A multidisciplinary approach in the treatment of thyroid eye disease

Relevance Endocrine ophthalmopathy (EOP) is a progressive autoimmune disease of the visual organ associated with autoimmune pathology of the thyroid gland, the treatment of which can be a long-term step-by-step process, including immunosuppressive therapy, orbital radiation therapy, and surgical treatment [1, 2]. EOP therapy is a multidisciplinary problem, the effectiveness of which depends on the well-coordinated teamwork of an endocrinologist, ophthalmologist, ophthalmic surgeon, and cardiologist. Objective Evaluation of the treatment results for a patient with severe EOP, refractory to high doses of glucocorticosteroids (GCS), complicated by the development of optic neuropathy (ON). Material and methods Patient N. has been under the observation of an endocrinologist and ophthalmologist since 2020 with the diagnosis: severe EOP, active phase (according to the clinical activity scale CAS = 6/7), complicated by ON, partial ophthalmoplegia. Best corrected visual acuity (BCVA): OD = 0.6, OS = 0.8. A course of pulse therapy with GCS was administered at a total dose of 5750 mg. Over the next two months, persistent EOP activity and progressive deterioration of visual functions were noted (BCVA OD = 0.4, OS = 0.6, impaired peripheral vision, color perception), in connection with which pulse therapy with GCS was continued at a dose of 1800 mg, deep bone decompressions of the lateral wall of both orbits (DBDO) were performed using a modified technique using an ultrasonic osteodestructor with additional expansion of the size of the primary bone "window" [3] and the formation of a beveled profile of its posterior edge (patent for invention RU2742799). In 2021, due to ongoing EOP activity, the patient was recommended to continue pulse therapy with GCS at a total dose of 3500 mg, and extrafascial thyroidectomy was performed. Results In the postoperative period and during a long-term observation period of 3 years, BCVA OD = 1.0; OS = 1.0, positive dynamics were observed in the computer perimetry parameters in the form of increased photosensitivity, a decrease in the number of absolute scotomas. Conclusion This case demonstrates multi-stage and continuity in the treatment of EOP. Since EOP was active, the first line of treatment was pulse therapy with GCS. However, due to its insufficient effectiveness and the progression of ON, bilateral deep LKDO was performed in order to normalize visual functions. Key words: endocrine ophthalmopathy; optic neuropathy; bone decompression of the orbit