Hyperthyroidism proptosis is a refractory complication of hyperthyroidism, clinically known as thyroid-associated ophthalmopathy or Graves’ ophthalmopathy (GO), etc. It is an organ-specific autoimmune ophthalmopathy closely related to thyroid disease. It can occur at any time during the course of the disease and is not significantly associated with the length of the disease or the severity of the disease. Hyperthyroidism proptosis has a high prevalence among orbital diseases, and the detailed pathogenesis is unclear and difficult to treat. When hyperthyroidism proptosis threatens vision due to the possibility of exposure keratitis or compressive optic neuropathy, treatment measures should be taken regardless of the early or late stage of the eye disease. Specifically, the following treatment methods are summarized.
I. Local treatment
First, to strengthen protective measures, pay attention to eye rest, wear sunglasses to avoid bright light and a variety of external stimuli; eyes if not fully closed, antibacterial eye ointment before bed, and wear an eye patch to protect the conjunctiva, cornea; unilateral eye patch to reduce diplopia, high pillow position, control salt intake, drops containing artificial tears antibacterial eye drops (cream) and cortisone eye drops (alternately); 1% methylcellulose drops to reduce eye irritation symptoms is more effective.
Secondly, the posterior bulb or subconjunctival injection of methylprednisolone or hyaluronidase and other drugs may have a certain effect on reducing postbulbar tissue edema in some patients.
Second, systemic treatment (immunosuppressive therapy)
For patients with proptosis with active ocular signs such as bulbar conjunctival congestion and edema, lacrimation, photophobia, etc., systemic drug therapy can be applied, and the following regimens can be selected according to the changes of the disease.
(1) Corticosteroid shock therapy. Shock therapy can be applied to cases with good proptosis and severe ocular symptoms. Administration regimen: methylprednisolone 500-1000mg/day, 3 days of sedation, 4 days of interval as a course of treatment, can be repeated for 2-4 courses. And then oral prednisone 60-90mg/day, gradually reduce to 5mg and maintain for 3-6 months.
(2) Prednisone high-dose oral therapy: For cases with proptosis and obvious ocular symptoms, prednisone (prednisone acetate) can be applied 60-90mg/day once daily in a single dose, and after the symptoms improve (about 2 weeks later), the dose will be reduced gradually (5mg/day per week) to the lowest level (5-10mg/day) that can maintain the improvement of symptoms, and the whole course of treatment will be about 3-6 months.
(3) Prednisone conventional dose treatment: For moderate (grade 2-4) infiltrative proptosis (mild symptoms) cases, 30-60mg of prednisone daily can be used as a single daily dose; dexamethasone can also be used, 1.5mg per day, divided into 3 doses. After the symptoms are reduced, continue to maintain a period of time (about 2 weeks) and then gradually reduce the dose (5mg/day per week), the total course of treatment is not less than 3 months.
(4) Immunosuppressive shock therapy: Usage: vincristine 1.5-2mg, cyclophosphamide 400-600mg, once a week, 7 days as a course, can be repeated for 3-4 courses. Indicated for those for whom hormone shock therapy is not effective or has contraindications.
(5) Combination or alternate application of immunosuppressants and hormones Combination application: methylprednisolone 0.5g in 250ml of saline and cyclophosphamide 0.2g in 500ml of saline IV once a day for 3 days, repeated at intervals of 5-7 days for a total of 3-5 courses of treatment. In addition, some scholars have tried local injection of dexamethasone 5mg + cyclophosphamide 50mg + cyclosporine A 50mg once daily in the thyroid gland during the interval and achieved better efficacy. Alternate application: cyclophosphamide 200mg daily (or every other day) intravenously (or CB1348 6mg daily) and prednisone 30-60mg daily (or every other day) orally every other week (or every other day) alternatively has better efficacy and can reduce the drug dosage and side effects. After 3-4 weeks of treatment, prednisone is gradually reduced or discontinued, and cyclophosphamide is changed to 50-100 mg (CB 2-4 mg/d) orally daily for a longer period.
Special attention should be paid to patients with peptic ulcers, osteoporosis, family history of psychiatric disorders, pregnant women, lactating women, and patients with hypertension and diabetes. The above drugs should be monitored for changes in blood pressure, blood glucose, blood electrolytes and liver and kidney functions, and treated accordingly.
Radiation therapy
Radiation therapy for hyperthyroidism proptosis has an efficiency of about 60%, and is more effective for recent soft tissue inflammation and recent eye muscle dysfunction. Diabetic and hypertensive retinopathy are contraindications to orbital radiation therapy, and cases with poor hormone therapy are often insensitive to radiation therapy. This therapy can be applied alone or in combination with glucocorticoids. The combination can increase the efficacy and reduce the incidence of temporary exacerbation of the disease with radiotherapy alone and the recurrence rate when glucocorticoids alone are discontinued.
The combination of glucocorticosteroid therapy can reduce the orbital and conjunctival edema caused by radiation therapy, which can cause increased orbital inflammation within 1 week. The method used nowadays is unilateral irradiation using a linear gas pedal releasing 4 to 6 MV of energy. The irradiation field includes the entire orbit and orbital apex, avoiding the crystal in front and the pituitary area in the back. The dose was 20 Gy per eye, with 5 weekly irradiations of 2 Gy each.
Radiation therapy is very effective in relieving the patient’s inflammatory symptoms, and regression of inflammation often occurs within 2 to 4 wk after radiation therapy is administered. In contrast, the relief of other signs is incomplete and sometimes uncertain.
IV. Surgical treatment
(1) Eyelid recession correction: The main objective is to adjust the Müller muscle of the upper eyelid so that the eyelid pull-up is improved. It is mainly indicated for lid recession in one or both eyes with lid fissures that are too large requiring improved appearance; or incomplete eyelid closure resulting in foreign body sensation and keratitis in patients.
(2) Orbital decompression: Orbital decompression is an effective treatment for severe proptosis. The goal is to increase the orbital volume and allow the eye to retract by removing the orbital wall and/or retrobulbar fibrofatty tissue, thereby reducing the pressure of the proptosis and the eye muscle on the optic nerve. Indications include optic neuropathy or recurrent subluxation of the eye that pulls on the optic nerve causing visual field loss, vision loss or even loss of vision, or severe protrusion of the eye causing severe damage to the cornea; or the patient cannot accept the change in appearance caused by the protrusion of the eye. Complications mainly include surgery may cause diplopia or aggravate diplopia, especially in those with a large surgical resection.
(3) Treatment of diplopia: With the help of eye muscle surgery, adjustments can be made to the enlarged fibrotic muscles to reduce diplopia. If the surgery is successful, usually the proptosis can be reduced by a few millimeters immediately after the surgery, and it can be retracted by 1 to 2 millimeters after 2 months, and the visual acuity and the phenomenon of double vision can be improved rapidly.
(4) Cosmetic surgery: The swollen subcutaneous tissues around the eye sockets are trimmed to improve the appearance of the eye. As for eyelid surgery it is.
V. Other treatment methods
Including post-ocular injection of dexamethasone hyaluronidase, intravenous injection of Yunque and oral treatment with drugs such as Comedogen, etc. Especially Yunque and Comedogen have been clinically applied by our department to show that they all have better effects and do not have the side effects of hormone and cyclophosphamide drug treatment, so it is worth promoting the application.