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Topilow NJ, Penteado RC, Ting M, Al-Sharif E, Villatoro GA, Yoon JS, Liu CY, Korn BS, Kikkawa DO. Orbital decompression following treatment with teprotumumab for thyroid eye disease. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00174-1. [PMID: 39059786 DOI: 10.1016/j.jcjo.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 03/17/2024] [Accepted: 06/03/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE To quantify the observed decrease in orbital decompressions being performed at one tertiary care institution and to determine the rate and predictive factors of orbital decompression surgery following treatment with teprotumumab for thyroid eye disease. METHODS Epic's SlicerDicer program was used to analyze recent trends in the overall number of thyroid eye disease (TED) patients evaluated in the oculoplastic surgery department, as well as usage trends of CPT codes 67445 (lateral orbitotomy with bone removal for decompression) and 67414 (orbitotomy with removal of bone for decompression). A retrospective chart review of active moderate-to-severe TED patients treated with teprotumumab was performed at a single tertiary care center. The main outcome measure was whether or not patients underwent bony orbital decompression surgery following treatment with teprotumumab. The SlicerDicer search demonstrated stable usage of CPT codes 67445 and 67414 from 2016 to 2019, followed by a significant decrease from 2020 to 2023, over a background of increasing numbers of TED patients evaluated in clinic. Following teprotumumab therapy, 25% of patients and 18% of orbits underwent bony decompression. Surgically decompressed patients had higher pre- and post-teprotumumab exophthalmometry measurements compared with patients who did not undergo bony decompression. Average time to decompression following conclusion or cessation of teprotumumab therapy was 12.6 months. CONCLUSION While the number of TED patients treated at one tertiary care center has risen over recent years, the number of orbital decompression surgeries has declined. Orbital decompression, however, is still needed in select patients after treatment with teprotumumab.
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Affiliation(s)
- Nicole J Topilow
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA.
| | - Rafaella Cleto Penteado
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA
| | - Michelle Ting
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA
| | - Eman Al-Sharif
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA
| | - George A Villatoro
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA
| | - Jin Sook Yoon
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Yonsei, Korea
| | - Catherine Y Liu
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA; Division of Plastic Surgery, Department of Surgery, University of California San Diego Department of Surgery, La Jolla, CA
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, La Jolla, CA; Division of Plastic Surgery, Department of Surgery, University of California San Diego Department of Surgery, La Jolla, CA
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Hou X, Tu Y, Min X, Du K, Li F, Wang J, Wu X. The effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid ophthalmopathy. J Fr Ophtalmol 2024; 47:103924. [PMID: 37775455 DOI: 10.1016/j.jfo.2023.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE To evaluate the effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy. METHODS This retrospective study enrolled 55 eyes of 33 patients treated in our hospital for restrictive strabismus caused by thyroid-associated ophthalmopathy. We performed muscle recession for the obviously restricted extraocular muscles, with 6 weeks of follow-up. Surgical outcomes were compared between the orbital decompression group (DG, n=15) and non-orbital decompression group (NDG, n=18). RESULTS A total of 33 patients with Graves' ophthalmopathy who underwent rectus muscle recession surgery were included. Of these, 15 patients had undergone orbital decompression prior to strabismus surgery, and 18 had not. The two groups did not differ in terms of the preoperative horizontal or vertical ocular deviation, degree of restriction of eye movement, degree of diplopia, or mean number of muscles that underwent surgery (P>0.05). There was no significant difference in the preoperative horizontal or vertical ocular deviation, level of eye movement restriction, degree of diplopia and the success rate of the surgery (P>0.05). CONCLUSION Rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy during the quiescent period could improve the ocular deviation and diplopia, and orbital decompression performed before strabismus surgery had no significant effect on surgical technique or outcomes of rectus muscle recession surgery.
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Affiliation(s)
- X Hou
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China
| | - Y Tu
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China
| | - X Min
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China
| | - K Du
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China
| | - F Li
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China
| | - J Wang
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China.
| | - X Wu
- Eye Center of Xiangya Hospital, Central South University, Changsha, 410008,Hunan Province, China; National Clinical Key Specialty of Ophthalmology,Changsha, 410008,Hunan Province, China; Hunan Key Laboratory of Ophthalmology, Changsha, 410008,Hunan Province, China.
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Goldberg RA, Gout T. Orbital Decompression: Conceptual Approach for Orbital Volume Expansion. Ophthalmic Plast Reconstr Surg 2023; 39:S105-S111. [PMID: 38054990 DOI: 10.1097/iop.0000000000002556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
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.
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Affiliation(s)
- Robert A Goldberg
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
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Grusha YO, Kochetkov PA, Danilov SS, Duvanova ED, Sviridenko NY. [Complications of transnasal endoscopic orbital decompression in thyroid eye disease]. Vestn Oftalmol 2023; 139:63-68. [PMID: 37379110 DOI: 10.17116/oftalma202313903163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
PURPOSE The study evaluates the frequency of complications after transnasal endoscopic orbital decompression (TEOD). MATERIAL AND METHODS The study included 40 patients (75 orbits) with thyroid eye disease (TED; also termed Graves' ophthalmopathy, GO; thyroid-associated orbitopathy, TAO), who were divided into three groups depending on the method of surgical treatment. The first group consisted of 12 patients (21 orbits) who were treated with TEOD as the only method of surgical treatment. In the second group, there were 9 patients (18 orbits) who underwent TEOD and lateral orbital decompression (LOD) simultaneously. The third group consisted of 19 patients (36 orbits) who underwent TEOD as the second stage after LOD. Pre- and postoperative observation included assessment of visual acuity, visual field, exophthalmos, heterotropia/heterophoria angle. RESULTS In group I the new-onset strabismus with binocular double vision was detected in 1 patient (8.3%). In 5 patients (41.7%), there was an increase in the angle of deviation and an increase in diplopia. In group II the new-onset strabismus with diplopia occurred in 2 patients (22.2%). In 8 patients (88.9%), an increase in the angle of deviation and an increase in diplopia were revealed. In group III the new-onset strabismus and diplopia occurred in 4 patients (21.0%). An increase in the deviation angle and an increase in diplopia were noted in 8 patients (42.1%). The number of postoperative otorhinolaryngologic complications in group I was 4 (19.0% of the number of orbits). Two intraoperative complications were recorded in group II - 1 case of cerebrospinal rhinorrhea (5.5% of the number of orbits) and 1 case of retrobulbar hematoma without permanent vision loss (5.5% of the number of orbits). The number of postoperative complications was 3 (16.7% of the number of orbits). In group III the number of postoperative complications was 3 (8.3% of the number of orbits). CONCLUSION The study showed that the most common ophthalmological complication after TEOD is strabismus with binocular double vision. Otorhinolaryngologic complications included synechiae of the nasal cavity, sinusitis and mucocele of the paranasal sinuses.
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Affiliation(s)
- Y O Grusha
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - P A Kochetkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - S S Danilov
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - E D Duvanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - N Yu Sviridenko
- National Medical Research Center for Endocrinology, Moscow, Russia
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Nair AA, Ediriwickrema LS, Dolman PJ, Law G, Harrison AR, Mokhtarzadeh A, Stewart K, Men C, Lucarelli MJ, van Landingham S, Wingelaar M, Verma R, Chen A, Selva D, Garrity J, Eckel L, Kazim M, Godfrey K, Baxter SL, Korn BS, Kikkawa DO. Predictive Modeling of New-Onset Postoperative Diplopia Following Orbital Decompression for Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2022; 38:551-557. [PMID: 35551414 DOI: 10.1097/iop.0000000000002196] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques. METHODS We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX). RESULTS A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3-156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective. CONCLUSIONS This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.
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Affiliation(s)
- Archana A Nair
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
| | - Lilangi S Ediriwickrema
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey Law
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew R Harrison
- Department of Ophthalmology and Visual Neurosciences and Otolaryngology, University of Minnesota, Minneapolis, Minnesota
| | - Ali Mokhtarzadeh
- Department of Ophthalmology and Visual Neurosciences and Otolaryngology, University of Minnesota, Minneapolis, Minnesota
| | - Krista Stewart
- Department of Ophthalmology and Visual Neurosciences and Otolaryngology, University of Minnesota, Minneapolis, Minnesota
| | - Clara Men
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
| | - Mark J Lucarelli
- Department of Ophthalmology, Oculoplastic, Facial Cosmetic and Orbital Surgery Service, University of Wisconsin-Madison, Madison, Wisconsin
| | - Suzanne van Landingham
- Department of Ophthalmology, Oculoplastic, Facial Cosmetic and Orbital Surgery Service, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maxwell Wingelaar
- Department of Ophthalmology, Oculoplastic, Facial Cosmetic and Orbital Surgery Service, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rohan Verma
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
| | - Allison Chen
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
| | - Dinesh Selva
- Department of Ophthalmology, Adelaide Skin and Eye Centre, University of Adelaide, Adelaide, Kent Town, South Australia
| | - James Garrity
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Laurence Eckel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Michael Kazim
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York
| | - Kyle Godfrey
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York
| | - Sally L Baxter
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology, Shiley Eye Institute, La Jolla, California
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California
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Kim J, Plitt AR, Vance A, Connors S, Caruso J, Welch B, Garzon-Muvdi T. Endoscopic Endonasal versus Transcranial Optic Canal Decompression: A Morphometric, Cadaveric Study. Skull Base Surg 2022; 83:e395-e400. [DOI: 10.1055/s-0041-1729909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Introduction Decompression of the optic nerve within the optic canal is indicated for compressive visual decline. The two most common approaches utilized for optic canal decompression are a medial approach with an endoscopic endonasal approach and a lateral approach with a craniotomy. Our study is a cadaveric anatomical study comparing the length and circumference of the orbit decompressed via an endoscopic endonasal approach versus a frontotemporal craniotomy.
Methods Five cadaveric specimens were utilized. Predissection computed tomography (CT) scans were performed on each specimen. On each specimen, a standard frontotemporal craniotomy with anterior clinoidectomy and superolateral orbital decompression was performed on one side and an endoscopic endonasal approach with medial wall decompression was performed on the contralateral side. Post-dissection CT scans were performed. An independent radiologist provided measurements of the length (mm) and circumference (degrees) of optic canal decompression bilaterally.
Results The mean length of optic canal decompression for open and endoscopic approach was 13 mm (range 12–15 mm) and 12.4 mm (range 10–16 mm), respectively. The mean circumference of decompression for open and endoscopic approaches was 252.8 degrees (range 205–280 degrees) and 124.6 degrees (range 100–163 degrees), respectively.
Conclusion The endoscopic endonasal and the transcranial approaches provide a similar length of optic canal decompression, but the transcranial approach leads to greater circumferential decompression. The endoscopic endonasal approach has the benefit of being minimally invasive, though. Ultimately, the surgical approach decision should be based on the location of the pathology and the surgeon's comfort.
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Affiliation(s)
- Jun Kim
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
| | - Aaron R Plitt
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
| | - Awais Vance
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
| | - Scott Connors
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
| | - James Caruso
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
| | - Babu Welch
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
| | - Tomas Garzon-Muvdi
- Department of Neurological Surgery, Southwestern Medical Center, University of Texas, Dallas, Texas, United States
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Stähr K, Eckstein A, Buschmeier M, Hussain T, Daser A, Oeverhaus M, Lang S, Mattheis S. Risk Factors for New Onset Diplopia After Graduated Orbital Decompression. Ophthalmic Plast Reconstr Surg 2021; 37:564-570. [PMID: 33587422 DOI: 10.1097/iop.0000000000001949] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of the study was to identify possible risk factors for new onset diplopia in 20° of primary position (NOD PP) after orbital decompression. A predisposition for NOD has been established for patients with pre-existing diplopia in secondary gaze; therefore, the authors focused on patients without preoperative diplopia. METHODS Retrospective chart review of patients who underwent balanced orbital decompression between 2012 and 2019 due to Graves orbitopathy at the authors' institution. Exclusion criteria were incomplete clinical data set, revision surgery, and medial or lateral decompression only. The following clinical parameters were evaluated preoperatively and postoperatively: Hertel exophthalmometry, objective measurement of misalignment using the prism-cover-test, assessment of the field of binocular single vision, and measurement of monocular excursions. In addition, the diameter of the extraocular eye muscles was measured in all preoperative CT scans. RESULTS We included 327 patients (612 orbits), 126 patients (242 orbits) had no preoperative diplopia. In patients with NOD PP (34%, n = 43/126), enlargement of the medial rectus muscle and restriction of abduction and elevation were significantly more frequent than in patients with no NOD PP. The degree of exophthalmos decrease positively correlated with postoperative squint angle. CONCLUSION We were able to identify the diameter of the medial rectus muscle, restriction of abduction, and elevation as well as an extensive reduction of exophthalmos as risk factors for NOD PP in patients with no preoperative diplopia.
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Affiliation(s)
- Kerstin Stähr
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Anja Eckstein
- Department of Ophthalmology (Chair: Prof. Bechrakis), University Hospital Essen, Germany
| | - Maren Buschmeier
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Timon Hussain
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Anke Daser
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Michael Oeverhaus
- Department of Ophthalmology (Chair: Prof. Bechrakis), University Hospital Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
| | - Stefan Mattheis
- Department of Otorhinolaryngology, Head and Neck Surgery (Chair: Prof. Lang)
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Stähr K, Daser A, Oeverhaus M, Hussain T, Lang S, Eckstein A, Mattheis S. Proposing a surgical algorithm for graduated orbital decompression in patients with Graves' orbitopathy. Eur Arch Otorhinolaryngol 2021; 279:2401-2407. [PMID: 34291345 PMCID: PMC8986704 DOI: 10.1007/s00405-021-07003-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine the outcome after orbital decompression using a graduated technique, adapting the surgical technique according to individual patients' disease characteristics. METHODS We retrospectively examined the postoperative outcome in patients treated with a graduated balanced orbital decompression regarding reduction of proptosis, new onset diplopia and improvement in visual function. 542 patients (1018 orbits) were treated between 2012 and 2020 and included in the study. Clinical examinations including visual acuity, exophthalmometry (Hertel) and orthoptic evaluation were performed preoperatively and at minimum 6 weeks postoperatively. Mean follow-up was 22.9 weeks. RESULTS Mean proptosis values have significantly decreased after surgery (p < 0.01). In 83.3% of the patients Hertel measurement normalized (≤ 18 mm) after surgery, New onset diplopia within 20° of primary position occurred in 33.0% of patients, of whom 16.0% had preoperative double vision in secondary gaze. Patients suffering from dysthyroid optic neuropathy (DON) had a significant increase in visual acuity (p < 0.01). CONCLUSION We demonstrated that individually adapted graduated orbital decompression successfully improves key disease parameters of Graves' orbitopathy with low morbidity.
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Affiliation(s)
- Kerstin Stähr
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Anke Daser
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Michael Oeverhaus
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Timon Hussain
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Anja Eckstein
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Stefan Mattheis
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
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Changes in Field of Binocular Single Vision and Ocular Deviation Angle After Balanced Orbital Decompression in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2021; 37:154-160. [PMID: 32427735 DOI: 10.1097/iop.0000000000001712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate influential factors for changes in the binocular single vision (BSV) and ocular deviation angle in the medial direction after bilateral balanced orbital decompression in thyroid eye disease. METHODS This retrospective study included 41 patients. The areas of BSV and the angles of medial ocular deviation on the Hess chart were measured. The percentages of pre- and postoperative areas against the normal area (%BSV) and the change in BSV after surgery were calculated. Postoperative change in the angle was calculated by subtraction of the preoperative angle from the postoperative one. Influential factors for the change in BSV and that in the medial deviation angle were evaluated via multivariate linear regression analysis. RESULTS The maximum cross-sectional area of the medial rectus muscle, preoperative %BSV, and preoperative medial ocular deviation angle were significant factors of change in BSV (adjusted r2 = 0.449, p < 0.001), although age, history of anti-inflammatory treatment, volume of removed orbital fat, findings on CT images, maximum cross-sectional areas of the other rectus muscles, and presence or absence of a periosteal flap did not affect change in BSV (p > 0.050). On the contrary, all variables did not influence postoperative changes in the medial ocular deviation angle (p > 0.050). CONCLUSIONS In balanced orbital decompression, the maximum cross-sectional area of medial rectus muscle, preoperative field of BSV, and medial ocular deviation were significant influential factors for postoperative changes in field of BSV.
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10
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Parrilla C, Mele DA, Gelli S, Zelano L, Bussu F, Rigante M, Savino G, Scarano E. Multidisciplinary approach to orbital decompression. A review. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2021; 41:S90-S101. [PMID: 34060524 PMCID: PMC8172106 DOI: 10.14639/0392-100x-suppl.1-41-2021-09] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/15/2021] [Indexed: 12/02/2022]
Abstract
Endoscopic orbital surgery has become a highly evolving multidisciplinary surgical field thanks to development in technical skills of ophthalmologists and otolaryngologists. These advances expanded the clinical application of orbital decompression, with a growing body of literature describing the multidisciplinary management of thyroid eye disease and compressive optic neuropathy, since 1990. Although techniques have improved considerably, only few Randomized Control Trials (RCT) provide evidence to support recommendations in clinical practice. This review provides an overview of the current knowledge of orbital decompression to clarify which is the most standardized therapeutic strategy. In the literature, we observed several approaches with contradicting results and the comparison of different surgical techniques was biased by inclusion of patients at different stage of disease (active or inactive), different surgical indications (dysthyroid neuropathy or disfiguring proptosis) and measures of outcomes (such as different system for ocular motility evaluation). The timing of surgical decompression is one of the debated issues. One RCT focusing on Graves’ orbitopathy showed how intravenous corticosteroids achieve better visual recovery than surgical orbital decompression; but in case of absent or poor response to medical therapy the patient should undergo surgery within two weeks. There is slight evidence that the removal of the medial and lateral wall (so-called balanced decompression) with or without fat removal could be the most effective surgical technique, with low complication rate, but an increasing number of authors are promoting, for selected cases, a pure endoscopic surgical approach (with removal of medial and infero-medial orbital wall), less invasive than the balanced one; the latter indicated to more severe proptosis or diplopia after endoscopic procedure. Three-wall decompression is chosen for high degrees of proptosis, but complications are more frequent. Timing of surgical orbital decompression, in particular when a concomitant optic neuropathy is present, is still to be determined. Additional ophthalmological procedures are needed to restore normal eye function and cosmesis. Strabismus surgery to address diplopia and lowering the position of the upper eyelid represent some of the additional steps for the final rehabilitation of Graves’ orbitopathy. The main clinical outcomes including visual acuity, proptosis, and new-onset diplopia are changing. Recent studies focused on the development of imaging measurements in order to objectively evaluate the surgical results and QOL questionnaires are gaining increasing importance.
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Affiliation(s)
- Claudio Parrilla
- Otorhinolaryngology and Head-Neck Surgery Unit, “A. Gemelli” Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Dario Antonio Mele
- Otorhinolaryngology and Head-Neck Surgery Unit, “A. Gemelli” Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Silvia Gelli
- Endocrinology Unit, “A. Gemelli” Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Lorenzo Zelano
- Endocrinology Unit, “A. Gemelli” Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Mario Rigante
- Otorhinolaryngology and Head-Neck Surgery Unit, “A. Gemelli” Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gustavo Savino
- Ophthalmology Unit, “A. Gemelli” Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Emanuele Scarano
- Division of Otolaryngology, Azienda Ospedaliera Pia Fondazione di Culto e Religione Cardinale G. Panico, Tricase, Italy
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11
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Limone PP, Mellano M, Ruo Redda MG, Macera A, Ferrero V, Sellari Franceschini S, Deandrea M. Graves' orbitopathy: a multidisciplinary approach. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2021; 65:157-171. [PMID: 33634673 DOI: 10.23736/s1824-4785.21.03350-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orbitopathy is the main extra thyroidal manifestation of Graves' disease. It is a very challenging condition, which requires a cooperation between many specialists (endocrinologists, ophthalmologists, radiologists, radiotherapeutic, orbital surgeons) for an optimal clinical management. An accurate diagnostic assessment is required, in order to plan an adequate treatment of Graves' orbitopathy. Medical therapy, radiotherapy or surgery may be necessary to control the disease. In this review, the authors analyze the various therapeutic strategies, as well the more recent therapies based on pharmacologic immunomodulation.
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Affiliation(s)
- Paolo P Limone
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy -
| | - Marco Mellano
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy
| | | | - Annalisa Macera
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy
| | - Vittorio Ferrero
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy
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12
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Cruz AAV, Equiterio BSN, Cunha BSA, Caetano FB, Souza RL. Deep lateral orbital decompression for Graves orbitopathy: a systematic review. Int Ophthalmol 2021; 41:1929-1947. [PMID: 33517506 DOI: 10.1007/s10792-021-01722-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Antonio Augusto V Cruz
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, Sao Paulo, Brazil.
| | - Bruna S N Equiterio
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, Sao Paulo, Brazil
| | - Barbara S A Cunha
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, Sao Paulo, Brazil
| | - Fabiana Batista Caetano
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, Sao Paulo, Brazil
| | - Roque Lima Souza
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, Sao Paulo, Brazil
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Leite CDA, Pereira TDS, Chiang J, Moritz RB, Gonçalves ACP, Monteiro MLR. Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study. Clinics (Sao Paulo) 2021; 76:e2592. [PMID: 33852655 PMCID: PMC8009066 DOI: 10.6061/clinics/2021/e2592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.
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Affiliation(s)
- Cristiane de Almeida Leite
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Thaís de Sousa Pereira
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Jeane Chiang
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rodrigo Bernal Moritz
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Allan Christian Pieroni Gonçalves
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mário Luiz Ribeiro Monteiro
- Laboratorio de Investigacao em Oftalmologia (LIM 33), Divisao de Oftalmologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Cheng AMS, Wei YH, Liao SL. Strategies in Surgical Decompression for Thyroid Eye Disease. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:3537675. [PMID: 32963693 PMCID: PMC7501557 DOI: 10.1155/2020/3537675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/23/2020] [Accepted: 09/01/2020] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Anny M S Cheng
- Florida International University, Herbert Wertheim College of Medicine, Florida, USA
- Department of Surgery, Miller School of Medicine, University of Medicine, Miami, Florida, USA
| | - Yi-Hsuan Wei
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Lang Liao
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University, Taipei, Taiwan
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Daser A, Mattheis S, Stähr K, Lang S, Bechrakis NE, Dekowski D, Eckstein A. Bony Orbital Decompression in Patients with High Myopia and Pseudoexophthalmos. Klin Monbl Augenheilkd 2020; 238:41-47. [PMID: 32869244 DOI: 10.1055/a-1214-6557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION High myopic eyes grow in length (> 0.35 mm/dpt) more than in height and width leading to a disturbing unilateral exophthalmos in patients with anisomyopia and - more rarely - a bilateral exophthalmos in high myopia affecting both eyes. Secondary consequences are sicca symptoms and painful eye mobility due to a large bulbus in a too small bony orbit. The aim of the work was to evaluate the effectiveness of bony orbital compression in cases of high myopia. MATERIAL AND METHODS Four patients underwent bony orbital decompression between the years 2012 and 2019. Two of the patients received lateral and two of them balanced (medial endonasal endoscopic and lateral) decompression. The decompression effect, complications and the influence of decompression on eye position and motility were evaluated. RESULTS Significant decompression effect was achieved in all patients. As a result, symmetry was restored in all unilaterally affected patients. No complications occurred. The lateral decompression had a positive effect on the preexisting convergent strabismus (reduction of the "eso" position, neutral to the vertical deviation). The carefully dosed medial decompression did not lead to any change of the horizontal position in one patient and in the other exotropic patient it resulted in a 10 pdpt of "exo" reduction without developing an "eso" position. DISCUSSION The bony orbital decompression provides a sufficient decompression effect in the four patients to reduce the myopic pseudoexophthalmos. The alignment anomalies associated with a high myopia ("heavy eye") was favourably influenced by the lateral decompression.
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Affiliation(s)
- Anke Daser
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Stefan Mattheis
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Kerstin Stähr
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Stephan Lang
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Nikolaos E Bechrakis
- Klinik für Augenheilkunde, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Dirk Dekowski
- Klinik für Augenheilkunde, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
| | - Anja Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Duisburg-Essen, Essen, Deutschland
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Endoscopic Orbital Decompression by Oculoplastic Surgeons for Proptosis in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2020; 35:590-593. [PMID: 31162299 DOI: 10.1097/iop.0000000000001406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Orbital decompression is an established surgical treatment option for a range of orbital conditions. Traditionally, Ear, Nose and Throat surgeons have adopted the endoscopic route while ophthalmologists operate via an external approach. The authors report the outcomes of endonasal decompression performed by oculoplastic surgeons experienced in endonasal techniques. METHODS This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to thyroid eye disease across 2 hospital sites between January 2011 and July 2018. Inclusion criteria were patients who had endoscopic decompression for proptosis in inactive thyroid eye disease or active disease without dysthyroid optic neuropathy. Information collected includes patient demographics, diagnosis, surgical details, preoperative and postoperative clinical findings (including, visual acuity, color vision, exophthalmometry readings, palpebral aperture, intraocular pressure, ocular motility, diplopia, and visual field), complications, and further treatment. RESULTS There were 70 cases of endoscopic decompression. The majority of patients had endoscopic medial and posterior medial wall/floor decompression (44.3%; 31/70 cases). Visual acuity remained stable in 98.6% (69/70). There was an average reduction in proptosis of 3.5 ± 1.2 mm (standard deviation [SD]) in the endoscopic medial wall only group, 3.9 ± 0.9 mm (SD) in endoscopic medial wall and posterior medial portion of the floor group, and 7.6 ± 2.1 mm (SD) in the 3-wall decompression group. Motility improved in 11.4% (8/70) and worsened in 2.9% (2/70). There were no significant intraoperative or postoperative complications associated with endoscopic surgery. CONCLUSIONS Oculoplastic surgeons experienced in endonasal techniques can perform endoscopic orbital decompression with outcomes comparable to the literature.The authors report the outcomes of a series of endonasal orbital decompression carried out by oculoplastic surgeons.
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Juniat V, McGilligan JA, Curragh D, Selva D, Rajak S. Endoscopic orbital decompression for proptosis in non-thyroid eye disease. Oral Maxillofac Surg 2019; 24:85-91. [PMID: 31853760 DOI: 10.1007/s10006-019-00826-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/06/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE Orbital decompression is an established surgical treatment option for a range of orbital conditions. We report the outcomes of endonasal decompression to recess the globe for conditions and pathologies other than thyroid eye disease. METHODS This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to non-thyroid eye disease orbital pathologies. The procedures were carried out by oculoplastic surgeons across two hospital sites between January 2011 and July 2018. Information collected includes patient demographics, diagnosis, surgical details, pre- and postoperative clinical findings (including visual acuity, exophthalmometry readings, intraocular pressure, ocular motility and diplopia), complications and further treatment. RESULTS There were seven cases of endoscopic decompression, each due to a different pathology. The reasons for decompression were proptosis secondary to optic nerve sheath meningioma (1); sphenoid wing meningioma (1); idiopathic myositis (1); axial myopia (1); chronic third nerve palsy (1); to protuberant keratoprosthesis (1); and Crouzon syndrome with corneal exposure (1). Visual acuity remained stable or improved in all patients postoperatively. There was an average reduction in proptosis of 3.5 ± 1.4 mm (standard deviation - SD). Ocular motility remained stable in 100% (7/7). There were no intraoperative or postoperative complications, including no new cases of postoperative diplopia. CONCLUSIONS Endoscopic orbital decompression can be performed for patients with proptosis associated with a large globe, facial dysplasia or medial and infero-medial orbital lesions.
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Affiliation(s)
- Valerie Juniat
- Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia.
| | - J Anthony McGilligan
- Department of Ears, Nose and Throat, Princess Royal Hospital,, RX16 4EX, Haywards Heath, UK
| | - David Curragh
- Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Dinesh Selva
- Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Saul Rajak
- Department of Ophthalmology, Sussex Eye Hospital, Eastern Road, Brighton, BN2 5BF, UK
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18
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Stähr K, Eckstein A, Holtmann L, Schlüter A, Dendy M, Lang S, Mattheis S. A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression. Orbit 2019; 38:433-439. [PMID: 30513237 DOI: 10.1080/01676830.2018.1552709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/07/2018] [Indexed: 06/09/2023]
Abstract
Introduction: Different minimally invasive surgical approaches to the orbit allow individualized bone resection to reduce proptosis and decompress the optic nerve in patients with Graves' orbitopathy (GO). This study aims to compare piezosurgery to an oscillating saw used to resect bone from the lateral orbital wall. Methods: In a retrospective study, we analyzed balanced orbital decompressions performed on 174 patients (318 cases) with GO. An oscillating saw was used in 165 cases (saw group) and piezosurgery in 153 cases (piezo group). Peri- and postoperative complications, reduction of proptosis, new onset of diplopia and improvement of visual acuity in cases of pre-operative optic nerve compression were analyzed. Results: We observed no significant differences in the surgical outcome between the two groups. Proptosis reduction was 4.6 mm in the saw group (p < 0.01) and 5.3 mm in the piezo group (p < 0.01). Intraoperative handling of the piezosurgery device was judged superior to the oscillating saw, due to soft tissue conservation and favourable cutting properties. Duration of the surgery did not differ between the groups. No serious adverse events were recorded in both groups. Conclusion: The application of piezosurgery in orbital decompression is more suitable than an oscillation saw due to superior cutting properties such as less damage to surrounding soft tissue or a thinner cutting grove.
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Affiliation(s)
- Kerstin Stähr
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen , Essen , Germany
| | - Anja Eckstein
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Laura Holtmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen , Essen , Germany
| | - Anke Schlüter
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen , Essen , Germany
| | - Meaghan Dendy
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen , Essen , Germany
| | - Stefan Mattheis
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen , Essen , Germany
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Wen Y, Yan JH. The effect of intravenous high-dose glucocorticoids and orbital decompression surgery on sight-threatening thyroid-associated ophthalmopathy. Int J Ophthalmol 2019; 12:1737-1745. [PMID: 31741863 DOI: 10.18240/ijo.2019.11.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 08/20/2019] [Indexed: 11/23/2022] Open
Abstract
AIM To report the effects of intravenous high-dose glucocorticoids (ivGC) and orbital decompression (OD) surgery for treatment of sight-threatening thyroid-associated ophthalmopathy (TAO). METHODS A retrospective review of medical records from patients with sight-threatening TAO [definite or highly suspected dysthyroid optic neuropathy (DON)] treated with ivGC (60 cases) and OD (25 cases) was conducted at the Zhongshan Ophthalmic Center between January 2001 and January 2009. Patients were initially treated with ivGC (ivGC group). If no significant improvement in visual function was obtained, they then received OD surgery (OD group). The pre- versus post-treatment efficacies of either ivGC or OD in these patients were assessed using several indices, including visual acuity, intraocular pressure, ocular alignment, ocular motility, and exophthalmos. RESULTS Nighty-one eyes had definite DON while 79 were considered to have highly suspected DON. In the ivGC group, 51 individuals (85.0%) eventually demonstrated normal vision, while 10 patients (16.7%) demonstrated a reduction in deviation (P<0.01), and 35 cases (58.3%) showed slight improvements in ocular motility (P<0.01). In OD group, visual acuity improved in 24 cases (96.0%, P<0.01) and all patients showed varying reductions of exophthalmos (mean: 4.35±1.13 mm, P<0.01). Eight cases (32.0%) experienced an 8-15 PD reduction of deviation and ocular motility improved in 12 cases (48.0%), while 3 patients (12.0%) developed new-onset strabismus with diplopia post-surgically (P<0.01). Patients were followed up at an average of 1.55±1.07y. CONCLUSION Both ivGC and OD show good therapeutic efficacy in the treatment of sight-threatening TAO. The presence of extremely poor eyesight (≥0.5logMAR) was corrected in some patients with ivGC alone, thus sparing these patients from subsequent OD surgery. In patients who were refractory to steroids, subsequent OD surgery often provided satisfactory outcomes, however, new-onset strabismus with diplopia was observed in 12.0% of these cases.
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Affiliation(s)
- Yun Wen
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Jian-Hua Yan
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
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Oeverhaus M, Copei A, Mattheis S, Ringelstein A, Tiemessen M, Esser J, Eckstein A, Stähr K. Influence of orbital morphology on proptosis reduction and ocular motility after decompression surgery in patients with Graves' orbitopathy. PLoS One 2019; 14:e0218701. [PMID: 31233522 PMCID: PMC6590818 DOI: 10.1371/journal.pone.0218701] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/08/2019] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Orbital decompression surgery is performed in patients with Graves' orbitopathy to treat dysthyroid optical neuropathy (DON) and reduce disfiguring proptosis. The intended proptosis reduction can deviate from the postoperative result and changes of motility with consecutive diplopia can occur. We performed a retrospective study to identify anatomical factors in computed tomography (CT), which influence the surgical effect and postoperative ocular motility and diplopia. METHODS Pre- and postoperative CT-scans of 125 eyes of 68 patients, who mainly underwent a balanced orbital decompression for disfiguring proptosis (≥18mm Hertel Index), have been analyzed. Proptosis, ductions, misalignment and diplopia were assessed before and after surgery. Medial and lateral orbital wall length, conus angle, depth of ethmoidal sinus, orbital surface, length of medial and orbital defect, depth of tissue prolapse and horizontal muscle diameters were analyzed in CT scans before and after surgery. With linear regression and multivariate analyses these parameters have been correlated with postoperative proptosis, abduction deficit, deviation and binocular single vision (BSV). RESULTS Proptosis could be reduced by 5.3±2mm. Patients with <5mm proptosis reduction had significantly less often new onset of diplopia compared to patients with >5mm reduction (13% vs. 56%, p = 0.02). Multiple linear regression showed a significant correlation between tissue prolapse and depth of the ethmoidal sinus as well as age (p<0.001, r = 0.71). Proptosis reduction could not be predicted by tissue prolapse, defect length or depth of ethmoidal sinus. The abduction deficit correlated significantly with tissue prolapse and orbital surface area (p<0.001, r = 0.37) but not with the horizontal muscle diameter. CONCLUSION We were able to show that orbital morphology influences the outcome of balanced orbital decompression surgery in terms of proptosis reduction and motility. However, the rather low coefficients of correlation show that the surgical outcome cannot be predicted with simple CT measurements, although risk factors for postoperative abduction deficit could be found. Therefore, preoperative planning should consider especially the orbital surface area and depth of ethmoidal sinus. Patients should be informed about the higher risk of diplopia with higher proptosis reduction.
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Affiliation(s)
- Michael Oeverhaus
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Anna Copei
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
- Department of Gynecology, University Hospital Oldenburg, Oldenburg, Germany
| | - Stefan Mattheis
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Essen, Essen, Germany
| | | | - Madeleine Tiemessen
- Department of Radiology and Neuroradiology, Alfried Krupp Hospital Essen, Essen, Germany
| | - Joachim Esser
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Anja Eckstein
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Kerstin Stähr
- Department of Gynecology, University Hospital Oldenburg, Oldenburg, Germany
- * E-mail:
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Sellari-Franceschini S, Rocchi R, Marinò M, Bajraktari A, Mazzi B, Fiacchini G, Lepri P, Dallan I, Vitti P, Marcocci C. Rehabilitative orbital decompression for Graves' orbitopathy: results of a randomized clinical trial. J Endocrinol Invest 2018; 41:1037-1042. [PMID: 29450866 DOI: 10.1007/s40618-018-0847-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/03/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Orbital decompression (OD) is a consolidated procedure for the treatment of exophthalmos in Graves' orbitopathy (GO). The efficacy of the various procedures remains unclear due to the variability of the techniques used. To address this issue, we performed a randomized clinical trial to compare the efficacy of two surgical techniques. The primary endpoint was the reduction in proptosis. Secondary aims were the risk of post-operative diplopia (POD) in primary gaze and other surgical complications. PATIENTS 38 patients (76 orbits) affected with GO were enrolled and randomized into single lateral decompression (LD) (n = 19) or balanced medial plus lateral wall decompression (MLD) (n = 19). Following surgery, patients were seen for a follow-up ophthalmological evaluation at 6 months. Pre-operative diplopia in secondary gaze was present in 13/38 patients (34.2%, 8/19 treated with LD and 5/19 treated with MLD). RESULTS The reduction of exophthalmos was greater in patients treated with MLD (5.1 ± 1.5 mm, range 2-8 mm) than in those treated with LD (3.5 ± 1.3 mm, range 1-6.5 mm) (p = 0.01). The overall incidence of POD in primary gaze was 5/38 (13.2%) and all of these patients had pre-operative diplopia in secondary gaze (5/13, 38.5%, vs patients with no pre-operative diplopia p = 0.005). Two of 19 patients (10.5%) treated with LD and 3/19 (15.8%) treated with MLD, developed POD in primary gaze, with no statistical difference between the two techniques. CONCLUSION MLD provides a better result in terms of proptosis reduction compared to LD. The two techniques used here appear to have a similar safety profile in terms of POD. Pre-operative diplopia in the secondary gaze remains a major risk factor for development of POD.
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Affiliation(s)
| | - R Rocchi
- Unit of Endocrinology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - M Marinò
- Unit of Endocrinology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - A Bajraktari
- First ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - B Mazzi
- Unit of Endocrinology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - G Fiacchini
- First ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - P Lepri
- Unit of Ophthalmology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - I Dallan
- First ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - P Vitti
- Unit of Endocrinology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - C Marcocci
- Unit of Endocrinology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
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The influence of orbital decompression on objective nasal function in patients with graves' orbitopathy. Eur Arch Otorhinolaryngol 2018; 275:2507-2513. [PMID: 30167837 DOI: 10.1007/s00405-018-5105-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/21/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE To determine the influence of anatomical changes after orbital decompression to nasal function. METHODS We examined postoperative nasal function after orbital decompression in patients with GO in a prospective study. 25 patients were enrolled between 2014 and 2016. Sense of smell (Sniffin' Test) and nasal airflow (anterior rhinomanometry) were tested pre- and 6 weeks postoperatively. In addition, postoperative incidence of sinus infections, persistent pressure pain, and infraorbital hypoesthesia were assessed by means of a questionnaire. RESULTS The olfactory performance showed a significant increase (p < 0.05) after surgery, while the nasal airflow significantly decreased (p < 0.05). Acute sinus infection occurred in three, infraorbital sensibility disorders in eight cases within the first 6 weeks after surgery. No persistent pain was recorded. CONCLUSION We demonstrate that decompression of the medial orbital wall leads to a decrease in nasal airflow, whereof patients should be informed before the procedure. This is most likely due to a medialization of the medial turbinate and the prolapse of orbital content into the nasal cavity. The increase of the olfactory performance is, in our opinion, more likely due to variation within the standard deviation than to anatomical changes.
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Cubuk MO, Konuk O, Unal M. Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results. Int J Ophthalmol 2018; 11:1363-1370. [PMID: 30140642 DOI: 10.18240/ijo.2018.08.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 01/03/2018] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Onur Konuk
- Department of Ophthalmology, Gazi University School of Medicine, Besevler, Ankara 06500, Turkey
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Re: "Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy". Ophthalmic Plast Reconstr Surg 2018. [PMID: 29517605 DOI: 10.1097/iop.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Di Somma A, Andaluz N, Cavallo LM, Keller JT, Solari D, Zimmer LA, de Notaris M, Zuccarello M, Cappabianca P. Supraorbital vs Endo-Orbital Routes to the Lateral Skull Base: A Quantitative and Qualitative Anatomic Study. Oper Neurosurg (Hagerstown) 2018; 15:567-576. [DOI: 10.1093/ons/opx256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 02/02/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Various extensions of the supraorbital approach reach the lateral and parasellar middle cranial fossa regions by removing the orbital rim and greater/lesser sphenoid wings. Recent proposals of a purely endoscopic ventral transorbital pathway to these regions heighten the need to compare these surgical windows.
OBJECTIVE
To detail the lateral and parasellar middle cranial fossa regions and quantify exposures by 2 surgical windows (transcranial and transorbital) through anatomic study.
METHODS
In 5 cadaveric specimens (10 sides), dissections consisted of 3 stages: stage 1 began with the supraorbital approach via the eyebrow; stage 2, endo-orbital approach via the superior eyelid, continued with removal of lesser and greater sphenoid wings; and stage 3, extended supraorbital, re-evaluated the gains of stage 2 from the perspective of stage 1. Operative working areas were quantified in Sylvian, anterolateral temporal, and parasellar regions; bone removal volumes were measured at each stage (nonpaired Student t-test).
RESULTS
Visualization into the anterolateral temporal and Sylvian areas, though varied in perspective, were comparable with either eyelid or transcranial routes. Compared with transcranial views through a supraorbital window, the eyelid approach significantly increased exposure in the parasellar region with wider angle of attack (P < .01) and achieved comparable bone removal volumes.
CONCLUSION
Stage 2’s unique anatomic view of the lateral and parasellar middle cranial fossa regions paves the way for possible surgical application to select pathologies typically treated via transcranial approaches. Disadvantages may be the surgeon's unfamiliarity with the anatomy of this purely endoscopic, ventral route and difficulties of dural and orbital repair.
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Affiliation(s)
- Alberto Di Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
| | - Norberto Andaluz
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
- Mayfield Clinic, Cincinnati, Ohio
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
| | - Jeffrey T Keller
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
- Mayfield Clinic, Cincinnati, Ohio
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
| | - Lee A Zimmer
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
| | - Matteo de Notaris
- Department of Neuroscience, G. Rummo Hospital, Neurosurgery Operative Unit, Benevento, Italy
| | - Mario Zuccarello
- Department of Neuro-surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio
- Comprehensive Stroke Center at UC Neuroscience Institute, Cincinnati, Ohio
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odon-tostomatological Sciences, Univers-itá degli Studi di Napoli Federico II, Naples, Italy
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Welkoborsky HJ, Graß SK, Küstermeyer J, Steinke KV. [Orbital decompression : Indications, technique, results]. HNO 2017; 65:1023-1038. [PMID: 29085976 DOI: 10.1007/s00106-017-0429-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Orbital decompression is an effective surgical procedure to reduce intraorbital pressure. Causes may diseases leading to rapid pressure increases, e. g., bleedings, and those causing slower, progressive pressure increases, e. g., tumors or Graves' orbitopathy. During fat tissue decompression, peri- and retrobulbar adipose tissue is removed; in bony decompression, one or more bony orbital walls are removed (one-, two-, or three-wall decompression). In many cases the procedures are combined. Recent developments are the transconjunctival approaches for removing parts of bony orbital walls. Complications include double vision, which occurs in up to 30% of cases depending on the approach, hemorrhage, infections, development of chronic sinusitis, and iatrogenic skull base lesions with consecutive meningitis. In the hands of an experienced rhino- and head and neck surgeon, the intervention has low complication rates.
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Affiliation(s)
- H-J Welkoborsky
- Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, region. Plast. Chirurgie, Klinikum Nordstadt der KRH, Hannover, Haltenhoffstr. 41, 30167, Hannover, Deutschland.
| | - S K Graß
- Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, region. Plast. Chirurgie, Klinikum Nordstadt der KRH, Hannover, Haltenhoffstr. 41, 30167, Hannover, Deutschland
| | - J Küstermeyer
- Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, region. Plast. Chirurgie, Klinikum Nordstadt der KRH, Hannover, Haltenhoffstr. 41, 30167, Hannover, Deutschland
| | - K V Steinke
- Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, region. Plast. Chirurgie, Klinikum Nordstadt der KRH, Hannover, Haltenhoffstr. 41, 30167, Hannover, Deutschland
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Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy. Ophthalmic Plast Reconstr Surg 2017; 33:289-293. [PMID: 27487726 DOI: 10.1097/iop.0000000000000758] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Dallan I, Sellari-Franceschini S, Turri-Zanoni M, de Notaris M, Fiacchini G, Fiorini FR, Battaglia P, Locatelli D, Castelnuovo P. Endoscopic Transorbital Superior Eyelid Approach for the Management of Selected Spheno-orbital Meningiomas: Preliminary Experience. Oper Neurosurg (Hagerstown) 2017; 14:243-251. [DOI: 10.1093/ons/opx100] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 03/30/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Feasibility and safety of spheno-orbital meningioma resection by means of endoscopic-assisted transorbital route.
OBJECTIVE
To evaluate the feasibility and outcomes of the transorbital endoscopic management of selected spheno-orbital meningiomas. As secondary aims, symptom improvement and tumor volume removed were evaluated.
METHODS
Retrospective chart evaluation of patients with spheno-orbital meningiomas treated by means of endoscopic transorbital superior eyelid approach in 3 referral centers over the last 4 yr.
RESULTS
Fourteen cases were included in this study. In 4 patients, the transorbital endoscopic approach was combined with an endonasal route. Mean age was 51 and male-to-female ratio was 1:6. In 8 patients (57.1%), an intraorbital involvement was observed, 3 of them (21.4%) showed significant intraconal disease. No patient presented significant cavernous sinus infiltration. Main presenting symptoms were proptosis, diplopia, and visual impairment in 14, 6, and 6 patients, respectively. Mean proptosis improvement was 2 mm (standard deviation 2.3). We observed no major postoperative complications.
CONCLUSION
Our preliminary clinical experience seems to demonstrate that selected spheno-orbital meningiomas can be safely managed by means of an endoscopic transorbital route through a superior eyelid approach. Patients with orbital or cavernous sinus infiltration are at highest risk of persistence.
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Affiliation(s)
- Iacopo Dallan
- First ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Head and Neck Surgery and Forensic Dissection Research center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | | | - Mario Turri-Zanoni
- Head and Neck Surgery and Forensic Dissection Research center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Matteo de Notaris
- Division of Neurosurgery, Azienda Ospedaliera G. Rummo, Benevento, Italy
| | - Giacomo Fiacchini
- First ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Paolo Battaglia
- Head and Neck Surgery and Forensic Dissection Research center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Paolo Castelnuovo
- Head and Neck Surgery and Forensic Dissection Research center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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Rootman DB. Orbital decompression for thyroid eye disease. Surv Ophthalmol 2017; 63:86-104. [PMID: 28343872 DOI: 10.1016/j.survophthal.2017.03.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 03/16/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Daniel B Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, Doheny and Stein Eye Institutes, University of California, Los Angeles, Los Angeles, California, USA.
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Dallan I, Di Somma A, Prats-Galino A, Solari D, Alobid I, Turri-Zanoni M, Fiacchini G, Castelnuovo P, Catapano G, de Notaris M. Endoscopic transorbital route to the cavernous sinus through the meningo-orbital band: a descriptive anatomical study. J Neurosurg 2016; 127:622-629. [PMID: 27858571 DOI: 10.3171/2016.8.jns16465] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Exposure of the cavernous sinus is technically challenging. The most common surgical approaches use well-known variations of the standard frontotemporal craniotomy. In this paper the authors describe a novel ventral route that enters the lateral wall of the cavernous sinus through an interdural corridor that includes the removal of the greater sphenoid wing via a purely endoscopic transorbital pathway. METHODS Five human cadaveric heads (10 sides) were dissected at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. To expose the lateral wall of the cavernous sinus, a superior eyelid endoscopic transorbital approach was performed and the anterior portion of the greater sphenoid wing was removed. The meningo-orbital band was exposed as the key starting point for revealing the cavernous sinus and its contents in a minimally invasive interdural fashion. RESULTS This endoscopic transorbital approach, with partial removal of the greater sphenoid wing followed by a "natural" ventral interdural dissection of the meningo-orbital band, allowed exposure of the entire lateral wall of the cavernous sinus up to the plexiform portion of the trigeminal root and the petrous bone posteriorly and the foramen spinosum, with the middle meningeal artery, laterally. CONCLUSIONS The purely endoscopic transorbital approach through the meningo-orbital band provides a direct view of the cavernous sinus through a simple and rapid means of access. Indeed, this interdural pathway lies in the same sagittal plane as the lateral wall of the cavernous sinus. Advantages include a favorable angle of attack, minimal brain retraction, and the possibility for dissection through the interdural space without entering the neurovascular compartment of the cavernous sinus. Surgical series are needed to demonstrate any clinical advantages and disadvantages of this novel route.
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Affiliation(s)
- Iacopo Dallan
- First Otorhinolaryngologic Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa
| | - Alberto Di Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona; and
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples
| | - Isam Alobid
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese
| | - Giacomo Fiacchini
- First Otorhinolaryngologic Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa
| | - Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese
| | - Giuseppe Catapano
- Department of Neuroscience, G. Rummo Hospital, Neurosurgery Operative Unit, Benevento, Italy
| | - Matteo de Notaris
- Department of Neuroscience, G. Rummo Hospital, Neurosurgery Operative Unit, Benevento, Italy
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Yao WC, Sedaghat AR, Yadav P, Fay A, Metson R. Orbital Decompression in the Endoscopic Age. Otolaryngol Head Neck Surg 2016; 154:963-9. [DOI: 10.1177/0194599816630722] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/14/2016] [Indexed: 11/16/2022]
Abstract
Objective Postoperative diplopia occurs in up to 45% of patients following orbital decompression for exophthalmos associated with Graves’ orbitopathy. We sought to describe outcomes of our balanced orbital decompression strategy that includes the preservation of a modified inferomedial orbital strut (mIOS). Study Design Case series with chart review. Setting Academic medical center. Subjects and Methods A total of 115 consecutive orbital decompressions were performed on 73 patients (42 bilateral) with Graves’ orbitopathy. All patients underwent (1) a balanced decompression technique incorporating an endoscopic medial and external lateral decompression and (2) a mIOS technique with preservation of the anterior half of the inferomedial orbital strut. A periorbital periosteal (orbital) sling was utilized in patients (n = 54) without threatened vision loss, proptosis >28 mm, or periorbital disruption to prevent prolapse of the medial rectus muscle. Results Utilization of the mIOS technique with or without a sling did not adversely affect the reduction in proptosis (5.1 mm with sling vs 5.0 mm without sling; P = .85).The incidence of new-onset postoperative diplopia was 17% (n = 6). The sling was not associated with postoperative diplopia (odds ratio = 0.54, 95% confidence interval: 0.08-3.40, P = .51), while it was associated with resolution of preexisting diplopia (odds ratio = 6.67, 95% confidence interval: 1.06-42.06, P = .04). No intraoperative complications occurred, and no patients suffered a decrement in visual acuity. Conclusion Balanced orbital decompression utilizing a mIOS in patients with Graves’ orbitopathy provides a safe and effective reduction in proptosis with a low rate of new-onset diplopia as compared with historical values. Utilization of an orbital sling may be beneficial in reducing postoperative diplopia in select patients.
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Affiliation(s)
- William C. Yao
- Department of Otorhinolaryngology, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Ahmad R. Sedaghat
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Prashant Yadav
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Fay
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ralph Metson
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
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Ryu IY, Kwon C, Koh TK, Lee KH, Cho JS, Kim SW. Changes in Clinical Characteristics of the Patients Who Received Endoscopic Sinus Surgery according to 10 Year Temporal Difference: A Retrospective Observational Study. JOURNAL OF RHINOLOGY 2016. [DOI: 10.18787/jr.2016.23.2.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- In Yong Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Chul Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Tae Kyung Koh
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Kun Hee Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Joong Saeng Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Wan Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
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Schiff BA, McMullen CP, Farinhas J, Jackman AH, Hagiwara M, McKellop J, Lui YW. Use of computed tomography to assess volume change after endoscopic orbital decompression for Graves' ophthalmopathy. Am J Otolaryngol 2015; 36:729-35. [PMID: 26545461 DOI: 10.1016/j.amjoto.2015.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 06/21/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Orbital decompression is frequently performed in the management of patients with sight-threatening and disfiguring Graves' ophthalmopathy. The quantitative measurements of the change in orbital volume after orbital decompression procedures are not definitively known. Furthermore, the quantitative effect of septal deviation on volume change has not been previously analyzed. OBJECTIVES To provide quantitative measurement of orbital volume change after medial and inferior endoscopic decompression and describe a straightforward method of measuring this change using open-source technologies. A secondary objective was to assess the effect of septal deviation on orbital volume change. METHODS A retrospective review was performed on all patients undergoing medial and inferior endoscopic orbital decompression for Graves' ophthalmopathy at a tertiary care academic medical center. Pre-operative and post-operative orbital volumes were calculated from computed tomography (CT) data using a semi-automated segmenting technique and Osirix™, an open-source DICOM reader. Data were collected for pre-operative and post-operative orbital volumes, degree of septal deviation, time to follow-up scan, and individual patient Hertel scores. RESULTS Nine patients (12 orbits) were imaged before and after decompression. Mean pre-operative orbital volume was 26.99 cm(3) (SD=2.86 cm(3)). Mean post-operative volume was 33.07 cm(3) (SD=3.96 cm(3)). The mean change in volume was 6.08 cm(3) (SD=2.31 cm(3)). The mean change in Hertel score was 4.83 (SD=0.75). Regression analysis of change in volume versus follow-up time to imaging indicates that follow-up time to imaging has little effect on change in volume (R=-0.2), and overall mean maximal septal deviation toward the operative side was -0.5mm. Negative values were attributed to deviation away form the operative site. A significant correlation was demonstrated between change in orbital volume and septal deviation distance site (R=0.66), as well as between change in orbital volume and septal deviation angle (R=0.67). Greater volume changes were associated with greater degree of septal deviation away from the surgical site, whereas smaller volume changes were associated with greater degree of septal deviation toward the surgical site. CONCLUSION A straightforward, semi-automated segmenting technique for measuring change in volume following endoscopic orbital decompression is described. This method proved useful in determining that a mean increase of approximately 6 cm in volume was achieved in this group of patients undergoing medial and inferior orbital decompression. Septal deviation appears to have an effect on the surgical outcome and should be considered during operative planning.
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Affiliation(s)
- Bradley A Schiff
- Department of Otorhinolaryngology-Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Ave., Medical Arts Pavilion, 3rd Floor, Bronx, NY, United States
| | - Caitlin P McMullen
- Department of Otorhinolaryngology-Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Ave., Medical Arts Pavilion, 3rd Floor, Bronx, NY, United States.
| | - Joaquim Farinhas
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E. 210th Street, Bronx, NY, United States
| | - Alexis H Jackman
- Department of Otorhinolaryngology-Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Ave., Medical Arts Pavilion, 3rd Floor, Bronx, NY, United States
| | - Mari Hagiwara
- Department of Radiology, NYU School of Medicine, 660 First Avenue 2nd Floor, New York, NY, United States
| | - Jason McKellop
- Department of Radiology, NYU School of Medicine, 660 First Avenue 2nd Floor, New York, NY, United States
| | - Yvonne W Lui
- Department of Radiology, NYU School of Medicine, 660 First Avenue 2nd Floor, New York, NY, United States
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Stereotactic Navigation With a Registration Mask in Orbital Decompression Surgery. Ophthalmic Plast Reconstr Surg 2015; 31:440-4. [DOI: 10.1097/iop.0000000000000369] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Savku E, Gündüz K. Diagnosis, Follow-Up and Treatment Results in Thyroid Ophthalmopathy. Turk J Ophthalmol 2015; 45:156-163. [PMID: 27800224 PMCID: PMC5082274 DOI: 10.4274/tjo.93609] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 11/02/2014] [Indexed: 12/01/2022] Open
Abstract
Objectives: To discuss our follow-up and treatment results in thyroid-associated ophthalmopathy (TAO). Materials and Methods: The records of 168 TAO cases who were followed at our clinic between October 1998 and October 2013 were reviewed retrospectively. The severity and activity of the disease were evaluated according to the criteria of the European Group on Graves’ Ophthalmopathy (EUGOGO) and Clinical Activity Score (CAS). Results: Sixty-three men and 105 women participated in the study. The mean age of the patients was 42.3±12.4 years. Smoking habit was noted in 54.2% of the cases. Graves’ disease was the most common (80.4%) thyroid pathology accompanying TAO. TAO was mild in 64.4%, moderate-to-severe in 33.6% and severe in 2% of the eyes. Male gender was found as an independent risk factor for severity of the disease (p=0.040). TAO was in the active phase in 32.6% of the eyes. Older age and high thyroid receptor antibody titer were correlated with disease activity (P=0.031 and P<0.001, respectively). Thirty-four patients (20%) were treated for ocular findings. The most common treatment was systemic steroid therapy (12%); others included orbital decompression (5%), orbital radiotherapy (2%), and topical application of guanethidine (1%). Conclusion: Non-infiltrative phase and mild ocular findings were generally seen in TAO. Therefore, treatment is not recommended for many cases. Systemic steroid therapy is the most commonly used treatment modality in the active phase. However, orbital decompression surgery is necessary in a small number of cases with sight-threatening ocular findings.
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Affiliation(s)
- Esra Savku
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Kaan Gündüz
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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Castelnuovo P, Turri-Zanoni M, Battaglia P, Locatelli D, Dallan I. Endoscopic Endonasal Management of Orbital Pathologies. Neurosurg Clin N Am 2015; 26:463-72. [PMID: 26141364 DOI: 10.1016/j.nec.2015.03.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Based on the anatomic relationship between sinonasal complex and orbit, endoscopic transnasal procedures could be a smart solution for approaching the medial orbital region. These techniques should be considered a valid option for optic nerve or orbital wall decompression in cases of Graves ophthalmopathy and post-traumatic optic neuropathy as well as for addressing extraconal or intraconal lesions placed medially to the optic nerve course. This article describes the anatomic principles, indications, technical nuances, and limitations of the endoscopic endonasal approaches for the management of selected orbital pathologic abnormalities.
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Affiliation(s)
- Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences (DBSV), Ospedale di Circolo e Fondazione Macchi, University of Insubria, via Guicciardini 9, Varese 21100, Italy; Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), DBSV, University of Insubria, via Guicciardini 9, Varese 21100, Italy
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences (DBSV), Ospedale di Circolo e Fondazione Macchi, University of Insubria, via Guicciardini 9, Varese 21100, Italy; Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), DBSV, University of Insubria, via Guicciardini 9, Varese 21100, Italy.
| | - Paolo Battaglia
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences (DBSV), Ospedale di Circolo e Fondazione Macchi, University of Insubria, via Guicciardini 9, Varese 21100, Italy; Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), DBSV, University of Insubria, via Guicciardini 9, Varese 21100, Italy
| | - Davide Locatelli
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), DBSV, University of Insubria, via Guicciardini 9, Varese 21100, Italy; Unit of Neurosurgery, Civic Hospital, via Papa Giovanni Paolo II, Legnano 20025, Italy
| | - Iacopo Dallan
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), DBSV, University of Insubria, via Guicciardini 9, Varese 21100, Italy; First Otorhinolaryngologic Unit, Azienda Ospedaliero-Universitaria Pisana, via Paradisa 2, Pisa 56124, Italy
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Orbital decompression for the management of thyroid eye disease: An analysis of outcomes and complications. Laryngoscope 2015; 125:2034-40. [DOI: 10.1002/lary.25320] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/07/2022]
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Wu W, Selva D, Bian Y, Wang X, Sun MT, Kong Q, Yan W. Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy. Am J Ophthalmol 2015; 159:277-84. [PMID: 25448997 DOI: 10.1016/j.ajo.2014.10.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 10/26/2014] [Accepted: 10/27/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Wencan Wu
- Department of Orbital & Oculoplastic Surgery, The Eye Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Dinesh Selva
- Discipline of Ophthalmology & Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Yang Bian
- Department of Orbital & Oculoplastic Surgery, The Eye Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaopeng Wang
- Department of Ophthalmology, Jinhua Center Hospital, Jinhua, China
| | - Michelle T Sun
- Discipline of Ophthalmology & Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Qiao Kong
- Department of Ophthalmology, Lihuili Hospital, Ningbo, China
| | - Wentao Yan
- Department of Orbital & Oculoplastic Surgery, The Eye Hospital of Wenzhou Medical University, Wenzhou, China
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Stereotactic Microdebrider in Deep Lateral Orbital Decompression for Patients With Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2014; 30:262-6. [DOI: 10.1097/iop.0000000000000132] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rocchi R, Lenzi R, Marinò M, Latrofa F, Nardi M, Piaggi P, Mazzi B, Altea MA, Pinchera A, Vitti P, Marcocci C, Sellari-Franceschini S. Rehabilitative orbital decompression for Graves' orbitopathy: risk factors influencing the new onset of diplopia in primary gaze, outcome, and patients' satisfaction. Thyroid 2012; 22:1170-5. [PMID: 23072549 DOI: 10.1089/thy.2012.0272] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients with moderate to severe Graves' orbitopathy (GO) rather frequently require rehabilitative surgery after medical therapy. Diplopia is the most common side effect of orbital decompression (OD). The aim of this study was to evaluate the occurrence of postoperative diplopia in primary gaze after OD, and the influence of the surgical approach on this outcome. Moreover, we investigated the results in terms of proptosis reduction, and the long-term subjective satisfaction of patients treated with OD with regard to their appearance and ocular function. METHODS A retrospective evaluation of 247 patients with GO treated with medial and lateral decompression (MLD) or lateral decompression (LD) OD between January 2002 and December 2009 was performed. RESULTS The overall prevalence of postoperative diplopia in primary gaze was 55/247 (22.3%), with a statistically significant difference (p<0.001) between patients with (36/113, 31.2%) and those without (19/134, 14.2%) preoperative diplopia in secondary gaze. The surgical procedure influenced the outcome in patients without preoperative diplopia (17.8% after MLD and 0% after LD, p=0.02), but not in patients with preoperative diplopia in secondary gaze (33.3% after MLD and 26.1% after LD, p=0.5). Overall, proptosis reduction was 5.7±2.2 mm (1-11 mm), after MLD and 4.0±1.6 mm (1-8 mm) after LD (p<0.001). Fifty-one out of 55 patients with constant, postoperative diplopia in primary gaze after OD underwent squint surgery, which was successful in all but two. Four patients refused squint surgery. Patients were also interviewed for satisfaction in terms of recovery of their appearance and ocular function after a mean of 6 years from surgery (range 2-9 years): more than 85% of patients reported a good to excellent postoperative satisfaction for both items. CONCLUSIONS Preoperative diplopia in secondary gaze is a risk factor for the development of diplopia in primary gaze after OD, independently of the surgical approach (MLD vs. LD). In absence of diplopia, MLD, but not LD, seems to be associated with its development in primary gaze. The reduction in proptosis after MLD is greater than that after LD. Most patients were satisfied with the results of both appearance and ocular function after OD.
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Affiliation(s)
- Roberto Rocchi
- Unit of Endocrinology, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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Hill RH, Czyz CN, Bersani TA. Transcaruncular medial wall orbital decompression: an effective approach for patients with unilateral graves ophthalmopathy. ScientificWorldJournal 2012; 2012:312361. [PMID: 22654589 PMCID: PMC3361230 DOI: 10.1100/2012/312361] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 01/03/2012] [Indexed: 11/19/2022] Open
Abstract
Purpose. To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. Methods. Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. Results. The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). Conclusions. Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results.
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Affiliation(s)
- Robert H Hill
- Department of Ophthalmology, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY 13210, USA.
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Babiński D, Skorek A, Nałęcz A, Stankiewicz C. [Orbital decompression for thyroid orbitopathy]. Otolaryngol Pol 2011; 65:262-5. [PMID: 22000142 DOI: 10.1016/s0030-6657(11)70687-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 02/16/2011] [Indexed: 11/25/2022]
Abstract
Thyroid orbitopathy may result in significant proptosis that causes visual lost. Besides pharmacologic and radiotherapeutic procedures surgically decompression of the orbital skeleton occasionally is managed. We present series of 3 patients (5 procedures) who underwent orbital decompressions. The preoperative proptosis ranged from 22 to 31mm. Decompression was performed by an external Walsh-Ogura approach in 3 orbits and in 2 by an endoscopic approach. The reduction in proptosis was 4-6mm in external approach cases and 4-5mm in endoscopic procedures. Diplopia was noted in 2 patients preoperatively, and no one had new postoperative diplopia. Surgical orbital decompression is occasionally necessary procedure or visual lost rescue in thyroid orbitopathy and in cases of diplopia can not improve muscular function. Endoscopic surgery is a safe and effective management in moderate proptosis. Autoimmunologic inflammatory changes in nasal mucosa do not increase postoperative complication risk.
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Affiliation(s)
- Dariusz Babiński
- Katedra i Klinika Chorób Uszu, Nosa, Gardła i Krtani, Gdański Uniwersytet Medyczny.
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Sellari-Franceschini S, Muscatello L, Seccia V, Lenzi R, Santoro A, Nardi M, Mazzi B, Pinchera A, Marcocci C. Reasons for revision surgery after orbital decompression for Graves' orbitopathy. Clin Ophthalmol 2011; 2:283-90. [PMID: 19668717 PMCID: PMC2693988 DOI: 10.2147/opth.s2416] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives An analysis of complications and causes of failure in orbital decompression necessitating a second operation. Methods Between December 1992 and April 2007, 375 patients (719 orbits) were operated on using various techniques. Fourteen patients were initially operated on in our unit: 8 (group A1) were re-operated on after a short time due to complications connected with the decompression operation, 7 (group A2) were operated on after some time due to recurrence of the illness or unsatisfactory decompression (one patient is in both group A1 and A2). Five patients (group B) underwent a first operation elsewhere. Results For group A1 the most serious complications were connected to the nasal approach. For group A2 the operations were performed either because of a neuropathy recurrence or for further proptosis reduction due to recurrence or patient dissatisfaction. Lack of preoperative data hinders conclusions about group B, apart from one patient where the operation had not resolved a serious optic neuropathy after decompression based on Olivari technique combined with three-wall operation according to Mourits and colleagues (1990). Conclusions We can deduce from group A1 that extreme attention is necessary during endonasal access, from group A2 that balancing the eyes is advisable, sacrificing maximum proptosis reduction to gain greater patient satisfaction, and from group B that decompression of the orbital apex is fundamental in the case of neuropathy.
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Affiliation(s)
- Stefano Sellari-Franceschini
- Department of Neuroscience, 1st ENT division, Sez., Otorinolaringoiatria 1 Universitaria, Ospedale S. Chiara – Via Savi 10, 56100 Pisa, Italy.
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Anatomy-based surgical concepts for individualized orbital decompression surgery in graves orbitopathy. I. Orbital size and geometry. Ophthalmic Plast Reconstr Surg 2010; 26:348-52. [PMID: 20592636 DOI: 10.1097/iop.0b013e3181c9bb52] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To analyze orbital morphological parameters that potentially could influence the effect of decompression surgery on exophthalmos reduction in Graves orbitopathy, thus making decompression surgery more predictable. METHODS To generate a reference database, a CT-based study was performed in 140 orbits obtained from adult patients with unaffected orbits in a European white ethnicity. The following parameters were chosen: orbital volume, globe volume, globe to orbital volume ratio, and orbital cone angle. Volumes were measured on postprocessed CT data using morphometric techniques. To define the cone angle, a 3-dimensional approach was chosen using the program Amira. RESULTS Significant interindividual variation was found in orbital volume from 18.9 to 33.4 ml and in globe volume from 6.0 to 10.1 ml. The globe to orbital volume ratio showed a relatively broad variation from 0.25 to 0.4. Differences in the orbital cone angle from 39.7° to 65.7° were observed. CONCLUSION The experienced large variations in orbital morphology might significantly influence the degree of exophthalmos reduction, which can be obtained by standardized decompression procedures. Based on our results, a prospective clinical study will be conducted to test our hypothesis.
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Jimenez-Chobillon MA, Lopez-Oliver RD. Transnasal endoscopic approach in the treatment of Graves ophthalmopathy: the value of a medial periorbital strip. Eur Ann Otorhinolaryngol Head Neck Dis 2010; 127:97-103. [PMID: 20822764 DOI: 10.1016/j.anorl.2010.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Present our experience with orbital decompression using an endoscopic transnasal approach and test whether preservation of an anteroposterior periorbital strip overlying the medial rectus muscle can reduce the incidence of postoperative diplopia. PATIENT AND METHODS Retrospective, descriptive study conducted on 16 patients with Graves ophthalmopathy operated on with orbital decompression between 2004 and 2009. RESULTS Twelve women and four men (mean age, 34.6 years), a total of 30 orbits, were operated. A medial periorbital strip along the medial rectus muscle was preserved in 13 patients. A single case (7.7%) presented postoperative diplopia. The mean reduction of proptosis was 4.3mm. CONCLUSIONS The endoscopic transnasal approach provides comparable results to those obtained with other techniques. The incidence of postoperative diplopia seems to decrease when an anteroposterior periorbital periosteal strip is preserved along the medial rectus muscle.
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Affiliation(s)
- M-A Jimenez-Chobillon
- Otolaryngology Department, National Institute of Respiratory Diseases Ismael Cosío Villegas, Calzada de Tlalpan 4502 Col. Sección XVI, Delegación Tlalpan, 14080 Mexico, Mexico.
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Sellari-Franceschini S, Bartalena L, Seccia V. The challenge of orbital decompression in a patient with multiple autoimmune diseases and graves' orbitopathy: a case report and review of literature. Orbit 2010; 29:48-50. [PMID: 20302412 DOI: 10.3109/01676830903207836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The association between multiple autoimmune diseases can make management of the ocular proptosis very difficult and challenging for the orbit surgeon. We report an interesting case of a patient affected by Stiff person syndrome, type-1 diabetes and Graves' disease with Graves' orbitopathy, who underwent orbital decompression. Anaesthesiologic problems, as well as factors affecting the post-operative result, are discussed in detail; pertinent literature review was performed and discussed.
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Surgical management of thyroid orbitopathy. J Plast Reconstr Aesthet Surg 2010; 63:240-6. [DOI: 10.1016/j.bjps.2008.09.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 08/31/2008] [Accepted: 09/21/2008] [Indexed: 11/18/2022]
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Outcomes following surgical decompression for dysthyroid orbitopathy (Graves' disease). Curr Opin Otolaryngol Head Neck Surg 2010; 18:37-43. [DOI: 10.1097/moo.0b013e328335017c] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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