الفهرس 
Introduction
Important anatomical relationsOnly 14 pages are availabe for public view
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Abstract
Exophthalmos is most commonly due to Graves ophthalmopathy. The latter is the most frequent extrathyroidal manifestation of Graves disease. This work aimed at reporting the impact and assessment of neartotal thyroidectomy on the course of ophthalmopathy including exophthalmos. During the period from June 2003 to February 2004 inclusive, a total of 20 patients, with thyrotoxic goiters suffering from mild to moderate exophthalmos were enrolled onto this prospective study that was conducted at the Endocrine Surgery Unit, Mansoura University Hospital. All patients were required to have a thyrotoxic goiter diagnosed through careful history taking, clinical examination, and laboratory and radiological investigations. Preoperative evaluation of ophthalmopathy was accomplished through the NOSPECS classification, MRI scanning for measuring the extraocular muscle diameters and measurement of the exophthalmos using Hertel<U+2019>s exophthalmometer. All the patients were of younger age (27.7 +/ 6.1 years) and females constituted 70% of the cases. However, severer forms of ophthalmopathy were more encountered in males. The goiter volumes ranged from 50 up to 250 cm3. At presentation, no case of visual acuity deterioration was detected, while diplopia existed in only 5% of the cases. The most frequent ocular symptoms and signs were related to soft tissue involvement. The degree of exophthalmos was not less than 21 mm and in non of the cases it exceeded 27mm. Enlargement of extraocular muscles were observed in the MRI scans of the orbits of all the cases. The patients underwent neartotal thyroidectomy following the standard steps to end with the complete removal of both thyroid lobes except a subcentimeter of the left lobe at the entrance of the recurrent laryngeal nerve into the larynx and around the parathyroids. Postoperatively, early institution of thyroxine was done to avoid hypothyroidism that might exaggerate ophthalmopathy. Six months postoperatively, ophthalmopathy including exophthalmos was reevaluated using the same parameters mentioned before. Clinical activity evaluation, exophthalmometry and extraocular muscles measurement by MRI revealed that the majority of the cases experienced improvement of their ophthalmopathy.This improvement was statistically significant. However, while our results are going in harmony with some of the reported ones they are not with the others. In general, it was difficult to compare our results with similar reported studies including subtotal and total thyroidectomy due to the great variation among the data even within each arm. Such conflict was due to several factors such as: the retrospective nature of most of the reported studies, the different ways of defining the term subtotal and neartotal thyroidectomy, the different methods of assessing ophthalmopathy and selection bias. The present study, unlike a number of reported ones, failed to specify any statistically significant prognostic factors affecting the course of ophthalmopathy. This might be due to the limited number of cases in general. In addition, all of the cases were of relatively young age and thyrotoxic, and the majority were females and nonsmoking. It is worth to note that the limited incidence of postoperative complications in the present study ascertained what have been reported about the fact that neartotal thyroidectomy adds the advantages of subtotal thyroidectomy (i,e. low incidence of injury of recurrent laryngeal nerve and the parathyroids) to those of total thyroidectomy (no recurrence of hyperthyroidism). In fact, there is a progressing tendency in the literature towards believing that the more the thyroid ablation, the more the thyroid antigen is ablated , the more the amelioration of ophthalmopathy.