Graves' orbitopathy and restrictive myopathy.

Restrictive myopathy in Graves' orbitopathy is a disabling disorder, difficult to treat, involving clinically the inferior and medial recti. Most patients do not return to the normal, premorbid state of muscular alignment and the goal of treatment is to reach binocular vision in the important directions of gaze--straight ahead (primary position) and downgaze (reading position). The treatment in the acute, congestive stage is optical, prisms or patching, or medical. The medical treatment principally consists of a course of oral or intravenous corticosteroid treatment, and in selected patients orbital irradiation can be of benefit. Surgery is performed on the euthyroid patient after the muscular imbalance has stabilized, usually six months from the onset of the disorder. The mainstay of therapy is a large recession of the involved muscles, if possible on an adjustable suture. Sometimes marginal myotomies are added to the muscle recession. A fadenoperation on the contralateral, minimally involved inferior rectus has been suggested as a means of increasing muscular alignment in both primary position and downgaze. Thorough evaluation of the course of the disease, and the benefit of different treatment modalities is possible only with long term follow-up.