Partial Vision Loss After Orbital Decompression in a Patient With Thyroid Eye Disease, Chorioretinal Folds, and Disc Edema

Concomitant chorioretinal folds with disc edema can be seen in cases of thyroid eye disease presenting with compressive optic neuropathy and may portend optic nerve ischemia. We describe an unusual case of a 64-year-old man who developed partial vision loss after orbital decompression

Photo and Video Essay Section Editors: Melissa W. Ko, MD Dean M. Cestari, MD Peter Quiros, MD Partial Vision Loss After Orbital Decompression in a Patient With Thyroid Eye Disease, Chorioretinal Folds, and Disc Edema Lauren N. DeMaria, MD, Ann Q. Tran, MD, Andrea A. Tooley, MD, Valerie I. Elmalem, MD, Irina Belinsky, MD FIG. 1. Fundus images of the (A) right and (B) left eye of a 64-year-old man with active thyroid disease demonstrating optic disc edema and chorioretinal folds. Optical coherence tomography of the (C) right and (D) left eye highlights the advantage of the vertical raster mode over the horizontal raster mode in showing chorioretinal folds. Abstract: Concomitant chorioretinal folds with disc edema can be seen in cases of thyroid eye disease presenting with compressive optic neuropathy and may portend optic nerve ischemia. We describe an unusual case of a 64-year-old Department of Ophthalmology (LD, AQT, AT, IB), New York University, New York, New York; Department of Ophthalmology (AQT, AT), Manhattan Eye, Ear, and Throat Hospital, Northwell Health, New York, New York; and Department of Ophthalmology (VIE), New York Eye and Ear Infirmary of Mount Sinai, New York, New York. Supported in part by an Unrestricted Grant from Research to Prevent Blindness to NYU Langone Health Department of Ophthalmology. V. I. Elmalem: Thyroid Eye Disease Advisory Board 8/24/2019, Horizon Therapeutics, Plc; I. Belinsky: Thyroid Eye Disease Advisory Board 7/31/2020, Horizon Therapeutics, Plc. The remaining authors report no conflicts of interest. Address correspondence to Irina Belinsky, MD, NYU Langone Medical Center, 222 East 41st Street, 3rd Floor, New York, NY 10017; E-mail: [e-mail] e366 man who developed partial vision loss after orbital decompression. Journal of Neuro-Ophthalmology 2021;41:e366–368 doi: 10.1097/WNO.0000000000001174 © 2021 by North American Neuro-Ophthalmology Society A 64-year-old man active smoker with uncontrolled hypothyroidism presented with 4 months of bilateral proptosis, eyelid swelling, and diplopia. The visual acuity was 20 of 25 bilaterally with a relative afferent pupillary defect on the left and a normal fundus examination except for mild bilateral disc edema. Orbital imaging demonstrated enlargement of the extraocular muscles, predominantly the inferior and medial recti, with crowding at the orbital apices more pronounced on the left, consistent with thyroid-related orbitopathy. Laboratory DeMaria et al: J Neuro-Ophthalmol 2021; 41: e366-e368 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay FIG. 2. A. Macula ganglion cell analysis of both eyes reveals diffuse thinning indicative of severe retinal nerve fiber layer loss. B. Magnetic resonance T1 coronal imaging of the orbits demonstrates enlargement of extraocular muscles with crowding at the orbital apex. C. Postoperative automated visual field 24-2 of the left eye with dense cecocentral loss. testing revealed an elevated thyroid-stimulating hormone and thyroid-stimulating immunoglobulin with negative workup for other etiologies of disc edema. The patient was started on intravenous steroids for thyroid-related compressive optic neuropathy, referred to endocrinology for medical control of his dysthyroid state, and was advised to quit smoking. He did not follow-up for 6 months and represented complaining of worsening left eye redness and blurry vision. His visual acuity was still 20 of 25 in both eyes, and intraocular pressure was 25 mm Hg bilaterally. There was a brisk left relative afferent pupillary defect and new edema of the left caruncle. Dilated funduscopic examination revealed bilateral optic disc edema, with pallor on the left, and new chorioretinal folds with absence of retinal hemorrhages (Fig. 1A, B). Optical coherence tomography (OCT), using vertical raster, highlighted the folds in both the retinal and choroidal layers (Fig. 1C, D). Macular ganglion cell analysis showed severe thinning bilaterally, suggestive of chronic and profound retinal nerve fiber layer (RNFL) loss (Fig. 2A). MRI of the orbits demonstrated progressive enlargement of extraocular muscles with crowding at the orbital apex (Fig. 2B). The patient underwent an uncomplicated urgent orbital decompression on the left by a combined approach: endoscopic medial wall decompression by otolaryngology and transorbital floor decompression by oculoplastics. Immediate postoperative examination revealed count fingers vision, and the patient complained of a noticeable loss of peripheral vision. A postoperative CT Orbits was unremarkable, showing an adequate bony decompression without hematoma. Vision improved to 20 of 80 the day after surgery. There was visual field loss in a cecocentral pattern, suggestive of an intraoperative focal ischemic event (Fig. 2C). His vision remained stable at 3 months follow-up. The most worrisome complication of orbital decompression surgery is postoperative worsening of vision. Worse yet, is postoperative blindness, which is reported to occur in ,1% of DeMaria et al: J Neuro-Ophthalmol 2021; 41: e366-e368 cases (1). Chorioretinal folds with disc edema in thyroid eye disease are rare (2–4). They indicate significant venous congestion and compressive stress along the choroid and Bruch’s membrane (2). OCT in a vertical raster mode (Fig. 1C, D) can help identify chorioretinal folds, especially when subtle on fundoscopy. OCT is also helpful in quantifying RNFL changes in patients with compressive optic neuropathy from TED, such as the resolution of optic disc edema after orbital decompression (5). Chorioretinal folds may resolve after orbital decompression (6), but may persist in some cases, causing long-term distortion in visual acuity. Under congestive orbital pressure, ischemia can occur spontaneously as illustrated in a report of a central retinal vein occlusion from Roelofs et al (7). Also, it is well known that with chronic disc edema, the nerve is susceptible to ischemia. Moreover, the added stress of orbital surgery can lead to intraoperative or immediate postoperative vasospastic ischemia. We suspect that in this case of a long standing untreated compressive optic neuropathy, the stress of orbitotomy may have caused a vascular event leading to partial visual field loss. In conclusion, among other factors, chorioretinal folds, disc edema, and macular ganglion cell loss may portend an increased risk of worsening vision from orbital decompressive surgery because of changes of orbital pressure and vasospastic ischemia (6,8). STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: I. Belinsky, A. Q. Tran, A. Tooley, and V. I. Elmalen; b. Acquisition of data: I. Belinsky, L. Demaria, A. Q. Tran, and A. Tooley; c. Analysis and interpretation of data: A. Q. Tran, V. I. Elmalen, and I. Belinsky. Category 2: a. Drafting the manuscript: L. Demaria, V. I. Elmalen, A. Q. Tran, and I. Belinsky; b. Revising it for intellectual content: V. I. Elmalen and I. Belinsky. Category 3: a. Final approval of the completed manuscript: L. Demaria, A. Tooley, V. I. Elmalen, A. Q. Tran, and I. Belinsky. e367 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay REFERENCES 1. 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