Graves’ Disease Ophthalmology in Children and Adolescents

>>All right, so last discussion this morning
is about Graves’s ophthalmology, Graves’s eye disease. And as you’ve already kind of
figured out we have one or two people we’ve selected from each discipline and Bill, actually had
some expertise prior from training in the UK and is a legacy, his dad is also an ophthalmologist
at CHOP [The Children’s Hospital of Philadelphia] so he has a real foundation and footing at
CHOP, and has been a wonderful addition for our team. So, all of our patients that have eye disease
Dr. Katowitz will see initially, and then – I’m not sure what the percentage is, he’ll
probably let you guys know how many patients eventually need some type of surgical intervention.
I think it’s less than the patients that just need follow-up. But the follow-up is care that I’m not capable
of providing all of our expertise, and Graves’ ophthalmopathy is Dr. Katowitz, it’s not mine.
I can identify it. He’s better at taking care of it, and deciding if and when something
has to be done. So, he is our only ophthalmologist. We have a neuro ophthalmologist, Dr. Liu as
well. So, between Dr. Liu and Dr. Katowitz, our patients, the ones that need care, are
referred to them. So, Dr. Katowitz?>>Thank you so much. And thank you, Dr. Bauer
and Dr. Adzick for inviting me to speak today. It’s an honor and I’m very excited to talk
to you about eye disease. Can everyone hear me OK? Great. So, I have no financial interest
in any of the materials I’m presenting today. So, who provides eye care? The primary care
doctor in many cases. Someone says they have dry eyes. Typically, a primary care doctor
may say, “Well, let’s try artificial tears.” Sometimes it’s even a nurse practitioner in
a practice or within a pediatrics – pediatrician’s office. And then there are eye practitioners.
And now, an eye practitioner could be an optometrist, someone who went to something called optometry
school. Sometimes even the optician, the person that dispenses glasses, will offer some eye
care and then finally, a person who is a medical doctor who is an ophthalmologist. And that’s
an eye doctor who completed a four-year ophthalmology residency, they’re board-certified in the
field of Ophthalmology – which is spelled kind of oddly. And this is a person who has
hospital privileges to perform eye surgery, as well as surgery around the eye, and they
do prescribe medications. Now, there are different kinds of ophthalmologists,
and this is where it gets confusing. There are general ophthalmologists, and they sometimes
see kids and adults. There are cornea specialists that will often address dry eye disease, as
well as other problems relating to the window of the eye. And then, also very relevant to
us here, are pediatric ophthalmologists who – we have a very large practice here at
Children’s Hospital in Philadelphia – and those are people that see children, and treat
most diseases. And then, within ophthalmology is this subset of eye doctors called ocular
plastic surgeons of which I am, and have had additional training in essentially plastic
surgery around the eye. So, I’m an eye doctor who did additional fellowship
training, and then had fellowship training in both pediatric ophthalmology, and this
field of oculoplastics. And I did train here at The Children’s Hospital of Philadelphia
and the University of Pennsylvania, and then I spent a year, actually in London, where
I saw a lot of patients with thyroid eye disease. When I speak with pediatricians and explain
what it is oculoplastic surgeons do, I say there are four T’s; tearing, tumors, trauma,
and ptosis – which is actually spelled with a P, but it sounds like a T so it works. So, today I’ll be speaking on the subject
of thyroid eye disease, and discussing the symptoms, and then finishing up with treatments.
And I know we’re going to have questions at the end, but if I’m going too quickly, or
if I’ve explained something, and I haven’t explained it very well please interrupt me,
and say, “Can you just clarify this,” because I’d like to just get these points across. So, I realize I’ve left some things off this
list that Dr. Bauer and Adzick presented because it’s quite a large team. But I think it’s
just important, and I think you’re hearing from today that you are not alone in this
process and we are here as a service, as a center to help you with many different supportive
figures. So, it was an Irish physician in 1835 who
recognized that there was an association in a large thyroid gland and bulging eyes, and
this was Dr. James Graves. And this is a patient I treated, who is in her teens, who has many
of the classic symptoms of thyroid eye disease. In fact, her symptoms in some ways represent
more of what we see in adults. But I thought this was a good person to start
with because, obviously, you can see that she has what you might see as very prominent
eyes, or what we call eye bulging and the medical term, it’s proptosis or even exophthalmos.
So, you can see here her eyes are prominent or bulging. And it was an endocrinologist by the name
of Rundle, who in 1945 published a series where he noted that the bulging of eyes associated
with hyperthyroidism occurred over a period of time got worse, and then actually would
get better, but never would resolve to what it was like before it all began for that patient. I was at an international meeting in LA about
10 years ago where a lot of the world leaders in thyroid eye disease – endocrinologist,
and surgeons – met and we tried to come up with a consensus of what we would call
this syndrome, meaning person who has some form of thyroid dysfunction, and eye symptoms.
And we couldn’t agree. Many of us liked the term thyroid eye disease, but a group of Europeans
actually have the term Graves’ ophthalmopathy in their name. So, we never really found an
agreement. Some people liked thyroid-associated obitopathy
because a small percentage of patients, not relevant today here, actually have
hypothyroidism, and present with eye disease. And some even have no symptoms – no thyroid
dysfunction at all, but have the same type of symptoms, and even on pathology look similar.
So, I’m going to use the term thyroid eye disease, but in the literature, and in – out
in the public, you may see a huge different – a wide range of terms. So, thyroid eye
disease, and you’ll see T-E-D as a short term so I don’t have to keep saying it. So, what can happen to your eyes if you have
thyroid eye disease? Well, going back to our patient here who had this presentation and
what we would call active thyroid eye disease, you can see that one of the most common things
we see in thyroid eye disease, and that is lid retraction. Your eyes look – they are
too high so almost like you have a surprised look. And this occurs often times because
there’s scarring and inflammation within the muscles that lift the eyelid, both the lower
and upper lid. And then you can see – obviously, we talked
about this already, the bulging eyes so the eyes appearing more prominent. If you just
sit in the audience and you do this for three seconds, you’re going to want to blink because
that actually leads to your eye feeling very dry. And this is unfortunately what some people
really live with on a daily basis when their eyes are more prominent, or they’re proptotic.
And that, in addition, leads to tearing because your cornea has a nerve in it that says, “Wait
a minute, I’m drying out, I need to wet my eye,” and that kicks in a gland here that
then secretes a lot more water so people with dry eye actually tear and we’ll get to that
later on. And then, less commonly in children, much,
much less commonly in children, is the eyes are not aligned. So, typically we see their
eyes are together. But sometimes patients with thyroid eye disease, because of the size
of their muscles, the eyes are no longer aligned. One eye may be turned in, may be turned out,
may be up, may be down. And because of all this exposure your – the
lining of your eye, or conjunctiva gets very red so you have eye redness. They can get
swollen and really, really less commonly in children is some form of vision loss. Although,
I will say that dry eye typically will knock your vision down by one line. So, people with
exposure, and dryness, and even tearing typically have less sharp vision than the average person. So, getting back to this curve, Rundle’s Curve,
there is what we would call an active phase of eye disease, and then a static phase. And
this active phase can last anywhere from six months to two years typically. And then the
static phase typically lasts for a lifetime, although, there are some things that can make
the static phase worse and I’ll get to that in just a moment. So, getting to why this happened. This is
where I get overwhelmed because I’m an ophthalmologist and not an immunologist. But when I try to
explain it to people I just say it’s – this is an autoimmune disease. But when I show
this slide, which is from a typical paper, you’ll see that we think we’re on to something,
but there is no way we know the thing that causes this. It’s really multifactorial. A colleague of mine has simplified it to recognize
that there are some things on the surface of the eye muscles and fat that perhaps are
related to the thyroid gland. But I really like to explain it this way. Your body is
a factory. The factory makes immune cells that make antibodies that recognize something
on your thyroid gland. And as luck would have it, in this case bad luck, those similar surface
markers are also on the muscles and the fat around your eye, therefore, giving you a similar
type of enlargement. And in this case, it behaves differently because
it’s your eyes. But as your thyroid gland will enlarge, your eyes – the eyeball doesn’t
enlarge – but the eye looks like it’s bigger because it’s being pushed out. So, what actually happens? Well, this is a
CAT scan. This is an X-ray that’s done in serial slices, and then a computer puts it
back together. That’s what computer tomography is, so a CAT scan. And this shows that the
eyes – while you may not appreciate this, but the eyes are being pushed outward because
that black space around – so let’s see how this pointer works. This is your optic
nerve, and these are eye muscles, and these are eyeballs. But this black space here is
actually larger because it’s essentially swollen. There’s more water and there’s more extra
cellular tissue, and later on there’s scarring so that pushes the eye out. Sometimes, if we go back for a second, see
how small this muscle is? Now, look how big this muscle is and that’s just giant. And
your eye sits in a room called your orbit, which is surrounded by bones, and as those
muscles enlarge, the eye has nowhere to go but out. So, this is a person with very large
eye muscles. And this is something we see less typically in children, but it can happen,
especially in adolescents. So, some people – and I’d say this is more
typical for many kids who are older, in their teen years – have more of a balanced appearance
where some of the fat is enlarged, and some of the muscles enlarged. And this becomes
relevant later on when we ever talk about surgery, if it ever comes to that. So, through my years of training, and in treating
adults because I also see adults and I also feel like a patient with thyroid eye disease,
especially a child, is my patient for life because this is not necessarily going to go
away. It’ll get better, but I really – I inherit them as adults, and I see the adults
at The Children’s Hospital of Philadelphia. I like this slide because it really shows
this wide spectrum of presentation that people have in thyroid eye disease. Some people look
essentially – you would almost say that person looks normal. Other people you would
say, “OK, this person has very red eyes,” or, “This person looks like she has a normal
eye, but one eye is actually sticking out.” And I put this picture in because this is
a pediatric patient, but just to show you the difference. The good news is that eye disease in pediatric
patients is not as severe as in adults, and I’ll get to that. And these are some of the
many patients I’ve treated over the years at The Children’s Hospital of Philadelphia
with thyroid eye disease. And also, you can see a varied presentation. This teenager is
much more like that the adult pictures I showed you. You’ll see – you may recognize, but may
be hard to tell. This is the only boy in the whole series because there really is a higher
prevalence of this presentation in female patients. But you can also see some patients
don’t look as severe, but if they showed you pictures of them previously, they’d say, “No,
my appearance has changed.” Whereas other people have one more eye that’s prevalent,
that’s sticking out versus the other. So, how does an eye doctor help in terms of
treating patients with thyroid eye disease, and in hyperthyroidism? Well, I would say
usually we don’t diagnose the hyperthyroidism. I’ve done it a few times, but usually I will
see a person who already has a known diagnosis. It’s bulging eyes or proptosis. The most common
cause in kids is usually actually an infection of the eye. But when we see a bulging eye
we usually get imaging, and are able to diagnose something that is related to thyroid function.
And then we send them to pediatrician, and then an endocrinologist for a true diagnosis
of hyperthyroidism. We’re really there to treat symptoms in this
active phase, and then help restore appearance in what we call the static phase. And that
usually does not involve surgery, but at the end I’ll discuss that. So, this is a young person we’ve seen. We’ve
put some yellow fluorescein dye in her eye, that’s why this is green there, so that we
can see if she has any dryness, and staining on her cornea. When you have eye dryness,
the surface of your cornea looks – I describe to parents it’s like the surface of the moon,
there these little craterations. I say to kids it’s like taking a chocolate chip cookie
and wiping the chocolate chips off, there’s these little, little spaces, and that actually
– causes a certain amount of discomfort. And people, when they have this they actually
sleep often with their eyes open at night, and I’ll explain that in a second. So, you can see this patient has some prominence
to the eyes, and the parents showed me on their cell phone, they said, “This is the
way my daughter looked before this all began.” So, you can definitely see a difference between,
before, and after the beginning of on-set of disease. So, the most common eye symptoms that we see
in pediatric patients is eyelid retraction, or lid lag – the lids are too high; dry
eye and tearing, proptosis, and crossing really is much less common; and severe vision loss
– as in blinding vision loss has never been reported in kids. Whereas in adults, you’ll
see numbers anywhere from 3 to 6 percent, not necessarily blinding, but severe vision
loss. This is a large study that came out of Boston
that looked at 163 children, and found that when they split up the difference between
kids that were prepubertal and postpubertal, that about a third of them had proptosis.
And the most common being still lid lag and about half of kids had some form of eye complaint
or presentation. And when we looked at – when they looked at their patients based on the
eye alignment, they also had a very small number of kids that present – well, it’s
not small in this series per se – but out of 163, these were … this is the patients
that were referred to the ophthalmologist. And so, their point – and we found a similar
thing in our study – is that out of a large group of patients very few are actually referred
to an eye doctor because most don’t actually have severe problems. When we looked at our practice, this was published
back in 2008, we followed 152 patients, only 27 of those were referred to us. And we found
about a third of the patients we followed had proptosis, and lid retractions. And there
were no cases of eye misalignment. And two of those patients went on to have eye surgery.
And I would say that’s probably the same for what – where I am now in my practice – it’s
about 10 percent of patients that might actually have eye surgery in their life. So, what happens when you have eyelid retraction?
Well, as I said, if you hold your eyelid open it becomes incredibly annoying just for even
two, three seconds. It leads to this inability to fully close your eyes. And patients can
sleep with their eyes partly open, and this leads to dry eyes, and it also leads to tearing. So, here’s a young person with prominent eyes
and you can see when she closes her eyes she has this incomplete closure. And about 80
percent of us have this thing called a Bell’s phenomenon so as we sleep – well, excuse
me, as we close our eyes, our eyes rotate upward, and that can occur during sleep as
well, but some people don’t. So, if a person doesn’t have this Bell phenomenon, they tend
to have worse dry eye symptoms when they don’t – when they have that inability to close
their eyes. And if we were to look at the balance of being
too dry or too wet, you would much rather have watery eye than a dry eye because a dry
eye every moment you’re just aware your eyes are dry, and you’re pretty much wetting your
eyes every hour whereas a wet eye is more of an annoyance, you’re just wiping your face. So, there is a syndrome of dry eye syndrome
where you’re not making enough tears. But what could happen to some people is because
of the dryness, they can develop a lot of inflammation in their eyelid, and it can give
them more of a dry eye, and as I said, this often leads to tearing. Right before I … last night I was thinking,
“Oh, maybe I should think about medications because I gave a similar presentation at a
thyroid cancer survivors meeting last year where we focused a lot on the symptoms and
medications where there much more associated with – with eye disease, and the setting
of thyroid cancer. But I looked to see if Methimazole, which is obviously this medication
many people have taken, if that leads to dry eye. And this one — this is not scientific
review, and I don’t know if eHealthMe is a legitimate website — but they said out of
1,478 people that queried, only four people said they had dry eyes associated with this
medication. So, I think it’s safe to say that if you have dry eye, and you have hyperthyroidism
that it’s probably more associated with some kind of eye disease rather than the medication
you’re on. So, getting back to our patient that we initially
saw. This is an adult with a similar thing just showing you how severe eye retraction
can be. And just to have a little bit, a brief review of the anatomy, your eyelid and the
eyeball itself makes tears. And then, you have this big gland here called your thyroid
gland and that’s the gland that kicks in when you win the lottery, or if you’re cutting
onions, but typically, that gland is not producing a lot of tears. But in a person with dry eye,
it might start kicking in more because your eye is saying, “I’m dry, I’m dry.” And then
your lacrimal gland is releasing more liquid and then what happens is you start to tear. The other thing that can happen is your tears
is this critical thing that provides nourishment to your cornea and improves lubrication. It
also has antibodies in them so tears can actually become very annoying to your eye if they stick
around too long. And the other thing that can happen, and this is more (You didn’t think
you were going to hear about tears today, right? So much detail about tears). But it’s
this little sandwich of different layers. There’s a little fatty layer on the surface,
and then there’s a watery layer, and then there’s a little mucinous layer. And as you get inflammation in your eyelid,
your tears start to evaporate so you make tears, but they’re actually not good functional
tears over time if you have a lot of problems with exposure. So, what do we do? We actually do what you
would think we’d do. And this is just to show you the lining of the eyelid how you could
get inflammation associated with having dry eye. So, the treatment option actually is to add
more tears. Why? Because you’re adding a healthier substance that’s going to stay on the surface
of your eye that going to fool your cornea into thinking you’re now properly lubricated
so that you don’t tear more. So, this is just a – of showing you some the armamentarium
of tears that you’ll see in a CVS, or Rite-Aid, or local pharmacy. And the one thing that I always stress to
patients and parents is that if you look at these boxes they’re all small, they’re all
very small because a big bottle to be able to sit on a shelf, or sit in your medicine
cabinet requires preservatives. And preservatives are very hyper allergenic. So, if you take
a – I mean, I know the saline solutions for contact lenses are big. But a lot of these
have a substance called methylcellulose. It’s a substance that actually doesn’t evaporate
so quickly. It lines the surface of your eye and stick around longer. Those have to be
very small because the bigger ones require a lot of preservatives, and they’re just – people
will develop allergies, a lot of itching and redness from the tears you’re using. So in general, if you see a big bottle you
may want to avoid it. The problem with these small things is they can be expensive. So,
we try to recommend them and people typically find one that works, it’s a lot of trial and
error, and they come in a range of mild to severe. If you look here at this medicine
cabinet, you see some of them are color-coded. This is a product gentile; we don’t sell or
promote any of them. In fact, I find some people like one or the other, and I just recommend
a little bit of trial and error, and we have samples in our office that we’ll give to patients. But I typically tell people to start with
the moderate ones and then to go up to severe if they feel like they need it. Or sometimes
they’ll use a severe at bedtime because it’s thicker. So, once again, big bottles equal
risk of allergy. The other option if you feel like tears aren’t
working, or if you say, “You know, I’ve been using tears is there anything else I can do?”
And you really feel like the artificial tears are helping there’s actually a plug we can
put where your tears drain. So, you have these two little pipes on your
eyelid, and when you close your eyes you pump the excess tears that haven’t evaporated into
your nose. And so you can put this little plug to cover either the lower, or the upper,
or both drains in your eyelid to help your tears stick around longer, and that sometimes
is a wonderful treatment. It’s a very common dry eye treatment. And we can insert these
even in really young kids in the office. It doesn’t require going to an operating room
and it’s usually not painful at all. It’s just a little scary, and annoying. This is just showing you – this actually
is a special kind of – of a punctal plug, it’s rather larger than the typical one. But
I like this picture because it’s easy to see that plug there. And that’s where we – they’d
typically be, and usually don’t feel them. People usually don’t feel them, and they come
in different sizes. So, sometimes we start with smaller ones, and if they fall out we
go to bigger ones. And we avoid trying to put in the big ones because initially some
people really can feel them. So, is this clear? Do you have any questions
initially about dry eyes? It’s kind of a surprising subject in the setting of thyroid eye disease.
But anecdotally, I will tell you that people I’ve treated with bulging eyes, especially
the ones we have decompression, some of the kids, and certainly adults, have said to me
is, “I feel better. I don’t feel dry anymore.” And so I feel like it’s one of the things
you should be aware of, especially having your armamentarium. And a lot of people, as
we’ve come richer in years, acquire dry eye syndromes, and this is a totally separate
subject, but they’re used to the use of artificial tears. So, eye bulging can be very disturbing, and
this is where we’re going to finish up, and talk about the treatment of proptosis, and
possible even surgery. And it’s, as I mentioned, due to swollen, and then scarred orbital fat
and muscles. And it usually will get worse in the setting of your thyroid dysfunction,
but it never resolves. But it usually gets a little bit better, but never, as I said,
goes back to the way it was before everything began. There are a few factors that may make things
worse for you. So, if you have poorly controlled thyroid function, and you’re actively inflamed
– in other words, we feel like you’re in this active phase of changing of your eyes,
then typically your eyes won’t improve. So, it really it’s important to try and get on
top of your thyroid function. This is obviously where the – the endocrinologist and thyroid
surgeons are critical. Now, smoking has really been shown to be one
of these exacerbating factors that can make your eyes worse, and that can reactivate your
eye disease. And smoking, obviously, we don’t necessarily think about it in kids. The problem
is, is that kids are around smoking. And so the European community, that have done two
large studies, have actually determined that second-hand smoke is a significant risk factor
for prolongation or reactivation of eye disease. And finally, if you have active eye disease,
and you’re going to be treated with radioactive iodine, sometimes I think it is helpful to
have a treatment of an oral steroid right before, and then after on a taper after you
have your radioactive iodine to help decrease an exacerbation, meaning a worsen of the eye
disease. So, when I meet children and adults with proptosis
in a setting of thyroid eye disease, I really want to know, “Are you bothered by how you
feel?” And I’m really careful when asking, but I do ask, “Are you bothered by how you
look?” And, I guess, the real question is, is should we even be talking about this. Should
we be sensitizing ourselves to whether or not having eyes that change is really bad
at all? And then finally, the subject of surgical
rehabilitation really is an option, it’s not a requirement. Especially, in the fact that
there is no vision loss. And I just want to show, because I like showing these pictures
of some people who have very prominent eyes. And people we’ve embraced as beautiful in
our society such as the actress Bette Davis or maybe – I don’t remember her name, she’s
from Modern Family. Do people recognize this actress? She has very prominent eyes. And then this is a model/actress some people
may recognize Mila Kunis. And then there’s some very people with thyroid eye disease.
This gentleman probably is famous because of his thyroid eye disease, the very famous
actor/comedian Marty Feldman. Barbara Bush had thyroid eye disease. Do people know that?
It was kind of hard to miss. And then, obviously, many people might be aware that Oprah Winfrey
had thyroid eye disease and I found it very interesting that in her Time Magazine story
about her they chose to give a great portrait of her showing her thyroid eye disease. I
mean, these are very prominent eyes. And you can see later on in life they – I’m assuming
she had a thyroid decompression surgery because she really does look quite different. And then I love this picture of Susan Sarandon
because she’s smoking, and it’s clearly that, you know, this is the one thing she shouldn’t
be doing. But she’s also someone who’s had thyroid eye disease, and has definitely had
surgery in the past. This is a patient I treated, it was an adult,
and she told me she’s bothered by her appearance. And you can see she has this flare of her
eyelid and sometimes people have what we call a lateral flare to their eyelids, and that’s
often seen in thyroid eye disease. And this was her before this all began. So,
you can see how there was really a change in her appearance and this was just – she
became hyperthyroid. You can even see her right eye’s more prominent and then it just
progressed to the first picture I showed you. Here is a young gentleman I showed you initially,
and you may see this gentleman looks normal to me. But hey, when he was younger, when
he was a teenager, this is how he looked. So, he developed thyroid eye disease in his
teens, and came, and sought us out for decompression surgery as an adult. And you can see really
how prominent his eyes are relative to the bones around his face. Another adult with eyes that you’d say, “Oh,
is she really have prominent eyes?” But when you see how she appeared when she was a bit
younger, in early 20s, you can see the difference. And then, getting back to the patient I showed
you before, her appearance, and then her appearance before her hyperthyroidism kicked in, and
then her eyes began to bulge. The European group of Graves’ obitopathy actually
has a quality-of-life questionnaire that they often give their patients asking. “Are you
seriously limited, a little limited, or not limited at all in your activities of daily
living; driving, moving around, reading, watching TV. Watching TV by the way is the worst because
you’re concentrating, and you forget to blink. So, one of the most common symptoms is a person
is tearing more when they’re working, or watching TV. Or when they go outside, and the wind
is blowing, and their eyes become actually dryer because their tears are being blown
off their eye. And this questionnaire goes on to ask more
questions in general. Do you feel that your appearance has changed? Do you feel that you
are stared at in the streets? Do you feel that people react unpleasantly, so on and
so forth? And once again, I think this is where – this
is a very tricky subject and I always prefer to have a family or a patient come to me,
and say, “I’m really bothered by this” rather than to sensitize them to it. I have one patient
who is in her teenage years and her friends use to call her Garfield, which I thought
was really cruel, and she was really bothered by this. Garfield, you know, is the cat that
has really prominent eyes. And so she sought me out because she really was unhappy with
her appearance, and she really felt that, that she was being teased. So, one of the things we can do is a surgical
decompression. And this is a treatment to help the eye sink backward into the orbit.
And it is a treatment for proptosis, and involves removal of bone and/or fat around the eye.
And so getting back to a CAT scan, and once again you see the two eyes, and you can see
these muscles have thickened. What our goal is, is to make more room so that this tissue
can actually sit back further. And so what we do is we make big windows in
the bone. I mean, these are very large. You can’t feel them, you certainly can’t see them.
And what they do is it allows the tissue to essentially prolapse, or pooch out through
these windows, and the eyes to sink backwards. That patient that I showed you that had the
pictures of when she was younger, you can see her before and after surgery. Now, you say is there any difference? Well,
actually, when you look at her there’s a huge difference. It’s a, maybe a little over half,
three quarters of an inch, it’s about eight millimeter of her eye being more sunken back,
and moving back up to here. I think it’s important to see the eyelids often remain very high.
And so patients often need another procedure to lower the eyelid. And we usually don’t
do them at the same time because sometimes the lids come down, and we don’t want to do
an unnecessary procedure, and make the lids too low. That’s what happened here in this patient.
This was a pediatric patient whose orbits we helped open and you can see we lowered
her eyelids, and we lowered her a little bit too much. We try to avoid doing it, but it
sometimes does happen. And so we wound up raising her eyelid here. But you can see the
– see all this white in her eyes here that you can see? You no longer see this so she
has much better closure of her eyes, and her eyes are more sunken back inward. Since we’ve been doing this surgery there
has been some advances in our surgical technique. So, a device we share with the neurosurgeons
is this bone aspirator that allows us to no longer make a little skin incision. We do
this, and we’ve found that our patients had a faster recovery, and it’s been less invasive.
And so I don’t promote this in terms of the maker, but it’s called a Sonopet, it’s slower,
but it’s less invasive. There’s less bleeding. And once again, what we’re able to do is push
the eye aside, and get to these bones specifically here, and here to make more room so the eyes
can sink backwards. And here’s another pediatric patient we had
operated on who has very prominent eyes. She’s smiling here so it almost makes her look a
little bit better, but I figured I’d use it, and she’s very happy with the surgery. And
you can see before and after less white being shown. She had about six millimeters reduction. Another patient who has prominent eyes and
this is her after surgery. You can see how you see more lid here. She’s more sunken in.
And she was one person in particularly that said, “My eyes just feel a lot better.” And
you can see before and after’s. But she actually went on to need lid lowering so we
actually just recently lowered her eyelids in the office. Another patient who felt that her left eye
was more prominent was really bothering her, and she wanted it evened. And we went ahead
and did that, and you can see the appearance is a little more symmetric, and it’s a little
more symmetric postoperatively here. So, the alternative to removing bone is we
can actually remove some fat if a person has their eyes bulging mainly due to the fat compartment.
And this is less of a decompression. So, if a person has a lot of high prominence we sometimes
remove fat and bone. But I just wanted to show you one particular
patient who we did this surgery on. And this is a young patient who was unhappy with her
eye appearance. And you can see her eye bulging here, a bit of proptosis. One thing we don’t typically talk much about
is, in kids once again, is her motility. So, you can see she can look left, up-and down
just fine, she’s not restricted. And this is her before surgery. And this is her CAT
scan just showing she has these very enlarged compartment mainly due to fat enlargement.
And this is the fat we removed from the four quadrants. And this is her after surgery.
So, this is the appearance before, then one year after surgery. And she had an eyelid
tightening procedure at the same time, which helped, actually helped her close her eyes. So, in terms of timing of surgery, patients
need to be at least nine, but ideally into their mid-to-late teens for multiple reasons.
One, is their head is growing, and so we would never operate on a child under the age of
nine unless they had vision loss and I’ve never heard of that happening and I don’t
anticipate it would ever be an issue. They really must be in the static phase of
thyroid eye disease, and we do check these TSI levels. And I ideally want a patient who
is at least one to two years out of their active phase of inflammation because the risk
of surgery when a – performing surgery on a patient whose actively inflamed around their
eyes, is when you do the surgery you can make their eye disease worse. So, and we typically
want a patient to be well out from their thyroid active disease. We usually will get a CAT scan to evaluate
their eye muscles and I usually don’t get a CAT scan actually. So, it’s only in patients
where it’s unclear what the diagnosis is, which is really rare in Graves’ disease, or
in patients who we are discussing surgery, who we would go on to then give a CAT scan
to. I always tell parents, and families, and patients
ideally you do this in the summer, or during a big break because it’s one to two weeks
of recovery, you’re pretty swollen. Although, I’d say we’re doing better in terms of how
people feel. We usually ask people to spend at least one night in the hospital. And I’d
say their average stay is about one and a half days because sometimes people are in
a little bit of pain afterwards. And just to summarize that obitopathy or the
problems we see in the eyes are typically much, much less severe than in adults. And
an eye doctor could be helpful in managing these symptoms related to thyroid dysfunction.
And pediatric patients with bulging eyes really can be successfully rehabilitated with surgery,
but this is purely optional. And we would perform bony and fat decompression in this
setting. And thank you once again for your attention tonight.

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