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Exophthalmos Surgery

Turkey is at the risk of goiter disease. And 60 out of every 100 people in the community have an incipient goiter. Unfortunately, the sex ratio is unfavorable for women again. The incidence rate of goiter disease in women is 5 times higher than that in men…
The unknowns about exophthalmos affecting social life that may lead to important physical losses; What is exophthalmos, why does it occur, and how is it treated?

What is thyroid?

The thyroid is one of the most important endocrine gland (secreting hormone into the blood) that regulates the body’s metabolism. In other words, thyroid is responsible for our metabolism. If there is a task-sharing, the right answer to the question of “what does the thyroid manage” would be the ‘brain’. So, what part of the brain is used to manage it? The pituitary gland acts like our orchestra conductor, and the thyroid acts like our leader violinist. If this orchestra has also an engineer responsible for voice, it is the hypothalamus. In this cycle functioning as the chain of command, the hypothalamus stimulates the thyroid gland to secrete hormones. After this point, the pituitary gland located at the top becomes responsible for receiving the message and doing what needs to be done.

What are Thyroid diseases?

The most commonly observed symptoms of thyroid disorder are the condition of a bulging/protruding eyeball(s). The cases of bulging eyes, diplopia and goiter with eye involvement that can also cause blindness are defined as thyroid ophthalmopathy (Graves’ Ophthalmopathy). Eye involvement may be caused by over-functioning of the thyroid glands (toxic goiter), and a more rarely, due to inadequate-functions of the thyroid gland (hyperthyroidism) or Hashimoto’s thyroiditis. The symptoms in the eyes can be observed as an increased opening of the upper eyelids, bulging eyeballs (exophthalmos), diplopia, eye nerve involvement, and blindness.

What are the symptoms of thyroid disease?

The most commonly observed symptoms of thyroid disorder are the condition of a bulging/protruding eyeball(s). The cases of bulging eyes, diplopia and goiter with eye involvement that can also cause blindness are defined as thyroid ophthalmopathy (Graves’ Ophthalmopathy). Eye involvement may be caused by over-functioning of the thyroid glands (toxic goiter), and a more rarely, due to inadequate-functions of the thyroid gland (hyperthyroidism) or Hashimoto’s thyroiditis. The symptoms in the eyes can be observed as an increased opening of the upper eyelids, bulging eyeballs (exophthalmos), diplopia, eye nerve involvement, and blindness.

Other symptoms include pain, lacrimation, dry eye, irritation, photophobia, ocular muscle weakness that causes diplopia, and optic nerve compression resulted in permanent loss of vision. Systemic symptoms include irritability, palpitation, weight loss despite an increased appetite, and insomnia. Besides these, “Pretibial myxedema” is a rare symptom, detection of which is very valuable in terms of diagnosis. It is located at the sides of the both legs (above the ankle). It is reflected by the increase in the thickness and hardness of the skin. It can be slightly sensitive, and in pink or reddish color. Especially its lower limit that ends with the foot is highly evident.

Who are at risk?

It can be seen in women and men of all ages. However, it is more common in women due to pregnancy, childbirth, and frequent changes in hormone balances. It can be more common in certain territories and regions. For example; it is more common in Eastern Black Sea and Central Anatolia. (It is more commonly seen in residential areas, where water has high lime content)

What are the symptoms that appear in the eyes ?

Exophthalmos, the major symptom, gives a sulky appearance to the patient’s face. The fact that the current appearance has been acquired in the course of time can be confirmed if the appearance is compared with the patient’s previous photographs. Eyeballs bulge in real terms. In addition, the protruding eye image causing the patient to take on a bewildered and annoyed expression is aesthetically disturbing for him/her.  It adversely affects the social life of the person.

Besides its effects on the social life, it also physically leads to redness of the eyes in early periods, swelling of the eyelids and eyelid edema in the mornings; dryness of the eyes and keratomalacia due to the inability to close the eyelids suffered at nights in the following periods and also during the day in later periods. The causes of this condition of the eye are an edema in the orbita behind the eye (eye socket), swelling in the muscles that move the eye, and contusion of the optic nerves.

How should the clinical evaluation be ?

The evaluation is initiated with a good clinical examination. In the clinical examination, first the beginning of the disorder, coexisting symptoms (impairment of visual acuity, diplopia, etc.) and the general symptoms (fever, impairment of the general state, etc.) should be asked.

Visual examination:  It enables the physician to determine whether the disorder is unilateral of bilateral; to measure the exophthalmos by measuring the distance between the outer edge of the eye socket and the transparent top layer by means of an exophthalmometer (perimeter); and to evaluate the condition of the eyelids, whether there is any inflammation and the possibility that the eye might be pushed not only forward but also to sides, upwards or downwards.

Palpation: The condition of the distance between the eyeball and the eye socket is examined from the top of the eyelids (normally free). A pulsating exophthalmos that cannot be pushed back is usually the sign of a tumor in the eye socket.

Complete eye examination: It enables the diagnosis of all coexisting eyeball abnormalities such as impairment of visual acuity, narrowed field of view, abnormal cornea sensitivity, increased intraocular pressure, bulbar palsy due to an internal or external factor, visual field abnormalities, etc.

Complementary examinations:Advanced imaging methods such as CT or MRI or laboratory tests are used to confirm the diagnosis and identify the underlying disease. These examination procedures selected in light of clinical examination data mostly enable the identification of the cause and make it possible to approach this diagnosis.

How is exophthalmos treated ?

The thyroid related symptoms in the eyes might include abnormal opening of the eyelids, bulging eyeballs, diplopia, and impairment of visual acuity. Each of these are different conditions involving different tissues in the eye, and should be taken care of individually. For example, abnormal opening of the eyelids suggests the presence of eyelid palsy, bulging in the eyes suggests the presence of an orbital edema, and diplopia suggests the existence of thickened muscles that move the eye. In such cases, early treatment can prevent further protrusiveness of the eye. Improvement of thyroid test results, smoking cessation, and using simple eye drops are recommended in an early period, and severe cases may require cortisone treatment.
If the protrusiveness of the eye cannot be prevented in later periods, the transpalpebral decompression procedure is carried out for taking the eye back into its place. The use of cortisone in late periods is useless and unnecessary in placing the eye in its place, and leads to nothing more than its side effects. Its treatment requires transpalpebral decompression surgery.

What is the transpalpebral decompression surgery ?

Transpalpebral decompression is a surgery done under general anaesthesia. It is a surgical procedure that involves the removal of increased intraorbital fat and fat located around the eyes. The eye socket (orbit) is the bone structure harboring the eyeball as well as the muscles and nerves around it. Since the bone walls are rigid, they cannot be flexed. The bony wall cannot be flexed in cases such as ophthalmopathy (Graves) caused by a tumor or thyroid that increases the volume of the eye and its surrounding tissues; and as a result, the eyeball and optic nerve remains under pressure. In these patients, an increase occurs in surrounding muscles and adipose tissues of the eyes. Due to the bony structure of the orbital wall, the eye is pushed forward and the optic nerve behind it starts to get compressed. If this condition lasts longer, the optic nerves will get damaged. In addition, these patients complain of the increased pressure and pain in and around the eyes. In such cases, the increased pressure in the eyes and around the optic nerve is reduced to normal, by means of transpalpebral decompression surgery.

Do the eyes look natural with this treatment ?

The surgical operation is done under general anaesthesia. During the operation, the enlarged intraorbital fat around the eye socket (orbit) is removed. When this process is completed, the eyeball goes back to its original place, and gains a more natural appearance.

Is exophthalmos surgery a difficult process ?

Transpalpebral decompression surgery is one of the most difficult surgeries, and takes a long time. In order not to keep the patient under anaesthesia for a long time, and because the eye will be kept closed for 3 days after surgery, it is better not to operate both eyes at the same time. However, if there are serious complaints about both eyes, and if there is no time to wait, the medical limits can be pushed. Apart from this, it would be appropriate to operate the eyes in two separate operations like 3 to 4 days after the first one. Therefore about a 1-week hospital stay is expected. The swelling in the eye will get better in 15 days, and we remove the sutures 1 week after the surgery so it is better for the patient to rest at home for 20 to 25 days.