Management of graves myopathy: a step-by-step approach
Achieving a successful surgical outcome for patients with vertical misalignment associated with thyroid eye disease remains a challenge, even for the experienced strabismus surgeon. Although tendon-sparing enlargement of the medial rectus and inferior rectus muscles with associated hypotropia and esotropia may be the classic manifestation of extraocular muscle involvement secondary to Graves' orbitopathy, neuroimaging and forced duction testing often confirm simultaneous involvement of additional extraocular muscles.

Accordingly, a comprehensive approach, integrating all pre- and intraoperative sensorimotor attributes, may reduce the risk of an unanticipated and undesirable postoperative outcome.

Published in the Journal of American Association for Pediatric Ophthalmology and Strabismus, is a step-by-step approach to the evaluation and treatment of vertical strabismus from thyroid eye disease. It addresses:-

(1) the diverse causes of late overcorrection after inferior rectus recession and methods to minimize its occurrence

(2) when to consider unilateral versus bilateral inferior rectus surgery

(3) management of A patterns associated with bilateral inferior rectus recessions

(4) sensorimotor clues, including torsional features, which indicate excessive superior rectus or superior oblique tone and should be considered in the surgical plan.

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