Cancer Of The Eye Symptoms

>> all right, so last discussion this morningis about graves's ophthalmology, graves's eye disease. and as you've already kind offigured out we have one or two people we've selected from each discipline and bill, actually hadsome expertise prior from training in the uk and is a legacy, his dad is also an ophthalmologistat chop [the children's hospital of philadelphia] so he has a real foundation and footing atchop, and has been a wonderful addition for our team. so, all of our patients that have eye diseasedr. katowitz will see initially, and then – i'm not sure what the percentage is, he'llprobably let you guys know how many patients eventually need some type of surgical intervention.i think it's less than the patients that just

need follow-up. but the follow-up is care that i'm not capableof providing all of our expertise, and graves' ophthalmopathy is dr. katowitz, it's not mine.i can identify it. he's better at taking care of it, and deciding if and when somethinghas to be done. so, he is our only ophthalmologist. we have a neuro ophthalmologist, dr. liu aswell. so, between dr. liu and dr. katowitz, our patients, the ones that need care, arereferred to them. so, dr. katowitz? >> thank you so much. and thank you, dr. bauerand dr. adzick for inviting me to speak today. it's an honor and i'm very excited to talkto you about eye disease. can everyone hear me ok? great. so, i have no financial interestin any of the materials i'm presenting today.

so, who provides eye care? the primary caredoctor in many cases. someone says they have dry eyes. typically, a primary care doctormay say, "well, let's try artificial tears." sometimes it's even a nurse practitioner ina practice or within a pediatrics – pediatrician's office. and then there are eye practitioners.and now, an eye practitioner could be an optometrist, someone who went to something called optometryschool. sometimes even the optician, the person that dispenses glasses, will offer some eyecare and then finally, a person who is a medical doctor who is an ophthalmologist. and that'san eye doctor who completed a four-year ophthalmology residency, they're board-certified in thefield of ophthalmology – which is spelled kind of oddly. and this is a person who hashospital privileges to perform eye surgery,

as well as surgery around the eye, and theydo prescribe medications. now, there are different kinds of ophthalmologists,and this is where it gets confusing. there are general ophthalmologists, and they sometimessee kids and adults. there are cornea specialists that will often address dry eye disease, aswell as other problems relating to the window of the eye. and then, also very relevant tous here, are pediatric ophthalmologists who – we have a very large practice here atchildren's hospital in philadelphia – and those are people that see children, and treatmost diseases. and then, within ophthalmology is this subset of eye doctors called ocularplastic surgeons of which i am, and have had additional training in essentially plasticsurgery around the eye.

so, i'm an eye doctor who did additional fellowshiptraining, and then had fellowship training in both pediatric ophthalmology, and thisfield of oculoplastics. and i did train here at the children's hospital of philadelphiaand the university of pennsylvania, and then i spent a year, actually in london, wherei saw a lot of patients with thyroid eye disease. when i speak with pediatricians and explainwhat it is oculoplastic surgeons do, i say there are four t's; tearing, tumors, trauma,and ptosis – which is actually spelled with a p, but it sounds like a t so it works. so, today i'll be speaking on the subjectof thyroid eye disease, and discussing the symptoms, and then finishing up with treatments.and i know we're going to have questions at

the end, but if i'm going too quickly, orif i've explained something, and i haven't explained it very well please interrupt me,and say, "can you just clarify this," because i'd like to just get these points across. so, i realize i've left some things off thislist that dr. bauer and adzick presented because it's quite a large team. but i think it'sjust important, and i think you're hearing from today that you are not alone in thisprocess and we are here as a service, as a center to help you with many different supportivefigures. so, it was an irish physician in 1835 whorecognized that there was an association in a large thyroid gland and bulging eyes, andthis was dr. james graves. and this is a patient

i treated, who is in her teens, who has manyof the classic symptoms of thyroid eye disease. in fact, her symptoms in some ways representmore of what we see in adults. but i thought this was a good person to startwith because, obviously, you can see that she has what you might see as very prominenteyes, or what we call eye bulging and the medical term, it's proptosis or even exophthalmos.so, you can see here her eyes are prominent or bulging. and it was an endocrinologist by the nameof rundle, who in 1945 published a series where he noted that the bulging of eyes associatedwith hyperthyroidism occurred over a period of time got worse, and then actually wouldget better, but never would resolve to what

it was like before it all began for that patient. i was at an international meeting in la about10 years ago where a lot of the world leaders in thyroid eye disease – endocrinologist,and surgeons – met and we tried to come up with a consensus of what we would callthis syndrome, meaning person who has some form of thyroid dysfunction, and eye symptoms.and we couldn't agree. many of us liked the term thyroid eye disease, but a group of europeansactually have the term graves' ophthalmopathy in their name. so, we never really found anagreement. some people liked thyroid-associated obitopathybecause a small percentage of patients, not relevant today here, actually havehypothyroidism, and present with eye disease.

and some even have no symptoms – no thyroiddysfunction at all, but have the same type of symptoms, and even on pathology look similar.so, i'm going to use the term thyroid eye disease, but in the literature, and in – outin the public, you may see a huge different – a wide range of terms. so, thyroid eyedisease, and you'll see t-e-d as a short term so i don't have to keep saying it. so, what can happen to your eyes if you havethyroid eye disease? well, going back to our patient here who had this presentation andwhat we would call active thyroid eye disease, you can see that one of the most common thingswe see in thyroid eye disease, and that is lid retraction. your eyes look – they aretoo high so almost like you have a surprised

look. and this occurs often times becausethere's scarring and inflammation within the muscles that lift the eyelid, both the lowerand upper lid. and then you can see – obviously, we talkedabout this already, the bulging eyes so the eyes appearing more prominent. if you justsit in the audience and you do this for three seconds, you're going to want to blink becausethat actually leads to your eye feeling very dry. and this is unfortunately what some peoplereally live with on a daily basis when their eyes are more prominent, or they're proptotic.and that, in addition, leads to tearing because your cornea has a nerve in it that says, "waita minute, i'm drying out, i need to wet my eye," and that kicks in a gland here thatthen secretes a lot more water so people with

dry eye actually tear and we'll get to thatlater on. and then, less commonly in children, much,much less commonly in children, is the eyes are not aligned. so, typically we see theireyes are together. but sometimes patients with thyroid eye disease, because of the sizeof their muscles, the eyes are no longer aligned. one eye may be turned in, may be turned out,may be up, may be down. and because of all this exposure your – thelining of your eye, or conjunctiva gets very red so you have eye redness. they can getswollen and really, really less commonly in children is some form of vision loss. although,i will say that dry eye typically will knock your vision down by one line. so, people withexposure, and dryness, and even tearing typically

have less sharp vision than the average person. so, getting back to this curve, rundle's curve,there is what we would call an active phase of eye disease, and then a static phase. andthis active phase can last anywhere from six months to two years typically. and then thestatic phase typically lasts for a lifetime, although, there are some things that can makethe static phase worse and i'll get to that in just a moment. so, getting to why this happened. this iswhere i get overwhelmed because i'm an ophthalmologist and not an immunologist. but when i try toexplain it to people i just say it's – this

is an autoimmune disease. but when i showthis slide, which is from a typical paper, you'll see that we think we're on to something,but there is no way we know the thing that causes this. it's really multifactorial. a colleague of mine has simplified it to recognizethat there are some things on the surface of the eye muscles and fat that perhaps arerelated to the thyroid gland. but i really like to explain it this way. your body isa factory. the factory makes immune cells that make antibodies that recognize somethingon your thyroid gland. and as luck would have it, in this case bad luck, those similar surfacemarkers are also on the muscles and the fat around your eye, therefore, giving you a similartype of enlargement.

and in this case, it behaves differently becauseit's your eyes. but as your thyroid gland will enlarge, your eyes – the eyeball doesn'tenlarge – but the eye looks like it's bigger because it's being pushed out. so, what actually happens? well, this is acat scan. this is an x-ray that's done in serial slices, and then a computer puts itback together. that's what computer tomography is, so a cat scan. and this shows that theeyes – while you may not appreciate this, but the eyes are being pushed outward becausethat black space around – so let’s see how this pointer works. this is your opticnerve, and these are eye muscles, and these are eyeballs. but this black space here isactually larger because it's essentially swollen.

there's more water and there's more extracellular tissue, and later on there's scarring so that pushes the eye out. sometimes, if we go back for a second, seehow small this muscle is? now, look how big this muscle is and that's just giant. andyour eye sits in a room called your orbit, which is surrounded by bones, and as thosemuscles enlarge, the eye has nowhere to go but out. so, this is a person with very largeeye muscles. and this is something we see less typically in children, but it can happen,especially in adolescents. so, some people – and i'd say this is moretypical for many kids who are older, in their teen years – have more of a balanced appearancewhere some of the fat is enlarged, and some

of the muscles enlarged. and this becomesrelevant later on when we ever talk about surgery, if it ever comes to that. so, through my years of training, and in treatingadults because i also see adults and i also feel like a patient with thyroid eye disease,especially a child, is my patient for life because this is not necessarily going to goaway. it'll get better, but i really – i inherit them as adults, and i see the adultsat the children's hospital of philadelphia. i like this slide because it really showsthis wide spectrum of presentation that people have in thyroid eye disease. some people lookessentially – you would almost say that person looks normal. other people you wouldsay, "ok, this person has very red eyes,"

or, "this person looks like she has a normaleye, but one eye is actually sticking out." and i put this picture in because this isa pediatric patient, but just to show you the difference. the good news is that eye disease in pediatricpatients is not as severe as in adults, and i'll get to that. and these are some of themany patients i've treated over the years at the children's hospital of philadelphiawith thyroid eye disease. and also, you can see a varied presentation. this teenager ismuch more like that the adult pictures i showed you. you'll see – you may recognize, but maybe hard to tell. this is the only boy in the

whole series because there really is a higherprevalence of this presentation in female patients. but you can also see some patientsdon't look as severe, but if they showed you pictures of them previously, they'd say, "no,my appearance has changed." whereas other people have one more eye that's prevalent,that's sticking out versus the other. so, how does an eye doctor help in terms oftreating patients with thyroid eye disease, and in hyperthyroidism? well, i would sayusually we don't diagnose the hyperthyroidism. i've done it a few times, but usually i willsee a person who already has a known diagnosis. it's bulging eyes or proptosis. the most commoncause in kids is usually actually an infection of the eye. but when we see a bulging eyewe usually get imaging, and are able to diagnose

something that is related to thyroid function.and then we send them to pediatrician, and then an endocrinologist for a true diagnosisof hyperthyroidism. we're really there to treat symptoms in thisactive phase, and then help restore appearance in what we call the static phase. and thatusually does not involve surgery, but at the end i'll discuss that. so, this is a young person we've seen. we'veput some yellow fluorescein dye in her eye, that's why this is green there, so that wecan see if she has any dryness, and staining on her cornea. when you have eye dryness,the surface of your cornea looks – i describe to parents it's like the surface of the moon,there these little craterations. i say to

kids it's like taking a chocolate chip cookieand wiping the chocolate chips off, there's these little, little spaces, and that actually– causes a certain amount of discomfort. and people, when they have this they actuallysleep often with their eyes open at night, and i'll explain that in a second. so, you can see this patient has some prominenceto the eyes, and the parents showed me on their cell phone, they said, "this is theway my daughter looked before this all began." so, you can definitely see a difference between,before, and after the beginning of on-set of disease. so, the most common eye symptoms that we seein pediatric patients is eyelid retraction,

or lid lag – the lids are too high; dryeye and tearing, proptosis, and crossing really is much less common; and severe vision loss– as in blinding vision loss has never been reported in kids. whereas in adults, you'llsee numbers anywhere from 3 to 6 percent, not necessarily blinding, but severe visionloss. this is a large study that came out of bostonthat looked at 163 children, and found that when they split up the difference betweenkids that were prepubertal and postpubertal, that about a third of them had proptosis.and the most common being still lid lag and about half of kids had some form of eye complaintor presentation. and when we looked at – when they looked at their patients based on theeye alignment, they also had a very small

number of kids that present – well, it'snot small in this series per se – but out of 163, these were … this is the patientsthat were referred to the ophthalmologist. and so, their point – and we found a similarthing in our study – is that out of a large group of patients very few are actually referredto an eye doctor because most don't actually have severe problems. when we looked at our practice, this was publishedback in 2008, we followed 152 patients, only 27 of those were referred to us. and we foundabout a third of the patients we followed had proptosis, and lid retractions. and therewere no cases of eye misalignment. and two of those patients went on to have eye surgery.and i would say that's probably the same for

what – where i am now in my practice – it'sabout 10 percent of patients that might actually have eye surgery in their life. so, what happens when you have eyelid retraction?well, as i said, if you hold your eyelid open it becomes incredibly annoying just for eventwo, three seconds. it leads to this inability to fully close your eyes. and patients cansleep with their eyes partly open, and this leads to dry eyes, and it also leads to tearing. so, here's a young person with prominent eyesand you can see when she closes her eyes she has this incomplete closure. and about 80percent of us have this thing called a bell's phenomenon so as we sleep – well, excuseme, as we close our eyes, our eyes rotate

upward, and that can occur during sleep aswell, but some people don't. so, if a person doesn't have this bell phenomenon, they tendto have worse dry eye symptoms when they don't – when they have that inability to closetheir eyes. and if we were to look at the balance of beingtoo dry or too wet, you would much rather have watery eye than a dry eye because a dryeye every moment you're just aware your eyes are dry, and you're pretty much wetting youreyes every hour whereas a wet eye is more of an annoyance, you're just wiping your face. so, there is a syndrome of dry eye syndromewhere you're not making enough tears. but what could happen to some people is becauseof the dryness, they can develop a lot of

inflammation in their eyelid, and it can givethem more of a dry eye, and as i said, this often leads to tearing. right before i … last night i was thinking,"oh, maybe i should think about medications because i gave a similar presentation at athyroid cancer survivors meeting last year where we focused a lot on the symptoms andmedications where there much more associated with – with eye disease, and the settingof thyroid cancer. but i looked to see if methimazole, which is obviously this medicationmany people have taken, if that leads to dry eye. and this one — this is not scientificreview, and i don't know if ehealthme is a legitimate website — but they said out of1,478 people that queried, only four people

said they had dry eyes associated with thismedication. so, i think it's safe to say that if you have dry eye, and you have hyperthyroidismthat it's probably more associated with some kind of eye disease rather than the medicationyou’re on. so, getting back to our patient that we initiallysaw. this is an adult with a similar thing just showing you how severe eye retractioncan be. and just to have a little bit, a brief review of the anatomy, your eyelid and theeyeball itself makes tears. and then, you have this big gland here called your thyroidgland and that's the gland that kicks in when you win the lottery, or if you're cuttingonions, but typically, that gland is not producing a lot of tears. but in a person with dry eye,it might start kicking in more because your

eye is saying, "i'm dry, i'm dry." and thenyour lacrimal gland is releasing more liquid and then what happens is you start to tear. the other thing that can happen is your tearsis this critical thing that provides nourishment to your cornea and improves lubrication. italso has antibodies in them so tears can actually become very annoying to your eye if they stickaround too long. and the other thing that can happen, and this is more (you didn't thinkyou were going to hear about tears today, right? so much detail about tears). but it'sthis little sandwich of different layers. there's a little fatty layer on the surface,and then there's a watery layer, and then there's a little mucinous layer.

and as you get inflammation in your eyelid,your tears start to evaporate so you make tears, but they're actually not good functionaltears over time if you have a lot of problems with exposure. so, what do we do? we actually do what youwould think we'd do. and this is just to show you the lining of the eyelid how you couldget inflammation associated with having dry eye. so, the treatment option actually is to addmore tears. why? because you're adding a healthier substance that's going to stay on the surfaceof your eye that going to fool your cornea into thinking you're now properly lubricatedso that you don't tear more. so, this is just

a – of showing you some the armamentariumof tears that you'll see in a cvs, or rite-aid, or local pharmacy. and the one thing that i always stress topatients and parents is that if you look at these boxes they're all small, they're allvery small because a big bottle to be able to sit on a shelf, or sit in your medicinecabinet requires preservatives. and preservatives are very hyper allergenic. so, if you takea – i mean, i know the saline solutions for contact lenses are big. but a lot of thesehave a substance called methylcellulose. it's a substance that actually doesn't evaporateso quickly. it lines the surface of your eye and stick around longer. those have to bevery small because the bigger ones require

a lot of preservatives, and they're just – peoplewill develop allergies, a lot of itching and redness from the tears you're using. so in general, if you see a big bottle youmay want to avoid it. the problem with these small things is they can be expensive. so,we try to recommend them and people typically find one that works, it's a lot of trial anderror, and they come in a range of mild to severe. if you look here at this medicinecabinet, you see some of them are color-coded. this is a product gentile; we don't sell orpromote any of them. in fact, i find some people like one or the other, and i just recommenda little bit of trial and error, and we have samples in our office that we'll give to patients.

but i typically tell people to start withthe moderate ones and then to go up to severe if they feel like they need it. or sometimesthey'll use a severe at bedtime because it's thicker. so, once again, big bottles equalrisk of allergy. the other option if you feel like tears aren'tworking, or if you say, "you know, i've been using tears is there anything else i can do?"and you really feel like the artificial tears are helping there's actually a plug we canput where your tears drain. so, you have these two little pipes on youreyelid, and when you close your eyes you pump the excess tears that haven't evaporated intoyour nose. and so you can put this little plug to cover either the lower, or the upper,or both drains in your eyelid to help your

tears stick around longer, and that sometimesis a wonderful treatment. it's a very common dry eye treatment. and we can insert theseeven in really young kids in the office. it doesn't require going to an operating roomand it's usually not painful at all. it's just a little scary, and annoying. this is just showing you – this actuallyis a special kind of – of a punctal plug, it's rather larger than the typical one. buti like this picture because it's easy to see that plug there. and that's where we – they'dtypically be, and usually don't feel them. people usually don't feel them, and they comein different sizes. so, sometimes we start with smaller ones, and if they fall out wego to bigger ones. and we avoid trying to

put in the big ones because initially somepeople really can feel them. so, is this clear? do you have any questionsinitially about dry eyes? it's kind of a surprising subject in the setting of thyroid eye disease.but anecdotally, i will tell you that people i've treated with bulging eyes, especiallythe ones we have decompression, some of the kids, and certainly adults, have said to meis, "i feel better. i don't feel dry anymore." and so i feel like it's one of the thingsyou should be aware of, especially having your armamentarium. and a lot of people, aswe've come richer in years, acquire dry eye syndromes, and this is a totally separatesubject, but they're used to the use of artificial tears.

so, eye bulging can be very disturbing, andthis is where we're going to finish up, and talk about the treatment of proptosis, andpossible even surgery. and it's, as i mentioned, due to swollen, and then scarred orbital fatand muscles. and it usually will get worse in the setting of your thyroid dysfunction,but it never resolves. but it usually gets a little bit better, but never, as i said,goes back to the way it was before everything began. there are a few factors that may make thingsworse for you. so, if you have poorly controlled thyroid function, and you're actively inflamed– in other words, we feel like you're in this active phase of changing of your eyes,then typically your eyes won't improve. so,

it really it's important to try and get ontop of your thyroid function. this is obviously where the – the endocrinologist and thyroidsurgeons are critical. now, smoking has really been shown to be oneof these exacerbating factors that can make your eyes worse, and that can reactivate youreye disease. and smoking, obviously, we don't necessarily think about it in kids. the problemis, is that kids are around smoking. and so the european community, that have done twolarge studies, have actually determined that second-hand smoke is a significant risk factorfor prolongation or reactivation of eye disease. and finally, if you have active eye disease,and you're going to be treated with radioactive iodine, sometimes i think it is helpful tohave a treatment of an oral steroid right

before, and then after on a taper after youhave your radioactive iodine to help decrease an exacerbation, meaning a worsen of the eyedisease. so, when i meet children and adults with proptosisin a setting of thyroid eye disease, i really want to know, "are you bothered by how youfeel?" and i'm really careful when asking, but i do ask, "are you bothered by how youlook?" and, i guess, the real question is, is should we even be talking about this. shouldwe be sensitizing ourselves to whether or not having eyes that change is really badat all? and then finally, the subject of surgicalrehabilitation really is an option, it's not a requirement. especially, in the fact thatthere is no vision loss. and i just want to

show, because i like showing these picturesof some people who have very prominent eyes. and people we've embraced as beautiful inour society such as the actress bette davis or maybe – i don't remember her name, she'sfrom modern family. do people recognize this actress? she has very prominent eyes. and then this is a model/actress some peoplemay recognize mila kunis. and then there's some very people with thyroid eye disease.this gentleman probably is famous because of his thyroid eye disease, the very famousactor/comedian marty feldman. barbara bush had thyroid eye disease. do people know that?it was kind of hard to miss. and then, obviously,

many people might be aware that oprah winfreyhad thyroid eye disease and i found it very interesting that in her time magazine storyabout her they chose to give a great portrait of her showing her thyroid eye disease. imean, these are very prominent eyes. and you can see later on in life they – i'm assumingshe had a thyroid decompression surgery because she really does look quite different. and then i love this picture of susan sarandonbecause she's smoking, and it's clearly that, you know, this is the one thing she shouldn'tbe doing. but she's also someone who’s had thyroid eye disease, and has definitely hadsurgery in the past. this is a patient i treated, it was an adult,and she told me she's bothered by her appearance.

and you can see she has this flare of hereyelid and sometimes people have what we call a lateral flare to their eyelids, and that'soften seen in thyroid eye disease. and this was her before this all began. so,you can see how there was really a change in her appearance and this was just – shebecame hyperthyroid. you can even see her right eye's more prominent and then it justprogressed to the first picture i showed you. here is a young gentleman i showed you initially,and you may see this gentleman looks normal to me. but hey, when he was younger, whenhe was a teenager, this is how he looked. so, he developed thyroid eye disease in histeens, and came, and sought us out for decompression surgery as an adult. and you can see reallyhow prominent his eyes are relative to the

bones around his face. another adult with eyes that you'd say, "oh,is she really have prominent eyes?" but when you see how she appeared when she was a bityounger, in early 20s, you can see the difference. and then, getting back to the patient i showedyou before, her appearance, and then her appearance before her hyperthyroidism kicked in, andthen her eyes began to bulge. the european group of graves' obitopathy actuallyhas a quality-of-life questionnaire that they often give their patients asking. "are youseriously limited, a little limited, or not limited at all in your activities of dailyliving; driving, moving around, reading, watching tv. watching tv by the way is the worst becauseyou're concentrating, and you forget to blink.

so, one of the most common symptoms is a personis tearing more when they're working, or watching tv. or when they go outside, and the windis blowing, and their eyes become actually dryer because their tears are being blownoff their eye. and this questionnaire goes on to ask morequestions in general. do you feel that your appearance has changed? do you feel that youare stared at in the streets? do you feel that people react unpleasantly, so on andso forth? and once again, i think this is where – thisis a very tricky subject and i always prefer to have a family or a patient come to me,and say, "i'm really bothered by this" rather than to sensitize them to it. i have one patientwho is in her teenage years and her friends

use to call her garfield, which i thoughtwas really cruel, and she was really bothered by this. garfield, you know, is the cat thathas really prominent eyes. and so she sought me out because she really was unhappy withher appearance, and she really felt that, that she was being teased. so, one of the things we can do is a surgicaldecompression. and this is a treatment to help the eye sink backward into the orbit.and it is a treatment for proptosis, and involves removal of bone and/or fat around the eye.and so getting back to a cat scan, and once again you see the two eyes, and you can seethese muscles have thickened. what our goal is, is to make more room so that this tissuecan actually sit back further.

and so what we do is we make big windows inthe bone. i mean, these are very large. you can't feel them, you certainly can't see them.and what they do is it allows the tissue to essentially prolapse, or pooch out throughthese windows, and the eyes to sink backwards. that patient that i showed you that had thepictures of when she was younger, you can see her before and after surgery. now, you say is there any difference? well,actually, when you look at her there's a huge difference. it's a, maybe a little over half,three quarters of an inch, it's about eight millimeter of her eye being more sunken back,and moving back up to here. i think it's important to see the eyelids often remain very high.and so patients often need another procedure

to lower the eyelid. and we usually don'tdo them at the same time because sometimes the lids come down, and we don't want to doan unnecessary procedure, and make the lids too low. that's what happened here in this patient.this was a pediatric patient whose orbits we helped open and you can see we loweredher eyelids, and we lowered her a little bit too much. we try to avoid doing it, but itsometimes does happen. and so we wound up raising her eyelid here. but you can see the– see all this white in her eyes here that you can see? you no longer see this so shehas much better closure of her eyes, and her eyes are more sunken back inward.

since we've been doing this surgery therehas been some advances in our surgical technique. so, a device we share with the neurosurgeonsis this bone aspirator that allows us to no longer make a little skin incision. we dothis, and we've found that our patients had a faster recovery, and it's been less invasive.and so i don't promote this in terms of the maker, but it's called a sonopet, it's slower,but it's less invasive. there's less bleeding. and once again, what we're able to do is pushthe eye aside, and get to these bones specifically here, and here to make more room so the eyescan sink backwards. and here's another pediatric patient we hadoperated on who has very prominent eyes. she's smiling here so it almost makes her look alittle bit better, but i figured i'd use it,

and she's very happy with the surgery. andyou can see before and after less white being shown. she had about six millimeters reduction. another patient who has prominent eyes andthis is her after surgery. you can see how you see more lid here. she's more sunken in.and she was one person in particularly that said, "my eyes just feel a lot better." andyou can see before and after’s. but she actually went on to need lid lowering so weactually just recently lowered her eyelids in the office. another patient who felt that her left eyewas more prominent was really bothering her, and she wanted it evened. and we went aheadand did that, and you can see the appearance

is a little more symmetric, and it's a littlemore symmetric postoperatively here. so, the alternative to removing bone is wecan actually remove some fat if a person has their eyes bulging mainly due to the fat compartment.and this is less of a decompression. so, if a person has a lot of high prominence we sometimesremove fat and bone. but i just wanted to show you one particularpatient who we did this surgery on. and this is a young patient who was unhappy with hereye appearance. and you can see her eye bulging here, a bit of proptosis. one thing we don't typically talk much aboutis, in kids once again, is her motility. so, you can see she can look left, up-and downjust fine, she's not restricted. and this

is her before surgery. and this is her catscan just showing she has these very enlarged compartment mainly due to fat enlargement.and this is the fat we removed from the four quadrants. and this is her after surgery.so, this is the appearance before, then one year after surgery. and she had an eyelidtightening procedure at the same time, which helped, actually helped her close her eyes. so, in terms of timing of surgery, patientsneed to be at least nine, but ideally into their mid-to-late teens for multiple reasons.one, is their head is growing, and so we would never operate on a child under the age ofnine unless they had vision loss and i've never heard of that happening and i don'tanticipate it would ever be an issue.

they really must be in the static phase ofthyroid eye disease, and we do check these tsi levels. and i ideally want a patient whois at least one to two years out of their active phase of inflammation because the riskof surgery when a – performing surgery on a patient whose actively inflamed around theireyes, is when you do the surgery you can make their eye disease worse. so, and we typicallywant a patient to be well out from their thyroid active disease. we usually will get a cat scan to evaluatetheir eye muscles and i usually don't get a cat scan actually. so, it's only in patientswhere it's unclear what the diagnosis is, which is really rare in graves' disease, orin patients who we are discussing surgery,

who we would go on to then give a cat scanto. i always tell parents, and families, and patientsideally you do this in the summer, or during a big break because it's one to two weeksof recovery, you're pretty swollen. although, i'd say we're doing better in terms of howpeople feel. we usually ask people to spend at least one night in the hospital. and i'dsay their average stay is about one and a half days because sometimes people are ina little bit of pain afterwards. and just to summarize that obitopathy or theproblems we see in the eyes are typically much, much less severe than in adults. andan eye doctor could be helpful in managing these symptoms related to thyroid dysfunction.and pediatric patients with bulging eyes really

can be successfully rehabilitated with surgery,but this is purely optional. and we would perform bony and fat decompression in thissetting. and thank you once again for your attention tonight.