Transnasal endoscopic approach in the treatment of Graves ophthalmopathy: the value of a medial periorbital strip

Identification of optimal surgical plan for treatment of extraocular muscle damage in thyroid eye disease patients based on computational biomechanics

This study replicated the behavior of intraorbital tissue in patients with thyroid eye disease (TED) based on finite element analysis for general orbital decompression risk evaluation in thyroid eye disease patients. The orbit and intraorbital tissues of thyroid eye disease patients who underwent orbital decompression were modeled as finite element models. The stress was examined at specific locations of the removed orbital wall of a thyroid eye disease patient with undergone orbital decompression, and its variation was analyzed as a function of the shape and dimension (to be removed). As a result, in orbital decompression surgery which removes the orbital wall in a rectangular shape, the stress at the orbital wall decreased as the width and depth of the removed orbital wall increased. In addition, in the case of orbital decompression, it can be seen that the chamfered model compared to the non-chamfered model (a form of general orbital decompression) have the stress reduction rate from 11.08% to 97.88%. It is inferred that if orbital decompression surgery considering the chamfered model is performed on an actual thyroid eye disease patient, it is expected that the damage to the extraocular muscle caused by the removed orbital wall will be reduced.

Single-stage Orbital Decompression, Strabismus and Eyelid Surgery in Moderate to Severe Thyroid Associated Orbitopathy

PURPOSE

To evaluate the outcome of orbital decompression, strabismus and/or eyelid surgery in patients with moderate to severe thyroid-associated orbitopathy, when combined approach is preferred.

METHODS

Retrospective, comparative, non-randomized review of 45 patients operated on from 2015 to 2018. Simultaneous decompression, eyelid and/or strabismus surgery was performed in 34 eyes of 20 subjects (group 1). Patients with multi-step procedures were used as control groups: group 2 included patients with staged decompression and eyelid retraction surgery (15 cases, 19 eyes); group 3 included patients with staged decompression and vertical strabismus surgery (10 cases, 13 eyes). Mean follow-up was 2.9 ± 1.8 years. Mann Whitney two-tailed test was used for paired data, and Fisher's exact test for categorical data; p <.05 were considered statistically significant.

RESULTS

Changes in margin reflex distance were not significantly different among patients of subgroup 1A (11 patients, one-step decompression/eyelid surgery) and group 2 (p >.05). Improvement in postoperative diplopia were not significantly different among patients of subgroup 1B (9 cases, one-step decompression/strabismus/eyelid surgery) and group 3 (p >.05). One patient of group 1 had recurrent dysthyroid optic neuropathy that recovered with steroid treatment. No other complications occurred in the one-step surgery group.

CONCLUSIONS

Simultaneous orbital decompression, strabismus and/or eyelid surgery resolved dysthyroid optic neuropathy, decreased proptosis, improved diplopia and eyelid position with a range comparable to that of a multi-step technique. If confirmed in prospective controlled studies, a one-stage approach might be advised to reduce the costs and time needed for rehabilitation in selected patients.

Factors Predicting the Success of Combined Orbital Decompression and Strabismus Surgery in Thyroid-Associated Orbitopathy

To evaluate the safety and efficacy of orbital decompression combined with strabismus surgery in thyroid-associated orbitopathy (TAO) and identify factors leading to surgical success. A retrospective comparative case series was conducted on 52 patients who were treated with combined orbital decompression and strabismus surgery. Outcome measurements included perioperative Hertel exophthalmometry and strabismus measurements. Surgical success was defined as binocular single vision (BSV) in the primary and reading positions within 5 prism diopters (PDs). As a result, the average reduction in proptosis was 3.23 mm, with a mean preoperative Hertel measurement of 22.64 mm. Forty-four patients (84.6%) achieved the success criterion and composed the success group. In addition to sex and underlying hyperthyroidism, symmetry of orbitopathy, interocular exophthalmos difference of more than 2 mm, predominant esotropia type, mixed type strabismus, baseline horizontal deviations, baseline vertical deviations, and combination with one-wall decompression surgery were significantly different between the success and failure groups. All complications were mild and temporary. Orbital decompression combined with strabismus surgery produced satisfactory outcomes in selected patients with efficacy and safety. Symmetry between the two eyes with relatively simple strabismus and proptosis ensured surgical success. With experienced surgeons, advanced techniques, and selected patients, this method can serve as an alternative treatment option to minimize the number of surgeries, medical costs and recovery period.

Long-term follow-up of surgical treatment of thyroid-associated orbitopathy restrictive strabismus

OBJECTIVE

Thyroid-associated orbitopathy (TAO) is the most frequent cause of extraocular muscle enlargement, with consecutive restrictive strabismus. The main muscles involved are inferior and medial rectus, resulting in horizontal esotropia and/or vertical strabismus. Surgery may either establish or improve binocular single vision. The aim of the present study is to describe long-term follow-up of patients who underwent horizontal or vertical TAO strabismus surgery.

METHODS

This observational retrospective study included 29 patients suffering from either vertical or horizontal TAO strabismus and diplopia, of whom 11 underwent bilateral medial recti muscle recession (Group A) and 18 underwent unilateral inferior rectus muscle recession (Group B). The endpoint of the study was the assessment of changes in deviation angle and diplopia across four time points (baseline, 7 days, 6 months, and 24 months) in each group.

RESULTS

In Group A, the horizontal deviation angle significantly decreased 7 days after intervention (p < 0.001), without modifications overtime. In Group B, both deviation angles in primary and down-gaze position significantly decreased from baseline, both 7 days after surgery (p < 0.001) and at 6 months (p = 0.040). An overcorrection, with an inversion of vertical deviation angle, was observed across the different time points.

CONCLUSIONS

Horizontal TAO strabismus correction leads to significant improvements of deviation angle and diplopia, with a stable undercorrection overtime. Inferior rectus recession leads to more unstable results, with a trend towards overcorrection limited to the first 6 months after surgery.

Management of Patients With Graves Orbitopathy Using Endonasal Endoscopic Techniques

OBJECTIVE

The aim of the authors' study is to show their surgical results in orbital decompression using different endonasal endoscopic techniques. These approaches are according to the degree of proptosis and the presence or not of sight threatening.

METHODS

The authors performed 31 orbital decompressions on 20 Graves orbitopathy patients. Average age at surgery was 52 years. There were 5 males and 15 females. Five patients were diagnosed as having severe or for sight-threatening Graves orbitopathy. These included 3 men and 2 women having an average age of 54 years old. Minimum postsurgical follow-up was 12 months in all patients.

RESULTS

Orbital decompression was performed in 15 patients for proptosis and in 5 patients for urgent sight threat. Thirteen orbits showed mild proptosis and 18 orbits presented moderate proptosis. In patients without sight threatening reduction of proptosis had a mean value of 2.8 mm as determined by exophtalmometry, being 3.3 mm when measured on magnetic resonance imaging. The mean millimeter in mild proptosis was between 1.5 and 1.7 and between 3.4 and 4.2 in moderate proptosis. In patients having sight threat mean visual acuity after surgery improved from 0.6 to 0.9.Only 1 patient without diplopia preoperative developed diplopia after surgery (17%). In 55% of patients strabismus and/or eyelid surgery were required.In postoperative follow-up, 2 patients developed a mucocele and 1 patient developed corneal erosion.

CONCLUSION

The authors recommend the preservation of the periorbital sling and the anterior ethmoido-maxillary angle in patients with mild-moderate exophthalmos and without threatened vision. In case of sight threatening the authors resected the most periorbita as much as possible.Evidence-based medicine Level V.

[Orbital decompression in Graves' orbitopathy-Experiences and results]

Hintergrund

Die endokrine Orbitopathie ist die häufigste extrathyreoidale Manifestation des Morbus Basedow und tritt bei schätzungsweise 25–50 % der betroffenen Patienten auf. Krankheitsbedingt kommt es zu einer entzündlichen Schwellung der Orbitaweichteile. Die Behandlung erfolgt meist konservativ. Bei schweren Fällen mit beeinträchtigendem Exophthalmus oder akuter, steroidrefraktärer Visusbedrohung kann eine chirurgische Orbitadekompression die Beschwerden der Patienten lindern oder das Sehvermögen erhalten. Ein wesentlicher Aspekt der Versorgungsqualität besteht in der Vermeidung postoperativer Doppelbilder.

Ziel der Arbeit

Erfahrungs- und Ergebnisbericht von 100 chirurgischen Orbitadekompressionen bei 62 Patienten an einem interdisziplinären Orbitazentrum. Patienten mit Kompression der Orbitaspitze wurden mittels pterionaler Dekompression behandelt. Patienten ohne Hinweise auf Orbitaspitzenbeteiligung wurden mittels tiefer lateraler Wandresektion oder pterionaler Dekompression behandelt.

Methodik

Retrospektive Datenanalyse.

Ergebnisse

Die mittlere Exophthalmusreduktion betrug 2,9 mm. Augen mit visusbedrohendem Schweregrad gewannen im Mittel 2,2 Zeilen an Sehschärfe, der Visus bei rehabilitativer Indikation blieb stabil. Die Komplikationsrate betrug 4 %. Neue Doppelbilder wurden nach 2 Eingriffen beobachtet. Bei einem Patienten kam es zu einer Visusminderung von 0,8 auf 0,1. In 9 Fällen führte die Operation zu einem vollständigen Rückgang zuvor beklagter Doppelbilder.

Diskussion

Visusgewinn, Exophthalmusreduktion und Komplikationsrate sind in diesem Kollektiv vergleichbar mit zuvor publizierten Arbeiten. Diese Studie bestätigt die Rolle der Orbitadekompression bei visusbedrohender und schwer beeinträchtigender endokriner Orbitopathie.

Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results

AIM

To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves' ophthalmopathy (GO).

METHODS

Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, medial-lateral (balanced), medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy (DON) were compared between different surgical techniques.

RESULTS

The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values (P<0.005). Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups (P=0.181).

CONCLUSION

The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

A Retrospective Review of Orbital Decompression for Thyroid Orbitopathy with Endoscopic Preservation of the Inferomedial Orbital Bone Strut

PURPOSE

To determine incidence of new-onset diplopia, resolution of preexisting diplopia, and impact on proptosis resulting from endoscopic orbital decompression with and without preservation of the inferomedial orbital strut for thyroid orbitopathy.

METHODS

Retrospective review of all patients undergoing endoscopic 2- or 3-wall decompression with or without preservation of the strut for thyroid orbitopathy from January 2012 to June 2015.

RESULTS

Twenty-six patients (45 orbits) were included and divided into 4 primary categories: 2-wall decompression with strut preservation (4 orbits, 8%), 2-wall decompression with strut removal (7 orbits, 16%), 3-wall decompression with strut preservation (27 orbits, 60%), and 3-wall decompression with strut removal (7 orbits, 16%). The incidence of new-onset diplopia was 20% (2/10 patients without preoperative diplopia) overall and 16% in the strut preservation group (1/6 patients without preoperative diplopia). Resolution of diplopia occurred in 4 of 16 patients (25%) with preoperative diplopia, and all 4 had been treated with a 3-wall decompression with strut preservation. Resolution of diplopia in the group treated with strut preservation was 36% (4/11 patients with preoperative diplopia), and 0% of the 5 diplopic patients treated without strut preservation. Reduction in proptosis was statistically greater in those treated with strut removal (p = 0.003).

CONCLUSIONS

This study demonstrates that endoscopic orbital decompression with preservation of the inferomedial bone strut results in a comparable to lower rate of new-onset diplopia compared with other reported techniques. When combined with 3-wall balanced decompression, this technique demonstrates a high rate of resolution of preexisting diplopia.

Orbital decompression for thyroid eye disease

The literature regarding orbital decompression for thyroid eye disease is vast, spanning multiple specialty areas including neurosurgery, head and neck, maxillofacial, and ophthalmic plastic surgery. Although techniques have advanced considerably over the more than 100 years during which this procedure has been performed, the 4 major approaches remain: transorbital, transcranial, transantral, and transnasal. The explosion in literature related to orbital decompression has mostly involved minor technical variations on broader surgical themes. The purpose of this review is to organize the major approaches in terms of bony anatomy and to contextualize variation in transdisciplinary techniques within a common conceptualization.

Long-term follow-up of patients with thyroid eye disease treated with endoscopic orbital decompression

PURPOSE

To evaluate the outcome of endoscopic decompression in a series of patients with thyroid eye disease.

METHODS

All 46 patients operated at our institution in the period 2001 to 2011 were invited for re-examination. Thirty-seven patients were included in the study and underwent a general otorhinolaryngological and ophthalmological examination. Nasal endoscopy, autoperimetry and a CT scan of the orbits and paranasal sinuses were performed. Preoperative and early postoperative data were obtained from hospital records. Re-examination was performed from 12 months to 9 years postoperatively. Paired t-test was used to evaluate the change in pre- and postoperative data. Image-guided surgery was used in two patients.

RESULTS

Visual acuity improved from a median value (range) of 0.8 (0.05-1.25) to 1.0 (0.4-1.25) (p=0.006). Intra-ocular pressure (IOP) was reduced from a median value (range) of 18 mmHg (10-27 mmHg) to 14 mmHg (8-24 mmHg) (p<0.001). Median (range) Hertel values were 22.5 mm (14-29 mm) preoperatively and 19 mm (11-26 mm) postoperatively (p<0.001). Mean reduction in proptosis was 4.0 mm. At follow-up, visual fields were normal in 16/37 patients (43%) and with small defects in 12/37 patients (32%). Seventeen patients (46%) had diplopia preoperatively in one or more directions of gaze while 9 (24%) suffered from constant diplopia. After endoscopic decompression, new onset diplopia was seen in seven (19%) individuals, while worsening of diplopia occurred in eight (22%). Impaired motility in abduction and/or elevation was seen in 20 (54%) individuals before decompression and in 23 (62%) after. Strabismus surgery was performed in 22 patients. On final examination 85% of the study population were totally free of diplopia or experienced diplopia only in the peripheral field of gaze. Three patients developed sinusitis. Of these, endoscopic sinus surgery was performed in two patients, and one patient was conservatively treated. Symptoms resolved in all three patients.

CONCLUSION

Endoscopic medial orbital decompression including removal of the medial floor of the orbit is a safe and effective procedure for treatment of thyroid eye disease. Navigation can be of valuable help to ensure complete resection of the bony walls. However, the majority of patients will need subsequent strabismus surgery, mainly due to significant increase of esotropia.

Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy

PURPOSE

To describe the surgical technique for endoscopic medial orbital fat decompression in type 1 (lipogenic) Graves orbitopathy and report outcomes.

DESIGN

Retrospective interventional case review.

METHODS

We reviewed 108 patients (206 orbits) with inactive, type 1 Graves orbitopathy without diplopia, who underwent endoscopic medial orbital fat decompression solely for proptosis reduction. Following endoscopic transethmoid medial orbital wall decompression, extraconal and intraconal orbital fat was removed with a low-suction cutting instrument. All patients were followed up for at least 12 months. Surgical time, preoperative and postoperative Hertel exophthalmometry, incidence of postoperative diplopia within 30-degree visual field in the primary gaze, and other complications were analyzed.

RESULTS

The mean surgical time was 97.7 ± 16.7 minutes (67-136 minutes). The mean follow-up was 16.0 ± 4.2 months (12-24 months). Preoperative and postoperative proptosis values at final review were 21.1 ± 2.3 mm (17-26 mm) and 13.0 ± 0.9 mm (12-15 mm), respectively (P < .001). Median reduction in proptosis was 8.0 mm with mean of 8.2 ± 1.8 mm (4-11 mm). Symmetry to within 2 mm was achieved in 106 of 108 patients (98.1%). Twenty-five of 108 patients (23.1%) had diplopia within 30-degree visual field of the gaze, and 23 of these had complete resolution within 3 months, while the remaining 2 patients required squint surgery.

CONCLUSIONS

Endoscopic medial orbital fat decompression may be an effective technique for proptosis in selected patients with type 1 Graves orbitopathy and is associated with a low rate of surgically induced diplopia.

Endoscopic orbital floor decompression with preservation of the inferomedial strut

BACKGROUND

Medial and inferior orbital decompression is most commonly performed in the setting of dysthyroid orbitopathy. Diplopia represents the most common complication and may be minimized through the preservation of a bony inferomedial strut (IMS). Historically, this has required a transconjunctival approach due to the technical demands of performing an isolated orbital floor decompression using endoscopic instrumentation. Here we describe a novel technique of a purely endoscopic orbital floor decompression with reliable preservation of the IMS.

METHODS

Description of a novel surgical technique for endoscopic orbital floor decompression with IMS preservation using frontal sinus instrumentation visualized by a 70-degree endoscope.

RESULTS

We have successfully used this technique in 12 orbits with 100% preservation of the bony inferomedial strut and no complications. The extent of decompression and width of the residual strut may be fine tuned as needed to optimize results.

CONCLUSION

Orbital floor decompression with IMS preservation may be reliably performed using purely endoscopic techniques. Successful completion of this procedure requires the adaptation of standard frontal sinus instrumentation to the maxillary sinus roof and thus may be readily mastered by any endoscopic surgeon comfortable with frontal sinus techniques.

[Reoperation after orbital decompression for Graves' ophthalmopathy]

INTRODUCTION

The aim of our study was to report the incidence of complications requiring early or late reoperation after bone and fat orbital decompression for Graves's ophthalmopathy.

PATIENTS AND METHOD

We conducted a retrospective bicentric study in the Maxillofacial Surgery Departments of Marseille and Lyon. Ninety patients were selected from 2006 to 2010, accounting for 168 orbital decompressions. The surgical indication was morphological and functional for all patients. Several surgical techniques were used: bone and fat orbital decompression by trans-palpebral resection, two or three wall orbital decompression, malar valgization.

RESULTS

Ten patients were reoperated for 12 revisions, two patients needed two revisions. There were four early revisions for two retro-orbital hematoma, one inadequate orbital decompression with persistent posterior compressive optic neuropathy, and one recurrent maxillary sinusitis with proptosis. The other eight revisions were carried out later for three cases of insufficient correction, four cases of proptosis relapse, and one for excessive correction with enophthalmos. All patients had satisfactory morphological and functional results despite revision surgery.

DISCUSSION

Most reoperations are difficult to anticipate and their prevention is based on more or less specific recommendations. Patients should be informed of the risks and benefits and accept the possibility of reoperation. A systematic multidisciplinary consultation would standardize and improve the management of these patients, by detecting patients at risk of complications and thus reoperation.