Shiley Thyroid Eye Clinic adopts team approach

By Sean Henahan

La Jolla, California — On the first visit, patients referred to the Thyroid Clinic at the Shiley Eye Centre see not one but three experienced clinicians, David Granet MD, Director of the Clinic and well-known strabismus surgeon, Don Kikkawa MD, Director of the Orbital and Oculoplastic Service and Leah Levy MD, a noted neuro-ophthalmologist.

“We developed our team approach in response to the increasing number of thyroid cases we were seeing. Patients were getting bounced around from one physician to the next. We thought we should co-ordinate our services and offer more cohesive care.

“Now we like to join forces and see the patients together. These patients are some of the most difficult cases we see at Shiley,” explained Dr Kikkawa.

The doctors get together once a month to see patients with thyroid-eye disease (TED). The volume of patients has doubled in the past year. The doctors assess new patients and plan a treatment strategy.

Nothing happens before the patient is stable and understands the procedure fully.
If necesssary, Dr Kikkawa first performs the orbital decompression. Then Dr Granet will do any strabismus surgery required and Dr Kikkawa steps in again later to complete any lid work or other reconstruction the patient may need.

Dr Levy makes up the third part of the triumvirate. She is on hand to look for problems with a neurological basis such as optic neuropathy or orbital inflammation. She can also spot uncommon diseases such as myasthenia gravis. This enables the team to catch rare and emergent situations as early as possible.

“If a patient comes in with a fairly uncommon complication, such as optic neuropathy, we’ve been able to handle the problem immediately, with no problems co-ordinating care.

“We’ve also been able to act on emergent situations that occur from time to time. It has been a very efficient way of taking care of the more dangerous problems,” Dr Levy noted.

Botox useful in variety of TED cases
Botox has become an important part of treatment at the thyroid clinic. In addition to using it for control of diplopia, it is also employed intra-operatively at the time of orbital decompression. The uses of Botox have expanded as the team members learn from one another’s experiences.

Dr Granet uses Botox to treat diplopia in cases where deviation is beyond what prism correction can help, but not so far advanced that surgery is the only option.

“We tell the patient that we can paralyse the muscle that is pulling the eye down, relax it and allow it to come back up. The eyes can then potentially fuse again. We found that there is a subset of patients that were completely cured by use of Botox for diplopia. Their disease was in a contracture phase, rather than a scarring or fibrotic phase, so we could reverse the changes in the muscle. This is very exciting,” he said.

Seeing the kind of results Dr Granet was getting, Dr Kikkawa started applying Botox during orbital decompression. In some cases, patients with pre-existing deviation may have been treated earlier with Botox in then office and then need decompression.
He injects the affected muscle directly in the operating room. He also used Botox intraoperatively in patients who may be at risk for developing diplopia after decompression.

“Some 15% to 20% of patients who have not had decompression before are at risk. Those with big muscles are at the highest risk. If they have big muscles and don’t have diplopia before surgery, we pre-emptively give them a Botox injection to try to stop that muscle contracting,” he explained.

He also uses Botox later on, when patients are ready for cosmetic repair. In some cases, Botox can be used to create a temporary ptosis effect in patients with severe lid retraction. Avoiding the levator muscle is key to avoiding unwanted eyelid drooping, he advised.

“We remind our patients that eye doctors were first to use Botox, more than 20 years ago. It has a long safety record. Interestingly, we have noticed that Botox seems to take effect faster in thyroid patients, and lasts not quite as long. We also see that larger doses are required. These are the kinds of things that we are able to observe thanks to our large volume of cases,” said Dr Granet.

Major emotional component common in TED
Seeing a large volume of patients also made the team aware of the emotional and psychological impact of TED on patients. They often see patients who are literally in tears.
When they looked more closely at a series of cases, they found that the people who were the most devastated, anxious and depressed were those who had the biggest change in their appearance. Those who had simple strabismus without too much proptosis or lid retraction were not nearly as affected.

The team plans to follow-up on this preliminary study. They hope to determine how best to address the emotional needs of the patients.
“We don’t give up here. We are willing to try every possible solution,” Dr Kikkawa stressed.