The effect of orbital decompression surgery on refraction and intraocular pressure in patients with thyroid orbitopathy

Central Retinal Artery Occlusion after Peribulbar Injection of Triamcinolone Acetonide in Thyroid-associated Ophthalmopathy

Central retinal artery occlusion (CRAO) is a form of acute ocular ischemic syndrome that causes visual loss. Timely treatment is of great importance for visual recovery, but the prognosis is usually poor. By analyzing the pathogenesis, diagnosis, and treatment process of a CRAO case after peribulbar injection of triamcinolone acetonide in thyroid-associated ophthalmopathy (TAO), this study aims to investigate the association of CRAO with hemodynamics and orbital pressure, thereby providing references in safety improvement of diagnosis and treatment on TAO.

Refractive changes associated with oculoplastic surgeries: A scoping review

PURPOSE

To carry out a comprehensive critical review of the peer-reviewed literature on the refractive changes associated with oculoplastic surgeries.

METHODS

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) statement recommendations. Following specific inclusion and exclusion criteria, 20 articles were selected for the current scoping review. Each of them was analyzed carefully and their risk of bias was assessed with the Quality Assessment Tool for case Series Studies from the National Heart, Lung and Blood Institute.

RESULTS

Data of 1428 eyes from 1051 patients were analyzed. All studies were case series. Regarding the oculoplastic pathologies, five articles focused on dermatochalasis, four on chalazion, five on ptosis and six on congenital ptosis. Most articles did not report changes in the spherical equivalent (SE), astigmatism changes of less than 0.5 diopters (D), changes in astigmatism axis of less than 11 degrees and changes in uncorrected distance visual acuity (UDVA) of less than 0.06 logMAR. Out of the 20 articles reviewed, 6 achieved a risk of bias score between 6 and 8, representing a low level of evidence and highlighting the limitations in the study design.

CONCLUSIONS

Based on the findings of this study, there is no evidence to suggest clinically significant refractive changes following oculoplastic surgeries. The most notable changes may occur after surgery for severe ptosis; however, further research is needed to confirm this observation.

Evaluation of lamina cribrosa and peripapillary vascular density in thyroid orbitopathy and effect of intravenous methylprednisolone therapy

OBJECTIVE

To evaluate optic nerve head changes in patients with thyroid orbitopathy (TO) and investigate the effects of intravenous methylprednisolone (IV MTP) on these changes.

METHODS

Eighty-two eyes of 41 patients with TO with and without dysthyroid optic neuropathy (DON) and 40 eyes of 40 healthy control subjects were included in the study. Lamina cribrosa thickness (LCT) and depth (LCD) measurements, peripapillary retinal nerve fibre layer thickness (RNFLT), and radial peripapillary capillary vascular density were measured using optical coherence tomography and optical coherence tomography angiography. Visual field examination and proptosis were evaluated. Patients with DON and active non-DON received IV MTP for 12 weeks, and the effect of this treatment was evaluated.

RESULTS

Peripapillary vascular density decreased in patients with DON compared with the other groups (p < 0.001 for all); there was no difference in the total, superior hemi-sector, and inferior hemi-sector of the RNFLT between the groups. LCT was decreased in the TO group (p < 0.001). After IV MTP treatment, the LCT and best-corrected visual acuity were increased. Thyroid-stimulating hormone receptor antibody levels, intraocular pressure, the superior hemi-sector of the RNFLT, and proptosis were decreased compared with the control subjects (p = 0.012, p = 0.008, p = 0.043, and p < 0.001, respectively).

CONCLUSIONS

The RNFLT may not always increase in DON. Lamina cribrosa morphology may change in patients with TO. IV MTP therapy has a positive effect on the LCT but not on radial peripapillary capillary vascular density or LCD.

The Changes in Ocular Biomechanical Response Parameters and Intraocular Pressure After Surgical Treatment for Thyroid Eye Disease

Purpose

To investigate changes in ocular biomechanical response parameters and intraocular pressure (IOP) in patients with thyroid eye disease (TED) undergoing orbital decompression or anterior blepharotomy.

Methods

Eighty-three eyes from 46 patients receiving orbital decompression (the orbital decompression group) and 45 eyes from 28 patients receiving anterior blepharotomy (the anterior blepharotomy group) were retrospectively enrolled from a tertiary center. Corvis ST tonometry was used to assess ocular biomechanical response and biomechanically corrected IOP (bIOP) pre- and postoperatively. Non-contact tonometry (IOP-NCT) was also performed.

Results

In the anterior blepharotomy group, the margin reflex distance decreased (P < 0001). The highest concavity radius (P = 0.026) and whole eye movement (P = 0.003) increased. Neither IOP-NCT nor bIOP had a significant change. In the orbital decompression group, the extent of exophthalmos decreased (P < 0.001). The A2 length (P = 0.009) decreased. The bIOP did not show a significant change (16.4 ± 2.7 vs. 16.7 ± 4.5; P = 0.415), but the IOP-NCT decreased significantly (17.5 ± 3.3 vs. 16.0 ± 3.3; P < 0.001). Higher baseline IOP-NCT (β = -0.40, P < 0.001) and greater reduction in stiffness parameter A1 (SP-A1; β = 0.05, P = 0.002) were associated with more significant IOP-NCT reduction after the orbital decompression.

Conclusions

Ocular biomechanical response parameters may change after TED surgery, potentially affecting IOP measurements, particularly in patients receiving orbital decompression.

Secondary Effects of Orbital Decompression in Thyroid Eye Disease: A Review

PURPOSE

Orbital decompression is mainly performed in thyroid eye disease to reduce proptosis and retrobulbar pressure, to improve venous congestion, and to relieve optic nerve compression. Secondary effects of orbital decompression are also occasionally encountered. The aim of this study was to review the secondary effects of orbital decompression.

METHODS

This is a comprehensive literature review that summarizes the secondary effects of orbital decompression.

RESULTS

Decreased intraocular pressure, inter-pupillary distance, and eyelid pressure, and improvement of eyelid retraction, lateral flare, orbital discomfort, and psychosocial condition after orbital decompression are favorable changes for patients. In contrast, refractive changes in some patients and decreased Bell's phenomenon and nasal function worsen patients' condition.

CONCLUSION

These favorable changes may reduce the patients' burden for treatment of thyroid eye disease. In contrast, as some of the adverse effects significantly worsen the patients' disease condition, we should carefully monitor these changes.

Treatment Results of Endoscopic Transnasal Orbital Decompression for Graves' Orbitopathy-A Single-Center Retrospective Analysis in 28 Orbits of 16 Patients

Graves’ orbitopathy (GO) is an extrathyroidal manifestation of Graves’ disease (GD), which can be associated with corneal ulcerations or optic neuropathy in severe forms. Transnasal endoscopic orbital decompression (TEOD) is a surgical procedure performed in order to decrease the intraorbital pressure by removing part of its bony borders in cases with excessive mass in orbit. The aim of this study was to present the results and evaluate the efficacy of TEOD for GO. The retrospective study included 28 orbits (16 patients) who underwent TEOD from 2017 to 2020. Outcome was evaluated based on visual acuity improvement, clinical activity score (CAS) decrease, proptosis, and intraocular pressure (IOP) reduction. A preoperative best-corrected visual acuity (BCVA) increased from 0.69 ± 0.385 (mean ± standard deviation) to 0.74 ± 0.332 (p = 0.17) postoperatively. CAS decreased in 15 orbits postoperatively. Proptosis decreased from 22.89 ± 1.873 mm to 21.25 ± 2.053 mm (p < 0.05). IOP decreased from a preoperative 16.11 ± 3.93 mmHg to 14.40 ± 3.27 mmHg (p < 0.05) postoperatively. In addition, postoperative relief of exposure keratitis was observed. The analysis of development of iatrogenic diplopia revealed increasing in degree of diplopia. TEOD shows rare complications, but significant improvements in BCVA, CAS, proptosis, and IOP.

Change of intraocular blood flow during treatment for thyroid eye disease

To report a sequential observational study of changes in the retinal and choroidal blood flow during medical and surgical treatments for a thyroid eye disease (TED) patient, using optical coherence tomography angiography (OCTA) and laser speckle flowgraphy (LSFG). A 28-year-old man with a history of Graves’ disease diagnosed 8 months prior was presented in the active phase of TED. His clinical activity score (CAS) was 6, but without diplopia or visual loss. Intraocular pressure measurement was OD 20 mmHg and OS 24 mmHg. Thyrotropin receptor antibody (TRAb) and thyroid-stimulating antibody levels were 18.8 IU/L and 4347%. Magnetic resonance imaging revealed enlargement of both extraocular muscles and fat compartments in both orbits. The patient underwent IV pulsed steroid therapy (1 g/day, 3 days) followed by an oral prednisone for 1 month. His CAS score decreased to 4. Bilateral orbital fat decompression decreased his final CAS score to 1 in both eyes. Intraocular blood flow was measured using laser speckle flowgraphy (LSFG), and OCTA was performed. Retinal blood flow increased slightly, but choroidal blood flow showed a robust increase. Choroidal blood flow measured using both LSFG and OCTA was negatively correlated with the CAS score and TRAb. In our case report, the ocular perfusion, especially choroidal blood flow, may decrease in active TED, which may be reversed by medical and surgical treatment.

Intraocular Pressure and Glaucoma in Thyroid Eye Disease

PURPOSE

Current literature lacks a summary of knowledge on intraocular pressure (IOP) elevation and glaucoma in thyroid eye disease (TED). This review aims to augment existing literature by providing such a summary. It qualitatively evaluates current knowledge on the pathogenesis, prevalence, and management of concomitant ocular hypertension or glaucoma in TED patients.

METHODS

In this narrative review, relevant publications were identified through a computerized database search. Search results were screened for relevance. Correspondence, Editorials, and Letters to the Editors were excluded. References cited within the identified articles were used to further augment the search. Information extracted for qualitative analysis included epidemiologic data, methods of IOP assessment, management protocols, and response to treatment.

RESULTS

Studies in current literature are relatively heterogenous, differing in country of origin, TED cohort sizes, and IOP measurement techniques. Further studies are required to elucidate the true epidemiologic relationship between TED and ocular hypertension or glaucoma. Proposed models of IOP elevation include elevation of episcleral venous pressure, mucopolysaccharide deposition within the trabecular meshwork, restrictive myopathy, steroid-induced glaucoma, and secondary glaucoma. IOP-reducing effects of TED treatment options are discussed.

CONCLUSIONS

While raised IOP in TED is a common phenomenon, the diagnosis of glaucoma in TED requires a high index of suspicion before any intervention.

Orbital wall decompression in the management of Graves' orbitopathy: a systematic review with meta-analysis

PURPOSE

To systematically review outcomes of orbital bony wall decompression for Grave's orbitopathy according to the surgical approach.

METHODS

A systematic search for studies published in "Ovid MEDLINE", "Web of Science" and "Embase" of patients with surgical treatment of Grave's orbitopathy was performed. The overall postoperative change in Hertel exophthalmometry was calculated by random-effect meta-analysis model with 95% confidence interval (CI).

RESULTS

A total of 33 studies, including 1686 patients and 2946 procedures, were included. The weighted mean Hertel value overall reduction was - 4.56 mm (95% CI - 5.05 to - 4.07 mm). According to surgical techniques the reduction was - 4.36 mm (95% CI - 5.22 to - 3.50) for infero-medial technique, - 4.88 mm (- 5.68 to - 4.08) for medial-lateral technique, - 4.32 mm (- 4.80to - 3.84) for lateral technique, - 5.45 mm (- 6.16 to - 4.74) for three-wall technique and - 3.47 mm (- 5.81 to - 1.12) for medial technique. The overall rate of new-onset of primary gaze diplopia was reported in 23 studies. The included procedures were 653 and results were heterogeneous (heterogeneity: Q = 78.8 df = 22, I2 = 72.09%, p < 0.01). The pooled proportion (95% CI) rate of new-onset of primary gaze diplopia was 12% (7-16).

CONCLUSION

Our metanalysis highlights that orbital bony wall decompression represents an effective surgical procedure. The three wall approach was associated with the best results in terms of exophthalmos reduction. Data suggest that an exclusive lateral approach may help to avoid the new-onset of primary gaze diplopia during the postoperative period.

Deep lateral orbital decompression for Graves orbitopathy: a systematic review

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Clinical Features of Graves' Orbitopathy with Elevated Intraocular Pressure

Background

To investigate the clinical characteristics of Graves' orbitopathy (GO) with elevated intraocular pressure (IOP) using the European Group of Graves' Orbitopathy (EUGOGO) system.

Methods

In this retrospective study, the clinical data of GO patients with elevated IOP (≥21 mmHg) were collected in Sun Yat-sen Memorial Hospital from January 2010 to June 2016. The demographic characteristics, clinical history of thyroid disease and GO, and ocular examination data were evaluated, and the activity and severity of GO were classified.

Results

Data were collected from 58 eyes of 39 patients. The durations of thyroid disease and GO were 15.9 ± 18.9 months and 7.5 ± 6.2 months, respectively. The average IOP was 24.8 ± 5.3 mmHg (range: 21–55 mmHg). No significant difference in IOP was observed between active and inactive eyes. Eight eyes (13.8%), 29 eyes (50.0%), and 21 eyes (36.2%) were graded as mild, moderate-severe, and sight-threatening disease, respectively, according to the EUGOGO classification. The IOP was not significantly different among the three EUGOGO grades. No glaucomatous optic nerve damage or visual field defects were found.

Conclusion

Increased IOP was evident for every grade of GO severity and activity of the EUGOGO system. IOP, glaucomatous optic nerve damage, and visual fields must be evaluated regularly during follow-up evaluations, regardless of the degree of activity and severity of GO.

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

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

Temporal hollowing and other adverse effects after lateral orbital wall decompression

PURPOSE

To evaluate the outcome and late postoperative complications after lateral orbital wall decompression in a series of patients with thyroid eye disease (TED).

METHODS

One hundred and three patients operated in the period 1999-2013 were invited to participate in the study, and 84 were included after a median (range) follow-up time of 124 (13-188) months. The patients were interviewed, and preoperative and postoperative data were collected from hospital records. Photographs ('selfies') were obtained from 64 patients. Wilcoxon signed-rank test was used to evaluate the change in pre- and postoperative data.

RESULTS

On average, visual acuity was unchanged with a median value (range) of 1.0 (0.4-1.25) before to 1.0 (0-1.25) after surgery (p = 0.5). Intraocular pressure (IOP) was reduced from a median value (range) of 17 (9-26) to 15 (8-23) mmHg (p < 0.001). Median (range) Hertel values were 23 (15-30) mm preoperatively and 20 (12-26) mm postoperatively (p < 0.001) respectively. Mean (SD) reduction in proptosis was 3.6 (±2.1) mm. Oscillopsia was reported in 24 patients (29%), 42 (50%) experienced a change in temporal sensation, and four (5%) had new-onset diplopia. In 47 patients (56%), some degree of temporal hollowing was reported. Among 64 photographed patients, 38 (59%) had noticeable hollowing on examination of postoperative pictures. There was agreement of the patient's perception of temporal hollowing and the appearance in photographs in 26 of 37 patients (70%).

CONCLUSION

Lateral orbital wall decompression has been considered a safe and effective procedure for treatment of TED. Serious side-effects are infrequent, but in rare circumstances, even blindness may occur. Less serious side-effects are relatively common. Among others, a significant number of the patients developed temporal hollowing after the procedure. The patients must be informed about the possible complications before surgery.

Clinical factors affecting intraocular pressure change after orbital decompression surgery in thyroid-associated ophthalmopathy

OBJECTIVE

To report the physiological monitoring of intraocular pressure (IOP) during the postoperative periods after orbital decompression surgery and ascertain the correlation between the clinical factors and IOP changes.

METHODS

The medical records of 113 orbits from 60 patients who underwent orbital decompression surgery were reviewed retrospectively. IOP measurement during the postoperative periods was classified based on the postoperative day: week 1 (1-7 days), month 1 (8-41 days), month 2 (42-70 days), month 3 (71-97 days), month 4 (98-126 days), and final (after 127 days). The mean postoperative follow-up was 286.5 days for orbits with at least 6 months of follow-up. Univariate and multivariate linear regression analyses were performed to assess the correlation between the IOP reduction percentage and clinical factors.

RESULTS

The mean IOP increased from 16.9 to 18.6 mmHg (10.1%) at postoperative week 1 and decreased to 14.4 mmHg (14.5%) after 2 months. Minimal little changes were observed postoperatively in the IOP after 2 months. Preoperative IOP had a significant positive effect on the reduction percentage both at postoperative week 1 (β=2.51, P=0.001) and after 2 months (β=1.07, P=0.029), and the spherical equivalent showed a positive correlation with the reduction level at postoperative week 1 (β=1.71, P=0.021).

CONCLUSION

Surgical decompression caused a significant reduction in the IOP in thyroid-associated orbitopathy, and the amount of reduction was closely related to preoperative IOP; however, it may also cause a transient elevation in the IOP during the early postoperative phase in highly myopic eyes.

Biometric and refractive changes after orbital decompression in Korean patients with thyroid-associated orbitopathy

PURPOSE

To determine the biometric and refractive changes after orbital decompression in Korean patients with thyroid-associated orbitopathy (TAO).

METHODS

Retrospective, observational study (between October 2012 and September 2014) was performed. Patients with TAO undergoing orbital decompression for stable proptosis received ophthalmic examinations, including Hertel exophthalmometry, A-scan biometry, autorefraction measures, corneal topography, and wavefront aberration measures, before orbital decompression and again 2 months after surgery.

RESULTS

Included in the study were 43 eyes from 23 patients. The mean exophthalmometric value decreased by 4.1 mm 2 months after orbital decompression (P<0.001). On average, axial length (AL) increased significantly by 0.08 mm (P<0.001); specifically, 37 (86%) of the 43 eyes had increased AL. Whereas anterior chamber depth and lens thickness showed no significant changes (P=0.086 and P=0.905, respectively), the mean spherical refraction and spherical equivalent (SE) decreased by 0.35 and 0.48 D, respectively (P=0.008 and P<0.001, respectively). However, cylindrical refraction and axis showed no significant changes (P=0.057 and P=0.218, respectively). The changes in AL and SE were significantly correlated (R=-0.411, P=0.009). Notably, there were no changes in corneal topography or wavefront aberration after orbital decompression.

CONCLUSIONS

TAO patients who underwent orbital decompression showed myopic refractive change via increase in AL. Possible refractive changes should be considered in cases of TAO complaining of decreased visual acuity after orbital decompression.

Effect of Orbital Decompression on Corneal Topography in Patients with Thyroid Ophthalmopathy

Objective

To evaluate changes in corneal astigmatism in patients undergoing orbital decompression surgery.

Methods

This retrospective, non randomized comparative study involved 42 eyes from 21 patients with thyroid ophthalmopathy who underwent orbital decompression surgery between September 2011 and September 2014. The 42 eyes were divided into three groups: control (9 eyes), two-wall decompression (25 eyes), and three-wall decompression (8 eyes). The control group was defined as the contralateral eyes of nine patients who underwent orbital decompression surgery in only one eye. Corneal topography (Orbscan II), Hertel exophthalmometry, and intraocular pressure were measured at 1 month before and 3 months after surgery. Corneal topographic parameters analyzed were total astigmatism (TA), steepest axis (SA), central corneal thickness (CCT), and anterior chamber depth (ACD).

Results

Exophthalmometry values and intraocular pressure decreased significantly after the decompression surgery. The change (absolute value (|x|) of the difference) in astigmatism at the 3 mm zone was significantly different between the decompression group and the controls (p = 0.025). There was also a significant change in the steepest axis at the 3 mm zone between the decompression group and the controls (p = 0.033). An analysis of relevant changes in astigmatism showed that there was a dominant tendency for incyclotorsion of the steepest axis in eyes that underwent decompression surgery. Using Astig PLOT, the mean surgically induced astigmatism (SIA) was 0.21±0.88 D with an axis of 46±22°, suggesting that decompression surgery did change the corneal shape and induced incyclotorsion of the steepest axis.

Conclusions

There was a significant change in corneal astigmatism after orbital decompression surgery and this change was sufficient to affect the optical function of the cornea. Surgeons and patients should be aware of these changes.

Quantitative Assessment of Orbital Volume and Intraocular Pressure after Two-Wall Decompression in Thyroid Ophthalmopathy

BACKGROUND

Surgical outcomes after orbital wall decompression have focused on the degree of exophthalmos and intraocular pressure. The aim of this research was to evaluate intraorbital volume using computed tomography (CT) images following two-wall decompression using a combined subcilliary and endoscopic approaches.

METHODS

A retrospective review was performed for all patients who had undergone the two-wall decompression method. The pre/postoperative CT images were used to evaluate changes in intraocular volume. Intraocular pressure was evaluated using applanation tonometry. Surgical details are discussed within the body of text.

RESULTS

Two-wall decompression thru the medial wall and floor was associated with an average intraorbital volume change of 7.3 cm³, with maximal accommodation up to 13 cm³. Changes in intraocular pressures were not statistically significant.

CONCLUSION

Two-wall decompression was effective in accommodation of up to 13 cm³ of soft tissue herniation. There was no statistically significant association between changes in volume to pressure.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Blood-aqueous barrier integrity in patients with Graves' ophthalmopathy (GO), before and after rehabilitative surgery

PURPOSE

The study was conducted to analyze aqueous flare and its correlations in patients with Graves' ophthalmopathy (GO) undergoing orbital decompression, extraocular muscle, and eyelid surgery. Prospective interventional case series.

PATIENTS AND METHODS

Forty-eight eyes of 27 patients (20 female and 7 male, aged 54.4 ± 5.7) undergoing surgical treatment for GO. Eighteen eyes of nine patients (aged 55.3 ± 3.6) undergoing orbital decompression. Nineteen eyes of 11 patients (aged 54.7 ± 5.6) undergoing extraocular muscle surgery and 13 eyes of 7 patients (aged 53.9 ± 4.9) undergoing eyelid surgery and control group (34 patients aged 53.9 ± 5.1). Laser flare analysis and clinical assessment were performed before surgery and at 1 day, 7 days, and 3 months following surgery.

RESULTS

Aqueous flare was significantly higher in patients with GO (14.03 ± 8.45) before intervention than in the control group (7.89 ± 3.56) (P<0.001), and correlated with Clinical Activity Score and intraocular pressure. In the patients undergoing orbital decompression, flare increased from 17.77 ± 10.63 pc/ms to 38.32 ± 13.56 pc/ms on the first day and 41.31 ± 17.19 pc/ms on the seventh day and returned to 16.01 ± 8.58 pc/ms in 3 months. In patients undergoing extraocular muscle surgery flare increased from 13.05 ± 6.50 to 23.04 ± 11.53 pc/ms (P<0.001) on the first day and returned to 18.02 ± 14.09 pc/ms on the seventh day. Eyelid surgery did not change flare values.

CONCLUSIONS

Orbital decompression disrupts blood-aqueous barrier (BAB). The integrity of BAB returns to preoperative status within 3 months. Extraocular muscle surgery mildly affects BAB integrity, and the effect subsides within 7 days. Eyelid surgery does not affect BAB.

Intraocular pressure lowering effect of orbital decompression is related to increased venous outflow in Graves orbitopathy

PURPOSE

To investigate the effects of combined orbital bone and fat decompression on intraocular pressure (IOP) and superior ophthalmic vein blood flow velocity (SOV-BFV), and their association with the clinical features of Graves orbitopathy (GO).

METHODS

During the 2002-2008 period, 72 eyes of 36 GO cases demonstrating moderate to severe orbitopathy were evaluated according to their clinical features as: cases with or without dysthyroid optic neuropathy (DON), and underwent orbital decompression. A control group comprised 40 eyes of 20 healthy subjects. In both groups, a full ophthalmic examination including IOP and Hertel measurements was performed, and SOV-BFV was analyzed with color Doppler imaging. Examinations were repeated after orbital decompression in GO patients.

RESULTS

All the cases demonstrated clinical features of inactive disease. Among the patients 24 of 72 eyes (33.3%) showed clinical features of DON. After surgery, the mean decrease in Hertel values was 6.2 ± 1.8 mm (p = 0.001). The mean decrease in IOP was 3.0 ± 1.7 mmHg (from 17.3 ± 2.7 to 14.3 ± 2.0 mmHg) after orbital decompression where the post-operative values were comparable with the control group (12.9 ± 1.4 mmHg, p = 0.36). The mean increase in SOV-BFV achieved with decompression was 1.2 ± 0.6 cm/s (from 4.8 ± 1.7 to 6.0 ± 1.8 cm/s) and post-operative SOV-BFV values were also comparable with the control group (6.6 ± 1.3 cm/s, p = 0.26). The increase in SOV-BFV in cases with DON did not differ from cases without DON (p = 0.32), however, post-operative SOV-BFV of cases with DON was stil lower than cases without DON (p = 0.035).

CONCLUSIONS

Combined orbital bone and fat decompression significantly reduced the IOP levels and increased the SOV-BFV in GO. This could be the confirmative finding of prediction that elevated IOP in GO is associated with increased episcleral venous pressure. The post-operative changes in IOP and SOV-BFV show differences regarding the clinical features of disease.