Temporal Fossa Orbital Decompression for Treatment of Disfiguring Thyroid-Related Orbitopathy

Superior orbital fissure syndrome after deep lateral orbital wall decompression in Graves' ophthalmopathy

PURPOSE

The superior orbital fissure contains cranial nerves III, IV, VI, and V1 with their three branches: frontal, lacrimal, and nasociliary. Superior orbital fissure syndrome (SOFS) is rare and can occur as a result of compression of these nerves due to trauma, bleeding, or inflammation in the retrobulbar space, but no cases of SOFS after deep lateral orbital wall decompression (DLOWD) have been reported. The aim of this paper is to describe this pathology, its possible causes, management, and outcome.

METHODS

Retrospective study of 575 DLOWD in patients with disfiguring exophthalmos due to Graves' ophthalmopathy performed in our hospital between 2010 and 2023. Three cases of postoperative SOFS were identified based on clinical presentation, history, physical examination, and radiological study. All patients were observed for a minimum of 12 months.

RESULTS

SOFS was diagnosed with the presence of ophthalmoplegia, ptosis, fixed and dilated pupils, hypo/anesthesia of the upper eyelid and forehead, loss of corneal reflex, and no loss of vision after DLOWD. Fractures, edema, and hemorrhages were excluded. They were treated with high-dose intravenous steroids and the patients recovered completely.

CONCLUSIONS

DLOWD challenges orbital surgeons because it requires removing bones near the globe or neurovascular structures. SOFS may occur due to the proximity and increased pressure on these structures.

Orbital Decompression: Conceptual Approach for Orbital Volume Expansion

PURPOSE

To review the advances in the surgical techniques of orbital decompression.

METHODS

A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression.

RESULTS

In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed.

CONCLUSION

A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms.

The effect of rim-off deep lateral orbital decompression on the lateral rectus shape and oculomotor balance

PURPOSE

The purpose of the study was to measure the effect of rim-off deep lateral decompression for Graves orbitopathy on the lateral rectus muscle path and oculomotor balance.

METHODS

Retrospective analysis of the medical records and pre- and postoperative computed tomography scans of 34 orbits of 23 patients who underwent deep lateral decompression alone. The oculomotor balance of these 23 patients was measured with the alternate cover test and prisms before and after surgery. Bezier functions were used to measure the postoperative path of the lateral rectus in all decompressed orbits.

RESULTS

Deep lateral decompression induced a curvilinear deformation of the lateral rectus. There was no significant correlation between the position of the point of maximum muscle displacement and the size of the residual lateral wall. The changes in the lateral rectus path had no adverse effects on the oculomotor balance of the patients.

CONCLUSIONS

The location of the curvilinear deformation of the lateral rectus does not depend on the residual segment of the lateral wall. The changes of the lateral rectus path have no deleterious effect on the oculomotor balance.

Effect of Rim-Off Deep Lateral Orbital Decompression on Interpalpebral Fissure Shape

PURPOSE

The purpose of this study is to compare the palpebral fissure shape after rim-off deep lateral decompression with and without restoration of the lateral orbital rim.

METHODS

Retrospective cross-sectional quantitative analysis of the palpebral fissure images of 17 patients (25 eyes) who underwent rim-off deep lateral orbital decompression without repositioning of the rim (G1) and of 20 patients (34 eyes) operated with rim restoration. Quantification of palpebral fissure images included MRD 1 and MRD 2 , two lateral mid-pupil lid margin (MPD) distances, the width of the palpebral fissure, and the height and shape of the lateral canthus.

RESULTS

Proptosis reduction did not differ significantly between G1 and G2. In both groups, decompression reduced the mean values of the MRD 1 and MRD 2 , the lateral height of the upper eyelid, and the height and angle of the lateral canthus. The palpebral fissure width and lateral height of the lateral lower eyelid were not affected. There was no significant difference between the mean changes of G1 and G2. Multivariate analysis showed that the lateral canthus decrease was correlated with changes in MRD 1 and MRD 2 .

CONCLUSIONS

Small changes in palpebral fissure shape after deep lateral decompression are not dependent on the presence or absence of the lateral rim.

Update on the surgical management of Graves' orbitopathy

Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.

Endoscopic Transconjunctival Deep Lateral Wall Decompression for Thyroid-associated Orbitopathy: A Minimally Invasive Alternative: Transconjunctival Endoscopic with Wall Decompression for TAO

PURPOSE

To investigate the feasibility, efficacy, and safety of endoscopic transconjunctival transorbital deep lateral wall decompression for thyroid-associated orbitopathy (TAO).

DESIGN

Prospective single-surgeon interventional case series.

METHODS

Twenty-two patients (39 orbits) diagnosed with thyroid-associated orbitopathy without dysthyroid optic neuropathy were enrolled in this study. All patients underwent endoscopic transconjunctival transorbital deep lateral wall decompression for proptosis reduction. The data, including measurement on exophthalmometry, volumetric change on computed tomography, and surgery-related complications, were analyzed.

RESULTS

We observed a proptosis reduction (mean, 3.42 ± 0.87 mm; range, 2.10-5.52 mm) and a corresponding decrease in the bony volume of the greater wing of the sphenoid bone (mean, 1.89 ± 0.81 cm³; range, 0.56-3.79 cm³) postoperatively. Preexisting diplopia improved in 5 patients (22.73%). Transient zygomaticotemporal hypoesthesia developed in all patients, and cerebrospinal fluid leakage occurred in 1 orbit (2.56%). No patient complained of temporal hollowing, oscillopsia, or new-onset or worsening diplopia during follow-up.

CONCLUSIONS

Endoscopic transconjunctival transorbital deep lateral wall decompression is an effective and minimally invasive treatment for proptosis reduction in patients with thyroid-associated orbitopathy. The surgery-related complications with this technique were fewer compared with traditional approaches.

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.

[Potential of bony regrowth after deep lateral orbital decompression]

The article describes a very rare case of bony regrowth after deep lateral orbital decompression for thyroid eye disease. Bony regrowth was observed in the area of the resected «trigone» of the greater wing of the sphenoid bone and in the area of the exposed dura mater. This case demonstrates that bony regrowth can be a possible cause of exophthalmos (proptosis) recurrence after orbital decompression in thyroid eye disease without clinical or laboratory evidence of reactivation of the disease.

Surgical management of the orbit in thyroid eye disease: lateral orbital decompression

PURPOSE OF REVIEW

Lateral orbital wall decompression is one of many well established techniques available to surgeons in management of patients with clinically significant thyroid eye disease (TED). Several different surgical approaches have been described in the literature and are reviewed herein.

RECENT FINDINGS

Lateral orbital wall decompression remains a popular technique for surgical management of TED, with a recent American Society of Ophthalmic Plastic and Reconstructive Surgery survey showing that 22.6% of respondents preferred a single-wall procedure, with 36.8% of that subset preferring lateral wall decompression alone. Surgical techniques for lateral orbital wall decompression differ based on several steps, such as the incisional approach, whether to take an ab-interno versus ab-externo approach, and whether to remove orbital fat to achieve further decompression. In addition, technological advances have produced an array of tools available to the orbital surgeon to achieve efficient and accurate bone removal.

SUMMARY

Lateral orbital wall decompression for TED, despite being an older technique, remains a popular and well established procedure for orbital decompression. Though no randomized controlled clinical trial supports one decompression technique over another for TED, lateral orbital wall decompression offers many benefits such as its ease of access and visualization of the orbital space.

Deep lateral orbital decompression for Graves orbitopathy: a systematic review

PURPOSE

To systematically review the literature on the deep lateral orbital decompression (DLD).

METHODS

The authors searched the MEDLINE, Lilac, Scopus, and EMBASE databases for all articles in English, Spanish, and French that used as keywords the terms orbital decompression and lateral wall. Two articles in German were also included. Data retrieved included the number of patients and orbits operated, types of the approach employed, exophthalmometric and horizontal eye position changes, and complications. The 95% confidence intervals (CI) of the mean Hertel changes induced by the surgery were calculated from series with 15 or more data.

RESULTS

Of the 204 publications initially retrieved, 131 were included. Detailed surgical techniques were analyzed from 59 articles representing 4559 procedures of 2705 patients. In 45.8% of the reports, the orbits were decompressed ab-interno. Ab-externo and rim-off techniques were used in 25.4% and 28.8% of the orbits, respectively. Mean and 95% CI intervals of Hertel changes, pooled from 15 articles, indicate that the effect of the surgery is not related to the technique and ranges from 2.5 to 4.5 mm. The rate of new onset of diplopia varied from zero to 8.6%. Several complications have been reported including dry eye, oscillopsia, temporal howling, lateral rectus damage, and bleeding. Unilateral amaurosis and subdural hematoma have been described in only one patients each.

CONCLUSIONS

The low rate of new-onset diplopia is the main benefit of DLD. Prospective studies are needed to compare the rate of complications induced by the 3 main surgical techniques used.

Strategies in Surgical Decompression for Thyroid Eye Disease

Surgical management of thyroid eye disease- (TED-) associated morbidity has been plagued by the complex interplay of different operative techniques. Orbital decompression is the well-recognized procedure for disfiguring exophthalmos and dysthyroid optic neuropathy (DON). There are numerous published techniques described for the removal of the orbital bone, fat, or a combination. The diverse studies are noncomparative as they include different indications, stages of disease, and methods of evaluation. Thus, it is difficult to conclude the most efficient decompression technique. To obtain effective and predictable results, it is therefore important to propose a logical and acceptable clinical guideline to customize patient treatment. Herein, we developed an algorithm based on the presence of DON, preoperative existing diplopia, and severity of proptosis which were defined by patient's disabling symptoms together with a set of ocular signs reflecting visual function or cosmesis. More specifically, we aimed to assess the minimal but effective surgical technique with acceptable potential complications to achieve therapeutic efficacy. Transcaruncular or inferomedial decompressions are indicated in restoring optic nerve function in patients with DON associated with mild or moderate to severe proptosis, respectively. Inferomedial or fatty decompressions are effective to treat patients with existing diplopia associated with mild or moderate to severe proptosis, respectively. Fatty or balanced decompressions can improve disfiguring exophthalmos in patients without existing diplopia associated with mild to moderate or severe proptosis, respectively. Inferomedial or 3-wall decompressions are preferred to address facial rehabilitation in patients associated with very severe proptosis but without preoperative diplopia.

Orbital anatomical parameters affecting outcome of deep lateral orbital wall decompression

PURPOSE

To determine orbital anatomical parameters that affect surgical outcome of deep lateral orbital wall decompression.

METHODS

Twenty orbits of 20 patients with moderate proptosis (maximum 25 mm) due to thyroid eye disease who were stable for at least 6 months were included in this prospective cohort study. Four parameters including lateral orbital wall distance (LOWD), removable surface area (RSA), removable surface length (RSL), and sphenoid door jamb thickness (SDJ) were evaluated by computed tomography (CT) scan prior to surgery in these patients. Deep lateral orbital wall decompression without fat removal was done in all patients. Relationship between all these factors and proptosis reduction, 6 months after surgery was assessed.

RESULTS

Mean proptosis before decompression surgery (mean ± SD) was 23.22 ± 1.19 mm and reduction in Hertel exophthalmometry (mean ± SD) was -3.27 ± 1.03 mm (p = 0.006). Pearson correlation showed that LOWD, RSL, and SDJ had statistically significant correlation with proptosis reduction (p = 0.017, 0.002, and 0.001, respectively.). Linear multivariate regression analysis showed SDJ as the only independent factor in predicting surgical outcome.

CONCLUSION

several orbital anatomical factors have significant role in predicting surgical outcome following deep lateral wall orbital decompression. Among these parameters, SDJ is an independent factor, whereas LOWD and RSL are dependent factors. Preoperative assessment of the bony sphenoid anatomy may be helpful in predicting the amount of potential decompression.

Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy

Purpose

To describe the results of thyroid-related orbitopathy (TRO) treated by ultrasonic deep lateral wall bony decompression with partial rim sparing (DLW-PRS).

Methods

A review was carried out, from January 2015 to September 2017, of all patients treated with ultrasonic DLW-PRS decompression using a SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator, using a lateral, small triangle flap incision for access. The primary outcome was the change in proptosis (measured by the difference in Hertel exophthalmometry measurements). Other secondary outcomes were changes in visual acuity (VA) (using Snellen scale, decimal fraction), presence of lagophthalmos, eyelid retraction (measured by upper eyelid margin distance to the corneal reflex (MRD₁) and lower eyelid margin distance to the corneal reflex (MRD₂), and presence of exposure keratopathy).

Results

A total of 58 orbital decompressions in 35 patients were reviewed, with 23 patients (65.7%) having bilateral decompressions. There was a female preponderance with 26 patients (74.2%), and the mean age ± standard deviation was 52.6 ± 13.9 years. Mean proptosis was 24.51 ± 1.76 mm preoperatively, reduced to 19.61 ± 1.27 mm in final follow-up. The mean reduction was 4.9 ± 1.54 mm. VA improved from 0.8 ± 0.14 to 0.9 ± 0.12, p=0.039. 5 of 13 patients (38.4%) with preoperative diplopia reported improvement or complete resolution after surgery. MRD₁ was reduced from 5.25 ± 0.88 mm to 4.49 ± 0.7 mm. MRD₂ was also reduced from 6.3 ± 0.88 mm to 5.0 ± 0.17 mm. Presence of lagophthalmos was reduced from 35 eyes (60.3%) to five (8.6%); the presence of epiphora was also reduced from 20 patients (57.1%) to 3 (8.5%) following decompression. Complications of the surgery included zygomatic hypoaesthesia in 14 (40%) patients in the early postoperative period and chewing alterations in 10 (28.5%) of the patients. All of these complications were resolved at the 6-month follow-up visit. We noted no surgical complications such as ocular or soft tissue damage, infection, inflammation, or visual loss.

Conclusions

The SONOPET® ultrasonic bone curette can be used safely and effectively for DLW orbital decompression surgery. The main benefits were good visualization and handling of tissues and speed and ease of use of the equipment. This trial is registered with ClinicalTrials.gov identifier: NCT04025034.

[Bony orbital decompression in the treatment of endocrine ophthalmopathy]

The article reveiws the problems of bony orbital decompression for thyroid-related orbitopathy. Indications for this kind of surgery and different approaches are discussed. Advantages and limitations of each method are analyzed. Special attention is paid to complications of different bony orbital decompression approaches, complication rate and its efficacy.

Orbital decompression in the system of treatment for complicated thyroid eye disease: case report and literature review

Orbital decompression is a surgical procedure aimed at increasing the orbital volume and/or decreasing the volume of the orbital fat. The indications for orbital decompression are determined in the course of thorough eye examination. An important objective of examination of a patient with thyroid eye disease (TED) is determination of inflammation activity and severity. Orbital decompression is a surgical procedure that can be performed in both the active and nonactive stages of the disease. However, the indications for the surgery in these cases are different. Optic neuropathy and severe corneal disease are threatening complications that may lead to permanent visual loss and generally occur in the presence of active orbital inflammation. If treatment with high-dose corticosteroids has proven ineffective, an urgent surgical procedure consisting of orbital decompression and, in case of involvement of the cornea, eyelid and corneal surgery has to be performed. Owing to significant progress in technology, improvement of methods and accumulated experience over the past decade, the indications for bone orbital decompression have extended compared to the time when this procedure was used only in patients with extremely severe TED. The most common complication of the orbital decompression is the development or deterioration of previously existing binocular diplopia and strabismus. In addition, other parameters may change as well, including the position of the globe, the eyelids, the angle of deviation of the eye, and intraocular pressure. Thus, bone orbital decompression is a major step of a comprehensive, often multistage, system of rehabilitation of patients with severe refractory TED.

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.

Orbital decompression for thyroid eye disease: methods, outcomes, and complications

PurposeTo determine the safety and effectiveness of orbital decompression for thyroid eye disease (TED) in our unit. To put this in the context of previously published literature.Patients and methodsA retrospective case review of all patients undergoing orbital decompression for TED under the care of one orbital surgeon (SMS) between January 2009 and December 2015. A systematic literature review of orbital decompression for TED.ResultsWithin the reviewed period, 93 orbits of 55 patients underwent decompression surgery for TED. There were 61 lateral (single) wall decompressions, 17 medial one-and-a-half wall, 11 two-and-a-half wall, 2 balanced two wall, and 2 orbital fat only decompressions. For the lateral (single) wall decompressions, mean reduction in exophthalmometry (95% confidence interval (CI) was 4.2 mm (3.7-4.8), for the medial one-and-a-half walls it was 2.9 mm (2.1-3.7), and for the two-and-a-half walls it was 7.6 mm (5.8-9.4). The most common complications were temporary postoperative numbness (29% of lateral decompressions, 17% of other bony decompressions, OR 0.50, 95% CI 0.12-2.11) and new postoperative diplopia (9% of lateral decompressions, 39% of other bony decompressions, OR 6.8, 95% CI 1. 5-30.9). Systematic literature searching showed reduction in exophthalmometry for lateral wall surgery of 3.6-4.8 mm, with new diplopia 0-38% and postoperative numbness 12-50%. For other bony decompressions, reduction in exophthalmometry was 2.5-8.0 mm with new diplopia 0-45% and postoperative numbness up to 52%.ConclusionDiffering approaches to orbital decompression exist. If the correct type of surgery is chosen, then safe, adequate surgical outcomes can be achieved.

Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy

INTRODUCTION

Surgical rehabilitation of thyroid orbitopathy involves reducing proptosis, treating strabismus, lengthening the eyelids, and managing aesthetic changes. Not all are necessary in each patient; however, they often are. The current investigation intends to describe postdecompression changes that may influence the staging of these procedures.

METHODS

In this retrospective cohort study, records of 169 patients who underwent orbital decompression between 1983 and 2001 were reviewed. A single orbital specialist confirmed all measurements. Time to follow up was defined as the most recent follow up after decompression and prior to any secondary procedures. No strabismus or eyelid surgery was performed at the time of decompression. Strabismus was measured with alternating prism cover test. Ductions were estimated utilizing Hirschberg's method. Exophthalmometry was measured with Hertel. Eyelid positions were defined relative to the pupillary light reflex. Strabismus data were analyzed within eye pairs. Ductions, exophthalmometry and eyelid position were analyzed for each eye. T-test for paired data was utilized to compare means pre- and postoperatively.

RESULTS

The study population was on average 45 years old and 73.4% women. Average length of follow up was 1.2 years. Esotropia was significantly increased after decompression by an average of 8.1 prism diopters (p < 0.01). Exotropia and vertical deviations were not significantly altered. Ductions decreased by >5 degrees in at least one meridian for 68.1% of the population. Upper eyelid retraction remained unchanged; however, lower eyelid retraction improved by 50% from 1.4 mm to 0.7 mm (p < 0.01). Exophthalmometry improved from 23.5 mm to 19.7 mm (p < 0.01), and this result was correlated with the number of walls removed (Pearson r = -0.302, p < 0.01).

CONCLUSIONS

On average, esotropia and ductions tend to worsen with decompression surgery. This result supports the clinical dictum to avoid strabismus surgery until after decompression. The improvement in lower eyelid retraction suggests that at least lower eyelid-lengthening surgery should be reserved for after decompression, as there may be significant spontaneous improvement, while the same may not be true for upper eyelid retraction, which does not tend to change with decompression.

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.

[Potentials of intraoperative navigation during balanced orbital bony decompression in thyroid eye disease (preliminary results)]

Precise instrument localization is of great importance in orbital decompression surgery. Different navigation systems were designed to fulfill this task and gained wide acceptance.

AIM

to describe principal features and determine advantages of intraoperatively navigated orbital bony decompression.

MATERIAL AND METHODS

Data on orbital decompression surgery performed with or without intraoperative image guidance is presented. Each time two surgeons were involved - an ophthalmologist (lateral wall decompression) and otolaryngologist (medial wall decompression).

RESULTS

In lateral wall decompression, electromagnetic navigation was mostly used to enlarge the created bone window upward and backward, which is particularly challenging in case of bone thinning in the posterior part of its inner rim. In transethmoidal decompression, the image guidance allowed a more extensive removing of the greater sphenoid wing as well as the posterior medial wall where it joins the lateral wall of the sphenoid sinus. As shown by MSCT, lateral rectus muscle dislocation into the created bone window was more significant in navigated procedures.

CONCLUSION

This preliminary data convincingly shows advantages and potentials of the use of electromagnetic navigation in orbital decompression surgery, especially, for optic neuropathy in thyroid eye disease patients.

Piezosurgery for orbital decompression surgery in thyroid associated orbitopathy

The purpose of this study was to assess a piezosurgical device as a novel tool for bony orbital decompression surgery. At a multidisciplinary orbital center, 62 surgeries were performed in 40 patients with thyroid associated orbitopathy (TAO). Within this retrospective case-series, we analyzed the medical records of these consecutive unselected patients. The reduction of proptosis was the main outcome measure. Indications for a two (n = 27, 44%) or three wall (35, 56%) decompression surgery were proptosis (n = 50 orbits, 81%) and optic neuropathy (n = 12, 19%). Piezosurgery enabled precise bone cuts without intraoperative complications. Proptosis decreased from 23.6 ± 2.8 mm (SD) by 3 mm (95% CI: -3.6 to -2.5 mm) after surgery and stayed stable at 3 months (-3 mm, 95% CI: -3.61 to -2.5 mm, p < 0.001, respectively). The effect was higher in those with preoperatively higher values (>24 mm versus ≤ 24 mm: -3.4 mm versus -2.81 mm before discharge from hospital and -4.1 mm versus -2.1 mm at 3 months: p < 0.001, respectively). After a mean long-term follow-up period of 14.6 ± 10.4 months proptosis decreased by further -0.7 ± 2.0 mm (p < 0.001). Signs of optic nerve compression improved after surgery. Infraorbital hypesthesia was present in 11 of 21 (52%) orbits 3 months after surgery. The piezosurgical device is a useful tool for orbital decompression surgery in TAO. By cutting bone selectively, it is precise and reduces the invasiveness of surgery. Nevertheless, no improvement in outcome or reduction in morbidity over conventional techniques has been shown so far.

Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated orbitopathy: a new technique and results of a case series

PURPOSE

To describe a new technique for deep lateral (single) wall orbital decompression surgery, developed by Mr. Geoffrey Rose, for proptosis in patients with thyroid-associated orbitopathy and to analyse the results achieved in our series.

METHODS

The study is an interventional, retrospective, non-comparative case series. Twenty-one eyes of seventeen patients underwent the described technique of deep lateral wall orbital decompression for thyroid-associated orbitopathy. All patients had controlled thyroid functions and underwent surgery for cosmetic rehabilitation, with analysis of the reduction in proptosis, changes in visual acuity and post-operative complications. The surgery involved removing the lateral orbital wall whilst preserving the lateral rim, the lateral wall being approached through a horizontal skin incision placed lateral to the lateral canthus. After reflecting the periosteum, most of the bone (deep lateral wall) between the skull base and inferior orbital fissure is removed.

RESULTS

A mean reduction in proptosis of 4.81 mm ± 1.23 (SD) (p < 0.0001) with a median of 5.0 mm (range 3-7 mm) was achieved and the best-corrected visual acuity was maintained in all patients. There were no complications during surgery, and post-operative complications included worsening of pre-existing diplopia in one patient (6%) and transient cheek/temple numbness seen in three patients (18%).

CONCLUSIONS

This technique of deep lateral wall orbital decompression developed by Mr. Rose is a safe and effective procedure for patients with mild to moderate proptosis. It carries a low risk of morbidity and avoids complications associated with decompressing the floor and medial wall, including new onset of motility disorders.

[Two-wall decompression without resection of the medial wall. Effect on squint angle]

BACKGROUND

Postoperative new onset diplopia can be a disadvantage for surgical orbital decompression in patients with exophthalmos in thyroid eye disease. The various modifications of decompression (number and combination of walls) differ in their influence on the postoperative squint angle. We report on postoperative diplopia in a modified 2 wall decompression strategy (lateral wall and floor).

METHODS

This study was a retrospective analysis of 36 consecutive 2-wall decompressions performed between 2006-2010 in 24 patients with 6 months of stable exophthalmos in thyroid eye disease after medical therapy and radiotherapy. The preoperative and postoperative squint angle in prism cover test (PCT), motility, induction of diplopia, reduction of exophthalmos, visual acuity and complications were evaluated.

RESULTS

In all 36 decompressions the postoperative squint angle was equal to or less than before surgery. In 8 eyes additional squint surgery was performed. The mean reduction in exopthalmos was 4.3 mm.

CONCLUSIONS

An adverse effect of decompression on the postoperative squint angle was not evident in this study. New induction of diplopia was not observed at all. One possible explanation is the preservation of the medial wall.

The importance of rim removal in deep lateral orbital wall decompression

Purpose:

To evaluate the surgical outcome of deep lateral orbital decompression with or without rim removal.

Design:

Retrospective case series.

Methods:

Thirty-two patients (47 orbits) with Graves’ orbitopathy who underwent simple deep lateral decompression or balanced lateral plus medial decompression. Of the 14 patients (24 orbits) who underwent simple deep lateral decompression, 8 (13 orbits) had temporary rim removal and in 6 (11 orbits) the rim was left intact. Of the 18 patients (23 orbits) who underwent a balanced decompression, 7 (9 orbits) had temporary rim removal and in 11 (14 orbits) the rim was left intact. The amount of postoperative reduction in proptosis was compared among these four groups.

Results:

The average reduction in proptosis in the simple deep lateral decompression group was 5.73 mm (range: 4.0–8.0 mm) in the rim removal group and 4.09 mm (range: 2.5–6.0 mm) in the intact rim group (P = 0.005). The average reduction in proptosis in the balanced decompression group was 6.39 mm (range: 5.0–8.5 mm) in the rim removal group and 5.07 mm (range: 3.0–8.0 mm) in the intact rim group (P = 0.039). There was no statistically significant difference in proptosis reduction between the simple deep lateral decompression with rim removal group and the balanced decompression with an intact rim group (P = 0.220).

Conclusion:

The rim removal approach allows a more effective decompression than the intact rim approach. Simple deep lateral decompression with rim removal approach has a similar effect to balanced decompression through an intact rim.

Comparison of lateral and medial orbital decompression for the treatment of compressive optic neuropathy in thyroid eye disease

PURPOSE

To compare the efficacy of lateral orbital decompression with medial orbital decompression for the treatment of compressive optic neuropathy (CON) caused by thyroid eye disease (TED).

METHODS

A retrospective review of all patients undergoing orbital decompression for TED-associated CON between 2003 and 2008 was conducted. Clinical outcome measures included visual acuity, mean deviation on Humphrey visual field, Ishihara color plate testing, afferent pupillary defect, and Hertel exophthalmometry. A composite CON score was also calculated for each patient based on the 3 visual outcome measures, with a higher CON score reflecting greater disease severity.

RESULTS

Twenty-eight eyes of 17 patients were included in the study. Ten orbits underwent lateral wall decompression, and 18 orbits underwent medial decompression. Both groups showed a significant postoperative improvement in visual acuity, Humphrey visual field testing, and color testing at 3 months following the initial surgery. The composite CON score improved 9.04 ± 9.97 points after lateral decompression (p = 0.02) and 9.03 ± 10.84 points after medial decompression (p = 0.003). There was no significant difference in the degree of improvement in any of the visual outcome measures between the lateral and medial groups. There was a statistically significant difference in the amount of proptosis reduction resulting from lateral decompression compared with medial decompression (6.3 versus 3.1 mm, respectively, p < 0.0001).

CONCLUSIONS

Lateral orbital decompression and medial orbital decompression are both efficacious for the treatment of TED-associated CON. Lateral decompression also results in a greater proptosis reduction than medial decompression.

Orbital decompression in the treatment of proptosis due to high axial myopia

PURPOSE

To report the results of orbital decompression surgery for proptosis due to high axial myopia.

METHODS

The clinical records and imaging of 8 consecutive patients with high axial myopia who underwent orbital decompression surgery to treat disfiguring proptosis were reviewed. Data collected included preoperative and postoperative best-corrected visual acuity, Hertel exophthalmometry, ocular motility examination findings, and surgical complications.

RESULTS

Eight patients (6 women) with a median presenting age of 53 years (range, 41-78 years) underwent unilateral bony orbital decompression surgery to treat proptosis due to unilateral or asymmetric high axial myopia. Indications for surgery were disfigurement in all patients and exposure keratopathy in 4 patients. All patients had more than 12 diopters of myopia on the operated side and axial lengths between 27.5 and 34.7 mm. Preoperative visual acuity was reduced in all patients owing to amblyopia and/or myopic retinal degeneration. In addition, 2 patients had mild symmetrical thyroid-related orbitopathy. After orbital decompression surgery, Hertel exophthalmometry measurements on the operated side were within 2 mm of the other side in all patients. The mean reduction in proptosis was 2.3 mm after deep lateral orbital wall decompression (3 patients), 4.3 mm after medial and lateral wall decompression (3 patients), and 5 mm after 3-wall decompression (2 patients). Five patients had a hypotropia on the operated side, and inferior rectus recession was performed in 4. Two patients underwent additional eyelid procedures. No surgical complications were observed.

CONCLUSIONS

Orbital decompression to reduce proptosis in patients with unilateral or asymmetric high axial myopia can improve cosmesis with low morbidity.

Lateral wall orbital decompression in Graves' orbitopathy

Orbital decompression can be carried out, for rehabilitative reasons, using various techniques, but a general consensus on the ideal surgical approach has not been reached. Postoperative diplopia is the most common side effect of decompression surgery. The authors report 39 patients (72 orbits) who underwent lateral wall orbital decompression. Mean preoperative and postoperative Hertel exophthalmometry were 22.8+/-2.2mm (mean+/-SD; range 16-26 mm) and 18.2+/-2.1mm (range 15-22 mm), respectively. Mean proptosis reduction was 4.5+/-1.9 mm. A new appearance of diplopia postoperatively in the extreme gaze direction was observed in three patients (8%). The complication rate in this series was low, making the procedure safe and well tolerated. In the authors' opinion, when a single-wall approach is feasible, lateral wall decompression should be the first choice because of its effectiveness in terms of proptosis reduction and safeness in terms of postoperative diplopia.