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Master Thesis

Évaluation des résultats post-opératoire des décompressions orbitaires pour neuropathie optique dysthyroïdienne

Abstract : Introduction: Dysthyroid optic neuropathy (DON) is a rare complication (3 to 5% of dysthyroid orbitopathies) that rapidly involves the visual prognosis and requires urgent management. The most commonly used treatment currently involves intravenous corticosteroid therapy combined with decompression surgery of one or more of the orbital walls to relieve congestion at the apex. The objective of this study is to evaluate the visual, anatomical and psychosocial outcome of patients undergoing orbital decompression for DON. Methods and materials: In this retrospective and prospective unicentric study, patients with unilateral or bilateral DON were included for surgery. The primary endpoint was visual acuity. We assessed global visual function (severity of DON evaluated by CON-Score, visual field, color vision, OCT, fundus, contrast vision, intraocular pressure) and parameters associated with dysthyroid orbitopathy (degree of exophthalmia, CAS disease activity score, volume and orbital morphology, diplopia) and the risk factors associated with optic neuropathy. A subgroup analysis focused on visual recovery and the severity of DON. Results: 20 patients were included (29 orbits) with an average follow-up of 18 months. Orbital decompression surgery has significantly improved the visual acuity of 0.79 log MAR +/- 0.27 (p = 0.01), has lowered the intraocular pressure levels of 3 +/- 1.7 mmHg on average (p = 0.032), decreased proptosis of 3.7 mm +/- 2.83 (p = 0.0025), and improved quality of life with a significantly gain of GO-QOL score of 43,7 +/- 25.88 (p = 0.004). The visual field was improved in 85% of cases; 8% found a strictly normalised visual field in the long term. The colour vision was improved postoperatively in 100% of cases. Postoperatively, dyschromatopsia (minimal to moderate) persisted in 24% of cases. The surgery has increased the global orbital volume (average 2,169 cm3) mostly attributed to the medial rectus muscle (+12.8%) and the orbital fat (+ 19.41%). We did not find a correlation between the decrease in CAS and better visual recovery (p = 0.15) or between the severity of DON and CAS. We observed greater severity, poorer recovery, and decreased quality of life in less advantaged socio-economic groups compared to those in the more advantaged social class. The overall complication rate was 41%, most of which was transient and resolutive. After decompression, the rate of constant diplopia decreased by 20%. We found a degree of de novo diplopia of 42 %( including gaze-evoked intermittent diplopia). In addition, 50% of patients will require additional muscle surgery for long-term strabismus. Patients with late evolution orbitopathy (> 4 years) older age, a restrictive pattern with a significant diplopia and reduced ocular motility, a high rate of TRAK, active smoking have a lower increase in postoperative orbital volumes which implies less compliance of the orbital tissues. The analysis of contrast perception showed that 100% of patients who recovered a complete visual function nevertheless retained alterations in contrast sensitivity. This item is felt by patients as handicapping in everyday life and causing an impairment of the quality of life, despite the normalization of the visual field, colour vision and visual acuity. At a distance from surgery, however, 40% of patients maintained ocular hypertension, the main risk factor of which was the male sex and a long duration of evolution of the orbital inflammation. Discussion: Our results are consistent in terms of effectiveness and tolerance with the data of the literature. Patients can maintain subclinical sequelae that should be investigated by extensive analysis that can significantly affect quality of life. This study confirms the effectiveness of orbital decompression surgery for the treatment of DON. The surgical results are closely related to orbital compliance, a notion that we introduce in the study : it implies that the plasticity of fatty and muscular orbital tissues plays a key role in anatomical and functional recovery. The concept of compliance could be explored on a larger scale by the analysis of orbital volumes after decompression surgery without DON and could lead to inform the surgeon on the subtype of orbitopathy and guide a customised surgical procedure based on each patient’s presentation of OD.
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Marie Callet. Évaluation des résultats post-opératoire des décompressions orbitaires pour neuropathie optique dysthyroïdienne. Sciences du Vivant [q-bio]. 2019. ⟨dumas-02364838⟩



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