompression; management — thyroid eye disease usually resolves spontaneously but diplopia persistent; use of prisms temporary measure that corrects diplopia in single direction of gaze; surgical intervention recommended only after ≈6 mo of stable inactive orbital disease; if orbital decompression performed, strabismus surgery should be delayed for ≈2 mo; ensure diplopia constant and significant, head position significant, and medical condition and orbitopathy stable

Surgical considerations: superiority of adjustable vs fixed sutures much debated; strabismus nomograms cannot be used to determine extent of recession in patients with thyroid eye disease; intraoperative or postoperative adjustment necessary; conjunctiva friable; tight muscles increase risk of tearing; inferior rectus must be separated from lower eyelid retractors

Examination: evaluate ductions; examine eyes separately; measuring extent of esotropia or hypertropia unnecessary; restrictions most important; measure degrees of excursion (more reliable than forced duction test)

Surgical procedures: operate on all tight muscles at same time (maximum of 2 muscles per eye recommended); inferonasal fornix incision provides access to medial and inferior muscles simultaneously; cut check ligaments and capsulopalpebral ligament; relaxed muscle positioning technique — with eye in primary position and muscle relaxed, mark point on globe where suture to be placed and secure with absorbable suture; in 2 studies, >82% of patients free of diplopia without prismatic correction in primary and reading positions, 1 in 5 required second surgery, and all showed improvement in ocular motility

Readings

Eckstein A et al: Surgical treatment of diplopia in Graves orbitopathy patients. Ophthalmic Plast Reconstr Surg 2018 Jul/Aug;34(4S Suppl 1):S75-S84; Harrad R: Management of strabismus in thyroid eye disease. Eye (Lond) 2015 Feb;29(2):234-7; Nicholson BP et al: Efficacy of the intraoperative relaxed muscle positioning technique in thyroid eye disease and analysis of cases requiring reoperation. J AAPOS 2011 Aug;15(4):321-5.

Disclosures

For this program the following has been disclosed: Dr. Traboulsi reported nothing to disclose. Members of the planning committee reported nothing to disclose.

Acknowledgements

Dr. Traboulsi was recorded at Ophthalmology Update 2018, held November 30 to December 1, 2018, in San Francisco, CA, and presented by the University of California, San Francisco, Beckman Vision Institute and Department of Ophthalmology. For information about future CME activities from this sponsor, please visit https://meded.ucsf.edu/. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the presentation of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP570501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.