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. Hyperthyroid 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 and late stages of the eye disease. Specific treatment methods include the following summarized.
(A) Local treatment.
First, strengthen protective measures, pay attention to eye rest, wear sunglasses to avoid bright light and various external stimuli; eyes if they are not fully closed, apply antibacterial eye ointment before bedtime and wear eye shields to protect the conjunctiva and cornea; use unilateral eye shields to reduce diplopia, high pillow position, control salt intake, drops of antibacterial eye drops (cream) containing artificial tears and cortisone eye drops (alternately); 1% methylcellulose eye drops to reduce eye irritation symptoms are more effective. Second, postbulbar or subconjunctival injections of methylprednisolone or hyaluronidase and other drugs may have some effect on reducing postbulbar tissue edema in some patients.
(ii) Systemic treatment (immunosuppressive therapy).
For proptosis with active ocular signs such as bulbar conjunctival congestion and edema, lacrimation and photophobia, systemic drug therapy can be applied, and the following regimens can be selected and applied according to changes in the condition.
(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, maintain for 3-6 months.
(2) Prednisone high-dose oral therapy: In cases of 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, 30-60 mg of prednisone daily can be used as a once-daily dose; dexamethasone, 1.5 mg daily, can also be used in 3 doses. After the symptoms are reduced, continue to maintain for a period of time (about 2 weeks) and then gradually reduce the dosage (5mg/day per week), the total course of treatment should not be less than 3 months.
(4) Immunosuppressive shock therapy: usage: vincristine 1.5-2mg, cyclophosphamide 400-600mg, once a week, 7 days as a course of treatment, can be repeated for 3-4 courses. Indicated for those who are ineffective in hormone shock therapy or have 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 once daily, 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 is more effective 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 orally daily (CB 2-4 mg/d) 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.
(iii) Radiation therapy.
Radiotherapy for hyperthyroidism proptosis has an efficiency of about 60%, and is more effective for recent soft tissue inflammation and recently occurred ocular muscle dysfunction. Diabetic and hypertensive retinopathy are contraindications to orbital radiation therapy, and cases with poor efficacy of hormonal 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 treatment 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 the resolution of inflammation often occurs within 2-4 wk after radiation therapy. In contrast, the relief of other signs is incomplete and sometimes indeterminate.
(iv) Surgical treatment.
(1) Eyelid regression correction: The main purpose 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 lid closure resulting in foreign body sensation and keratitis in patients.
(2) Orbital decompression: Orbital decompression is an effective treatment for severe proptosis. The purpose is to increase the orbital volume by removing the orbital wall and/or retrobulbar fibrous adipose tissue, allowing the eye to retract, thereby reducing the proptosis and the pressure of 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 large surgical resection areas.
(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, the proptosis can be reduced by a few millimeters immediately after surgery, and it can be retracted by 1 to 2 millimeters after 2 months, and the visual acuity and double vision can be improved rapidly.
(4) Cosmetic surgery: The swollen subcutaneous tissue around the eye sockets is modified to improve the appearance of the eye. As for eyelid surgery it is.
(5) Other treatment methods.
Including post-ocular injection of dexamethasone hyaluronidase, intravenous injection of Yunque and oral treatment with drugs such as Comedogen, etc. In particular, Yunque and Comedogen have been clinically applied in our department to show that they have better results and do not have the side effects of hormone and cyclophosphamide drug treatment, so it is worth promoting their application.