In Graves' orbitopathy, a subset of patients develops sight-threatening thyroid eye disease characterised by stretch of the optic nerve as a consequence of severe proptosis, or by globe subluxation — a presentation with distinct management requirements that differ from the more common apex compression form.
Sight-threatening thyroid eye disease where the optic nerve is at risk due to stretch from advanced proptosis, or where globe subluxation is present. Radiographic distinction from apex compression-type optic neuropathy is essential: the stretch form does not respond to medical treatments and carries specific surgical indications.
Surgical orbital decompression is the indicated intervention for this presentation.
Clinical goal: reduction of proptosisdoi: 10.1089/thy.2022.0251
DON may result from compression of the optic nerve by enlarged EOM at the apex of the orbit, or infrequently (<5%), due to stretch of the nerve because of proptosis.
It is important to distinguish these two forms radiographically, as optic nerve stretch does not respond to medical treatments and requires surgical decompression to reduce proptosis.
Orbital decompression for the rare case of stretch optic neuropathy is usually designed to maximize reduction of proptosis by expansion into adjoining sinuses and fat excision.
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