1
|
Jellema HM, Althaus M, Merckel-Timmer E, Hartong DT, Kloos R, Saeed P. Effects of orbital decompression on duction, cyclotorsion and diplopia. Br J Ophthalmol 2024; 108:1075-1080. [PMID: 38041682 DOI: 10.1136/bjo-2023-323480] [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: 02/25/2023] [Accepted: 10/23/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Orbital decompression is commonly performed to correct proptosis in patients with Graves' orbitopathy (GO). In literature, the incidence of new-onset constant diplopia after orbital decompression varies. Few studies have evaluated changes in duction and cyclodeviation after orbital decompression. We evaluated the changes in duction, cyclodeviation, eye position and degree of diplopia after orbital decompression. METHODS We retrospectively analysed data from patients who underwent orbital decompression at our hospital between January 2016 and July 2020. Data regarding the type of decompression, eye position, duction, cyclodeviation and level of diplopia according to the Gorman score were recorded. RESULTS Data from 281 eyes/orbits of 156 patients were analysed. Proptosis decreased from 23.8±2.5 to 20.9±2.5 mm. Horizontal and vertical duction range decreased (horizontal d=0.40 and vertical 0.30; p=0.000) after surgery; however, the change was not clinically significant (≤5°). Horizontal deviation changed towards esodeviation (d=-0.45; p=0.000), whereas vertical deviation remained stable (d=0.15; p=0.161). Preoperative cyclotorsion in the primary and downgaze positions changed towards incyclodeviation (primary: d=0.30, p=0.021; downgaze d=0.30, p=0.039). Diplopia improved in 22% (18 patients), whereas new-onset constant diplopia developed in 11% (12 patients). Elevation has an excellent predictive value of causing new-onset constant diplopia when measured preoperatively as <19°, sensitivity 88.0%, specificity 41.7% (area under the curve 0.812 (95% CI 0.660 to 0.963); p=0.000). CONCLUSION After orbital decompression, incidence of new-onset constant diplopia was 11% and 22% of the patients had partial or complete improvement of their diplopia. The changes in duction, cyclodeviation and horizontal deviation showed a statistical but not clinical difference. Patients with GO and a preoperatively restricted elevation of <19° are at risk of developing new-onset constant diplopia. In addition, preoperative incyclodeviation may worsen after decompression surgery.
Collapse
Affiliation(s)
| | | | - Elly Merckel-Timmer
- Department of Ophthalmology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Dyonne T Hartong
- Department of Ophthalmology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Roel Kloos
- Department of Ophthalmology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Peerooz Saeed
- Department of Ophthalmology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Delayed Cerebrospinal Fluid Leaks Complicating Endoscopic Orbital Surgeries. J Craniofac Surg 2023; 34:695-697. [PMID: 36372926 DOI: 10.1097/scs.0000000000009114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To report cerebrospinal fluid leak as an uncommon but noteworthy delayed complication after endoscopic orbital surgeries and to describe its incidence, mechanism, prevention, diagnosis, and management. METHODS Case series of 3 patients who underwent endoscopic orbital surgery in the Department of Ophthalmology, Shanghai Ninth People's Hospital affiliated to Shanghai JiaoTong University School of Medicine from January 2003 to December 2020. A review of the literature was also conducted. RESULTS Three cases of delayed cerebrospinal fluid leaks occurred 10 years, 3 months, and 4 months after endoscopic orbital surgeries, respectively, were reviewed and reported. Two patients developed cerebrospinal fluid leaks after surgical repair of orbital blowout fractures with titanium mesh and porous polyethylene (Medpor), respectively, and 1 patient developed cerebrospinal fluid leak after transantral optic canal decompression. In the first case, head computed tomography (CT) cisternography and magnetic resonance imaging confirmed the site of the leak that required surgical repair. In the second case, a coronal CT showed that the implanted titanium mesh was tightly against the cribriform plate, which might cause defect of skull base and dura. In the third case, orbital CT identified a dehiscence on the sphenoidal wall as the leak site, which was repaired in a secondary endoscopic surgery. CONCLUSIONS A cerebrospinal fluid leak, as an uncommon but noteworthy complication, can occur as delayed as 10 more years after surgery. For patients with specific anatomic characteristics, such as Kero type III, surgeons should perform meticulous preoperative evaluation and intraoperative procedures to prevent this complication.
Collapse
|
3
|
Baeg J, Choi HS, Kim C, Kim H, Jang SY. Update on the surgical management of Graves' orbitopathy. Front Endocrinol (Lausanne) 2023; 13:1080204. [PMID: 36824601 PMCID: PMC9941741 DOI: 10.3389/fendo.2022.1080204] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/15/2022] [Indexed: 02/10/2023] Open
Abstract
Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.
Collapse
Affiliation(s)
- Joonyoung Baeg
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Han Sol Choi
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Charm Kim
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
- Department of Ophthalmology, AIN Woman`s Hospital, Incheon, Republic of Korea
| | - Hyuna Kim
- Department of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sun Young Jang
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| |
Collapse
|
4
|
Hsieh MW, Hsu CK, Kuo PC, Chang HC, Chen YH, Chien KH. Factors Predicting the Success of Combined Orbital Decompression and Strabismus Surgery in Thyroid-Associated Orbitopathy. J Pers Med 2022; 12:jpm12020186. [PMID: 35207674 PMCID: PMC8879140 DOI: 10.3390/jpm12020186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 11/18/2022] Open
Abstract
To evaluate the safety and efficacy of orbital decompression combined with strabismus surgery in thyroid-associated orbitopathy (TAO) and identify factors leading to surgical success. A retrospective comparative case series was conducted on 52 patients who were treated with combined orbital decompression and strabismus surgery. Outcome measurements included perioperative Hertel exophthalmometry and strabismus measurements. Surgical success was defined as binocular single vision (BSV) in the primary and reading positions within 5 prism diopters (PDs). As a result, the average reduction in proptosis was 3.23 mm, with a mean preoperative Hertel measurement of 22.64 mm. Forty-four patients (84.6%) achieved the success criterion and composed the success group. In addition to sex and underlying hyperthyroidism, symmetry of orbitopathy, interocular exophthalmos difference of more than 2 mm, predominant esotropia type, mixed type strabismus, baseline horizontal deviations, baseline vertical deviations, and combination with one-wall decompression surgery were significantly different between the success and failure groups. All complications were mild and temporary. Orbital decompression combined with strabismus surgery produced satisfactory outcomes in selected patients with efficacy and safety. Symmetry between the two eyes with relatively simple strabismus and proptosis ensured surgical success. With experienced surgeons, advanced techniques, and selected patients, this method can serve as an alternative treatment option to minimize the number of surgeries, medical costs and recovery period.
Collapse
Affiliation(s)
- Meng-Wei Hsieh
- Department of Ophthalmology, Taoyuan Armed Forces General Hospital, Taoyuan 325, Taiwan;
| | - Chih-Kang Hsu
- Department of Ophthalmology, Tri-Service General Hospital Songshan Branch, Songshan, Taipei 105, Taiwan;
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Pao-Cheng Kuo
- Department of Orthopedics, Taipei Veterans General Hospital, Taipei 112, Taiwan;
| | - Hsu-Chieh Chang
- Department of Nursing, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
- Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei 110, Taiwan
| | - Yi-Hao Chen
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Ke-Hung Chien
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
- Correspondence: ; Tel.: +886-2-8792-3311
| |
Collapse
|
5
|
Krause M, Kamal M, Kruber D, Sterker I, Sander AK, Zimmerer R, Lethaus B, Bartella AK. Effect of orbital wall resection areas in the treatment of patients with endocrine orbitopathy. Br J Oral Maxillofac Surg 2021; 60:610-616. [PMID: 35184917 DOI: 10.1016/j.bjoms.2021.10.021] [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: 07/13/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
In patients treated by orbital wall decompression for endocrine orbitopathy (EO) there is limited evidence on the effect of orbital wall resections. Thus, the aim of this study was to evaluate the effect of one, two, and three-wall resections on orbital parameters to determine if any such correlations exist. Preoperative and postoperative data from all patients at a tertiary care centre who underwent decompression surgery from 2010 - 2020 were digitally analysed. The effect of the number and area of resected walls on orbital area, orbital volume, and Hertel value, and the effect of lateral rim advancement (LARA) were determined. A total of 131 orbital areas showed an increase from a mean (SD) preoperative area of 42.0 (4.6) cm2 to 47.3 (6.1) cm2 postoperatively (p<0.001). In total, the mean (SD) area of osseous wall removed in all patients was 6.2 (1.7) cm2 at the lateral orbit (n = 129), 6.7 (2.3) cm2 at the orbital floor (n = 123), and 5.8 (1.8) cm2 at the medial orbital wall (n =30). The mean (SD) orbital volume increased by 6.0 (3.0) cm3 after decompression. There was also a significant reduction in exophthalmos of 7.3 (3.2) mm (from 25.2 (3.9) to 17.9 (3.5), p<0.001). LARA was performed in 50 patients. Changes in volume and area, and reduction in exophthalmos were not significantly different with or without LARA. The postoperative effects of orbital wall resection are predictable and exhibit a relation with six units of change. Two-wall resection is the most common intervention.
Collapse
Affiliation(s)
- Matthias Krause
- Department of Oral and Maxillofacial Surgery, Leipzig University, Liebigstraße 12, 04103 Leipzig, Germany
| | - Mohammad Kamal
- Department of Surgical Sciences, Faculty of Dentistry, Kuwait University, Safat, Kuwait
| | - Daniel Kruber
- Faculty of Mechanical and Energy Engineering, University of Applied Sciences (HTWK), Karl- Liebknecht Str. 145, 04277 Leipzig, Germany
| | - Ina Sterker
- Department of Ophthalmology, Leipzig University, Liebigstraße 12, 04103 Leipzig, Germany
| | - Anna K Sander
- Department of Oral and Maxillofacial Surgery, Leipzig University, Liebigstraße 12, 04103 Leipzig, Germany
| | - Rüdiger Zimmerer
- Department of Oral and Maxillofacial Surgery, Leipzig University, Liebigstraße 12, 04103 Leipzig, Germany
| | - Bernd Lethaus
- Department of Oral and Maxillofacial Surgery, Leipzig University, Liebigstraße 12, 04103 Leipzig, Germany
| | - Alexander K Bartella
- Department of Oral and Maxillofacial Surgery, Leipzig University, Liebigstraße 12, 04103 Leipzig, Germany.
| |
Collapse
|
6
|
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.
Collapse
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)
| |
Collapse
|
7
|
Ong AA, DeVictor S, Vincent AG, Namin AW, Wang W, Ducic Y. Bony Orbital Surgery for Graves' Ophthalmopathy. Facial Plast Surg 2021; 37:692-697. [PMID: 34500489 DOI: 10.1055/s-0041-1735638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The majority of Graves' ophthalmopathy, or thyroid eye disease, can be managed medically; however, in refractory or severe cases, surgical intervention with orbital decompression may be necessary. The majority of the published literature is retrospective in nature, and there is no standardized approach to orbital decompression. The purpose of this review is to evaluate the various surgical approaches and techniques for orbital decompression. Outcomes are ultimately dependent on individual patient factors, surgical approach, and surgeon experience.
Collapse
Affiliation(s)
- Adrian A Ong
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Samuel DeVictor
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York
| | - Aurora G Vincent
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Arya W Namin
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Weitao Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Rochester, Rochester, New York
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| |
Collapse
|
8
|
Islamaj E, Jordaan‐Kuip CP, De Waard PW, Vermeer KA, Lemij HG. Ocular motility changes and diplopia in sutured versus unsutured implantation of the Baerveldt glaucoma device. Acta Ophthalmol 2021; 99:e949-e955. [PMID: 33576161 PMCID: PMC8518686 DOI: 10.1111/aos.14707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 11/07/2020] [Accepted: 11/09/2020] [Indexed: 12/04/2022]
Abstract
Purpose To investigate the effect of two surgical techniques in primary Baerveldt glaucoma implant (BGI) surgery, that is the sutured technique and the unsutured (free) plate technique, on the ocular motility and prevalence of diplopia. We hypothesize that the free plate technique results in a lower diplopia prevalence. Methods We performed a prospective study of patients who underwent BGI surgery with the free plate technique and compared them with patients from a previous study who had undergone BGI surgery with the sutured technique. Their ductions, ocular alignment and fusion range and the prevalence of diplopia were measured before surgery and at 3 months, 6 months and 1 year postoperatively. Results We analysed 57 free plate and 51 sutured plate patients. One year postoperatively, we found no statistically significant difference in the prevalence of diplopia between the two techniques. All duction changes between baseline and 1‐year follow‐up were restrictions and occurred statistically significantly more frequently in the free plate than in the sutured plate group (p = 0.03; 60% versus 34%). About the ocular alignment, in the horizontal direction, a change in exodirection was more common in both groups, while in the vertical direction, a hyperdeviation of the operated eye was more common. The vertical ocular alignment change was smaller in the free plate group than in the sutured plate group (p = 0.04 at near and p = 0.02 at distance). Conclusions One year postoperatively, the prevalence of diplopia was not significantly different between patients with the sutured plate and patients with the free plate technique. Both surgical techniques induce diplopia and changes in ocular motility and/or in ocular alignment.
Collapse
Affiliation(s)
- Esma Islamaj
- Rotterdam Ophthalmic Institute Rotterdam Eye Hospital Rotterdam the Netherlands
| | | | | | - Koen A. Vermeer
- Rotterdam Ophthalmic Institute Rotterdam Eye Hospital Rotterdam the Netherlands
| | - Hans G. Lemij
- Glaucoma Department Rotterdam Eye Hospital Rotterdam the Netherlands
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Oscillopsia After Isolated Lateral Wall Decompression Versus Balanced or 3-Wall Decompression. Ophthalmic Plast Reconstr Surg 2021; 37:141-144. [PMID: 32467520 DOI: 10.1097/iop.0000000000001716] [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 assess the incidence of postoperative masticatory oscillopsia after orbital decompression, comparing results between isolated lateral wall and balanced or 3-wall orbital decompression. METHODS An observational retrospective study was performed, involving 161 consecutive patients who underwent orbital decompression between 2008 and 2018. Patients' clinical data were registered, and archives were revised for data compilation. Patients were divided into 2 groups according to the type of surgery: "lateral" group included patients who underwent isolated lateral wall decompression and "lateral plus" group involved patients with balanced or 3-wall decompression. Exclusion criteria were secondary decompressions, those not including lateral wall and asymmetrical surgeries, so analysis was performed among 131 remaining patients. Oscillopsia was self-reported and was registered as present or not. Diplopia was evaluated according to Paridaens grading system. RESULTS Statistical analysis among the 131 patients with lateral wall decompression (isolated or in combination) was performed. Seven patients referred oscillopsia, 5 among "lateral" group, while 2 reported oscillopsia on "lateral plus" group (p = 0.001). The authors found no differences on new-onset or worsening of diplopia between groups (p = 1). CONCLUSIONS Oscillopsia was significantly higher after isolated lateral wall decompression than after balanced or 3-wall decompression, while no differences were found between groups according to diplopia status. Transmission of temporal muscle contraction to the orbit seems to be the cause of the oscillopsia. The authors postulate that the absence of orbital floor or medial wall may act as a dampener for the temporalis muscle contractions, allowing the orbital contents to be expanded through them, and avoiding oscillopsia.
Collapse
|
11
|
Pterional Orbit Decompression in Grave Disease with Dysthyroid Optic Neuropathy. World Neurosurg 2021; 149:e1007-e1016. [PMID: 33476778 DOI: 10.1016/j.wneu.2021.01.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/09/2021] [Accepted: 01/10/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The choice of surgical technique in sight-threatening Grave orbitopathy remains controversial. Available data are mostly derived from mixed cohorts with multiple surgical indications and techniques. The authors assessed predictors for visual outcome after standardized pterional orbital decompression for dysthyroid optic neuropathy. METHODS Retrospective analysis of 62 pterional orbital decompressions performed on 40 patients with dysthyroid optic neuropathy. RESULTS Visual acuity improved by an average of 3.8 lines in eyes with preoperative visual impairment (95% confidence interval [CI]: 1.8-5.8 lines, P < 0.001) and remained stable in eyes without prior visual impairment (95% CI -1.3 to 1 line, P = 0.81). Proptosis was reduced by an average of 3.1 mm (95% CI 1.8-4.3 mm, P < 0.001). Higher degrees of proptosis were predictive of worse visual outcomes (P = 0.017). New-onset diplopia developed in 2 patients, while previous diplopia resolved after surgery in 6 patients. CONCLUSIONS This cohort is the largest series of pterional orbit decompressions and the first to focus exclusively on dysthyroid neuropathy. Complication rates were low. Decompression surgery was highly effective at restoring and maintaining visual acuity in patients with dysthyroid optic neuropathy.
Collapse
|
12
|
Zah-Bi G, Abeillon-du Payrat J, Vie AL, Bournaud-Salinas C, Jouanneau E, Berhouma M. Minimal-Access Endoscopic Endonasal Management of Dysthyroid Optic Neuropathy: The Dysthone Study. Neurosurgery 2020; 85:E1059-E1067. [PMID: 31393984 DOI: 10.1093/neuros/nyz268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/16/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Dysthyroid optic neuropathy (DON) is a devastating complication of thyroid eye disease. Corticosteroids are the primary medical treatment for DON, but some refractory patients may require surgical management. OBJECTIVE To evaluate the efficacy of endoscopic endonasal decompression of the orbital apex in refractory DON. METHODS This study included patients with refractory DON who underwent endoscopic endonasal decompression of the orbital apex from February 2015 to October 2016. A total of 23 orbital apices were decompressed across 17 patients. Visual acuity, ophthalmometry, tonometry, and visual field were evaluated at the preoperative, early and delayed postoperative stages. Statistical analyses were performed using RStudio software. A Wilcoxon test for matched data was performed to determine if there was a statistically significant difference between pre- and postsurgical treatment for the following items: visual acuity, proptosis, visual field, and intraocular pressure. RESULTS Visual acuity improved in 69.5% of the cases with a mean gain of 2.5 points ± 1.6 (P < .05). Additionally, there was an 18.3% reduction in mean proptosis across all cases (P < .05) and a 13.7% decrease in intraocular pressure (P < .05) for all patients. Finally, visual field improved in 82.6% (P < .05) of the cases. The mean time for follow-up was of 6.28 ± 3.7 mo. There were 3 cases of transient postoperative rhinitis and 2 cases of transient diplopia. Two patients experienced recurrence at 4 and 8 mo, respectively. CONCLUSION Endoscopic endonasal decompression of the orbital apex significantly improves visual parameters. As a result, multidisciplinary screening for patients is crucial to ensure prompt surgical decompression.
Collapse
Affiliation(s)
- Gilles Zah-Bi
- Department of Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Anne Laure Vie
- Department of Neuro-Ophthalmology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Claire Bournaud-Salinas
- Department of Nuclear Medicine, Louis Pradel Hospital, Hospices civils de Lyon, Lyon, France
| | - Emmanuel Jouanneau
- Department of Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France
| | - Moncef Berhouma
- Department of Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Hospices Civils de Lyon, Lyon, France.,Laboratory CREATIS, CNRS UMR5220, INSERM U1206, Lyon 1 University, INSA, Villeurbanne, France
| |
Collapse
|
13
|
Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy. J Ophthalmol 2019; 2019:9478512. [PMID: 31885895 PMCID: PMC6914951 DOI: 10.1155/2019/9478512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/27/2019] [Accepted: 11/04/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose To describe the results of thyroid-related orbitopathy (TRO) treated by ultrasonic deep lateral wall bony decompression with partial rim sparing (DLW-PRS). Methods A review was carried out, from January 2015 to September 2017, of all patients treated with ultrasonic DLW-PRS decompression using a SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator, using a lateral, small triangle flap incision for access. The primary outcome was the change in proptosis (measured by the difference in Hertel exophthalmometry measurements). Other secondary outcomes were changes in visual acuity (VA) (using Snellen scale, decimal fraction), presence of lagophthalmos, eyelid retraction (measured by upper eyelid margin distance to the corneal reflex (MRD1) and lower eyelid margin distance to the corneal reflex (MRD2), and presence of exposure keratopathy). Results A total of 58 orbital decompressions in 35 patients were reviewed, with 23 patients (65.7%) having bilateral decompressions. There was a female preponderance with 26 patients (74.2%), and the mean age ± standard deviation was 52.6 ± 13.9 years. Mean proptosis was 24.51 ± 1.76 mm preoperatively, reduced to 19.61 ± 1.27 mm in final follow-up. The mean reduction was 4.9 ± 1.54 mm. VA improved from 0.8 ± 0.14 to 0.9 ± 0.12, p=0.039. 5 of 13 patients (38.4%) with preoperative diplopia reported improvement or complete resolution after surgery. MRD1 was reduced from 5.25 ± 0.88 mm to 4.49 ± 0.7 mm. MRD2 was also reduced from 6.3 ± 0.88 mm to 5.0 ± 0.17 mm. Presence of lagophthalmos was reduced from 35 eyes (60.3%) to five (8.6%); the presence of epiphora was also reduced from 20 patients (57.1%) to 3 (8.5%) following decompression. Complications of the surgery included zygomatic hypoaesthesia in 14 (40%) patients in the early postoperative period and chewing alterations in 10 (28.5%) of the patients. All of these complications were resolved at the 6-month follow-up visit. We noted no surgical complications such as ocular or soft tissue damage, infection, inflammation, or visual loss. Conclusions The SONOPET® ultrasonic bone curette can be used safely and effectively for DLW orbital decompression surgery. The main benefits were good visualization and handling of tissues and speed and ease of use of the equipment. This trial is registered with ClinicalTrials.gov identifier: NCT04025034.
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
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.
Collapse
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:
| |
Collapse
|
16
|
Orbital Expansion in Cranial Vault After Minimally Invasive Extradural Transorbital Decompression for Thyroid Orbitopathy. Ophthalmic Plast Reconstr Surg 2019; 35:17-21. [DOI: 10.1097/iop.0000000000001124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Islamaj E, Jordaan-Kuip CP, Vermeer KA, Lemij HG, de Waard PWT. Motility Changes and Diplopia After Baerveldt Glaucoma Drainage Device Implantation or After Trabeculectomy. Transl Vis Sci Technol 2018; 7:7. [PMID: 30221073 PMCID: PMC6136847 DOI: 10.1167/tvst.7.5.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022] Open
Abstract
Purpose The purpose of this study was to quantify any diplopia and motility changes after the implantation of a Baerveldt glaucoma implant (BGI) or after trabeculectomy (TE). Methods We analyzed 51 patients with a BGI and 52 patients with a TE from a prospective cohort study. To quantify any diplopia, we asked patients about the presence of diplopia at 1 year after surgery. To quantify any ocular motility changes, we measured ductions in eight gaze directions, the patients' ocular alignment and their fusion range before and 1 year after surgery. Results In the BGI group, 14 patients (28%) experienced diplopia compared with one patient (2%) in the TE group (P < 0.001). Duction changes were more commonly observed in the BGI group (35%) than in the TE group (19%). In the BGI group, ductions were mostly restricted in elevation (13%; P < 0.001), in abduction (13%), in elevation in 25° adduction (13%; P = 0.044), and in elevation in 25° abduction (25%; P < 0.001). In 32% of the patients, their near horizontal ocular alignment shifted, notably in exodirection (P = 0.04). The fusion range decreased significantly in the horizontal direction (−12.6° ± 10.3°, mean ± standard deviation; P = 0.01). Conclusions BGI surgery was significantly associated with postoperative diplopia and impaired eye motility (reduced ductions), mostly present in abduction, elevation, elevation in 25° adduction, and elevation in 25° abduction. Even without impaired ductions, diplopia could come about. Translational Relevance By studying diplopia across glaucoma patients prospectively with diplopia questionnaires and extensive orthoptic measurements, we gain better insight into its occurrence.
Collapse
Affiliation(s)
- Esma Islamaj
- Rotterdam Ophthalmic Institute, Rotterdam Eye Hospital, Schiedamse Vest 160d 3011BH Rotterdam, The Netherlands
| | - Caroline P Jordaan-Kuip
- Rotterdam Ophthalmic Institute, Rotterdam Eye Hospital, Schiedamse Vest 160d 3011BH Rotterdam, The Netherlands
| | - Koen A Vermeer
- Rotterdam Ophthalmic Institute, Rotterdam Eye Hospital, Schiedamse Vest 160d 3011BH Rotterdam, The Netherlands
| | - Hans G Lemij
- Rotterdam Eye Hospital, Glaucoma Department, Schiedamse Vest 180 3011BH Rotterdam, The Netherlands
| | - Peter W T de Waard
- Rotterdam Eye Hospital, Glaucoma Department, Schiedamse Vest 180 3011BH Rotterdam, The Netherlands
| |
Collapse
|
18
|
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.
Collapse
|
19
|
Hainăroșie R, Ioniță I, Pietroșanu C, Pițuru S, Hainăroșie M, Zainea V. Transnasal endoscopic orbital decompression. Rom J Ophthalmol 2018; 61:192-195. [PMID: 29450397 PMCID: PMC5710037 DOI: 10.22336/rjo.2017.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Transnasal endoscopic orbital decompression is a viable alternative for external orbital decompression. Today, it can be performed due to the great development of endoscopic technology and specific endoscopic surgical instruments. It requires strong anatomic knowledge and skilled hands. We present our experience with endoscopic orbital decompression focusing on the surgical technique used in our department. The surgical maneuvers must be firm and gentle protecting the local risk elements and respecting the orbital content.
Collapse
Affiliation(s)
- Răzvan Hainăroșie
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Prof. Dr. Dorin Hociotă" Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania
| | - Irina Ioniță
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Prof. Dr. Dorin Hociotă" Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania
| | - Cătălina Pietroșanu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Prof. Dr. Dorin Hociotă" Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania
| | - Silviu Pițuru
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Mura Hainăroșie
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Prof. Dr. Dorin Hociotă" Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania
| | - Viorel Zainea
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"Prof. Dr. Dorin Hociotă" Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania
| |
Collapse
|
20
|
Abstract
INTRODUCTION Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED. AIM We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery. RESULTS Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring. DISCUSSION Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.
Collapse
Affiliation(s)
- Shani Golan
- a Department of Ophthalmology , University of California Los Angeles , Los Angeles , California , USA
| | - Robert A Goldberg
- a Department of Ophthalmology , University of California Los Angeles , Los Angeles , California , USA
| |
Collapse
|
21
|
Abstract
INTRODUCTION New onset Diplopia following orbital decompression in thyroid eye disease patients is estimated to occur in up to 30% to 40% of decompression patients, mostly related to deep lateral and medial wall decompressions. METHODS A retrospective chart review of all minimally invasive (fat and minimal bone orbital decompression performed at the UCLA Stein Eye Institute between 2005 and 2015. Inclusion criteria were thyroid eye disease patients older than 18 years undergoing fat only orbital decompression with no previous muscle surgery. RESULTS The chart review revealed only 5 patients with new onset diplopia after this surgery. The cases are discussed and a possible mechanism for the diplopia is proposed. DISCUSSION Double vision following minimally invasive orbital decompression is rare and the mechanisms are poorly understood.
Collapse
|
22
|
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.
Collapse
|
23
|
Correction of Lower Eyelid Retraction Using Acellular Human Dermis During Orbital Decompression. Ophthalmic Plast Reconstr Surg 2017; 33:168-172. [DOI: 10.1097/iop.0000000000000683] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Woo YJ, Yoon JS. Changes in pupillary distance after fat versus bony orbital decompression in Graves’ orbitopathy. Can J Ophthalmol 2017; 52:186-191. [DOI: 10.1016/j.jcjo.2016.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 06/13/2016] [Accepted: 08/15/2016] [Indexed: 11/28/2022]
|
25
|
Schwaiger N, Richter DF. Commentary on: Expanding Role of Orbital Decompression in Aesthetic Surgery. Aesthet Surg J 2017; 37:396-397. [PMID: 28364539 DOI: 10.1093/asj/sjx032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nina Schwaiger
- From the Department for Plastic Surgery, Dreifaltigkeits-Hospital, Wesseling, Germany
| | - Dirk F. Richter
- From the Department for Plastic Surgery, Dreifaltigkeits-Hospital, Wesseling, Germany
| |
Collapse
|
26
|
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: 59] [Impact Index Per Article: 8.4] [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.
Collapse
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.
| |
Collapse
|
27
|
Ganguly A, Ramarao K, Mohapatra S, Rath S. Transconjunctival dacryocystorhinostomy: An aesthetic approach. Indian J Ophthalmol 2017; 64:893-897. [PMID: 28112129 PMCID: PMC5322703 DOI: 10.4103/0301-4738.198855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To report the anatomical and cosmetic outcome of transconjunctival dacryocystorhinostomy (TDCR) in an Asian Indian population. METHODS TDCR was initially performed in cadaver eyes followed by patients with primary acquired nasolacrimal duct obstruction (NLDO). This was a prospective noncomparative case series of all consecutive TDCRs performed between April 2013 and June 2015. Outcome measures were anatomical patency, epiphora, presence of diplopia, aesthetic outcome, and health status. RESULTS A total of 17 (18 eyes) patients with a mean age 43.9 ± 11.8 years (range, 32-75) were included in the study. Eight were males, and one patient underwent TDCR in both eyes. TDCR was successfully performed in 15/18 (82%) eyes under local anesthesia. Procedure converted to transcutaneous external DCR in two and dacryocystectomy in one patient each. Mean duration of surgery was 52.6 (range, 29-110) min. Anatomical patency and relief from epiphora was achieved in all (15/15) eyes after TDCR at a median follow-up of 15.5 months. At final follow-up, objective assessment of the cosmetic outcome graded the surgical scar at the lateral canthus as invisible in all except one and conjunctival fornix as visible only after eyelid eversion in all patients. Disturbance of the medial fat pad was not seen in any patient. A questionnaire-based health status evaluation showed marked improvement in anxiety/depression before and after TDCR with an overall well-being score of 88 on a scale of 0-100 (worst-best) after TDCR. CONCLUSIONS TDCR offers a promising aesthetic approach in patients with primary acquired NLDO and gives excellent functional and cosmetic outcome.
Collapse
Affiliation(s)
- Anasua Ganguly
- Department of Ophthalmic Plastic and Reconstructive Surgery, Orbit and Ocular Oncology, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Kesarpu Ramarao
- Department of Anatomy, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Samir Mohapatra
- Department of Ophthalmic Plastic and Reconstructive Surgery, Orbit and Ocular Oncology, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Suryasnata Rath
- Department of Ophthalmic Plastic and Reconstructive Surgery, Orbit and Ocular Oncology, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| |
Collapse
|
28
|
Jellema HM, Braaksma-Besselink Y, Limpens J, von Arx G, Wiersinga WM, Mourits MP. Proposal of success criteria for strabismus surgery in patients with Graves' orbitopathy based on a systematic literature review. Acta Ophthalmol 2015; 93:601-9. [PMID: 25876459 DOI: 10.1111/aos.12717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/18/2015] [Indexed: 11/29/2022]
Abstract
Proposal of success criteria for strabismus surgery for patients with Graves' orbitopathy (GO) based on a systematic review of the literature. We performed a systematic search of OVID MEDLINE, OVID Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and the publisher subset of PubMed, to identify studies reporting on success criteria of strabismus surgery in GO. In addition, we handsearched several orthoptic journals and proceedings of strabismological congresses. Of the 789 articles retrieved, 42 articles described success criteria for strabismus surgery in GO. Most studies defined success in terms of a subjective diplopia-free field in primary and down gaze. Almost half of the studies used a graded scale (excellent, good, acceptable and failure) to describe the outcome of surgery. Three of the eligible studies described a tool to quantify the field of single vision in detail. Quality of life was not reported as an outcome measure in any of the published studies. In conclusion, success criteria for strabismus surgery in patients with GO are poorly defined and no consensus is available. The lack of standardization hampers comparative studies and thus the search for the best surgical treatment for diplopia in patients with GO. Therefore, we propose strict success criteria including a tool for quantification of remaining diplopia plus a disease-specific quality of life questionnaire (the GO-QoL).
Collapse
Affiliation(s)
| | | | | | - Georg von Arx
- ADMEDICO Augenzentrum; Interdisziplinäres Zentrum für Endokrine Orbitopathie; Olten Switzerland
| | - Wilmar M. Wiersinga
- Department of Endocrinology and Metabolism; Academic Medical Center; Amsterdam The Netherlands
| | - Maarten P. Mourits
- Department of Ophthalmology; Academic Medical Center; Amsterdam The Netherlands
| |
Collapse
|
29
|
Kim SA, Jung SK, Paik JS, Yang SW. Effect of Orbital Decompression on Corneal Topography in Patients with Thyroid Ophthalmopathy. PLoS One 2015; 10:e0133612. [PMID: 26352432 PMCID: PMC4564163 DOI: 10.1371/journal.pone.0133612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 06/29/2015] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Su Ah Kim
- Department of Ophthalmology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su Kyung Jung
- Department of Ophthalmology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Sun Paik
- Department of Ophthalmology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suk-Woo Yang
- Department of Ophthalmology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- * E-mail:
| |
Collapse
|
30
|
Zhang-Nunes SX, Dang S, Garneau HC, Hwang C, Isaacs D, Chang SH, Goldberg R. Characterization and outcomes of repeat orbital decompression for thyroid-associated orbitopathy. Orbit 2015; 34:57-65. [PMID: 25244551 DOI: 10.3109/01676830.2014.949784] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Orbital decompression for thyroid-associated orbitopathy (TAO) is commonly performed for disfiguring proptosis, congestion, and optic neuropathy. Although one decompression typically achieves goals, a small percentage requires repeat decompression. We performed a 10-year retrospective chart review of all orbital decompressions for TAO at a single tertiary referral institution. Four-hundred and ninety-five orbits (330 patients) were decompressed for TAO, with 45 orbits (37 patients) requiring repeat decompression. We reviewed the repeat cases for indications, clinical activity scores, approach, walls decompressed, and outcomes. Nine percent of orbits required repeat decompression for proptosis (70%), optic neuropathy (25%) or congestion (45%). Sixty-four percent were for recurrence of disease, 36% were for suboptimal decompression. Three incisional approaches were used: lateral upper eyelid crease, inferior transconjunctival, and transcaruncular, with inferior transconjunctival being most common. Of the three walls removed, deep lateral, inferior, and medial, the deep lateral wall was most common (51%). A repeat lateral decompression was the most frequent pattern. Of 37 patients requiring repeat decompression, 40% had diplopia prior to repeat, and an additional 24% developed diplopia after the repeat. Whereas previous studies published by our group cited only 2.6% of deep lateral wall orbital decompressions leading to new-onset primary gaze diplopia, repeat orbital decompressions have a much higher rate of post-operative diplopia. The new onset primary gaze diplopia after repeat decompression group had a higher average preoperative CAS (3.3 vs. 2.4, p < 0.01), higher mean blood loss (56 vs. 19 mL, p = 0.04), more frequent medial wall decompressions (47% vs. 29%, p = 0.33), and greater proptosis reduction (2.4 vs. 1.7 mm, p = 0.24).
Collapse
Affiliation(s)
- Sandy X Zhang-Nunes
- USC Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California , USA
| | | | | | | | | | | | | |
Collapse
|
31
|
|
32
|
Ponto KA, Zwiener I, Al-Nawas B, Kahaly GJ, Otto AF, Karbach J, Pfeiffer N, Pitz S. Piezosurgery for orbital decompression surgery in thyroid associated orbitopathy. J Craniomaxillofac Surg 2014; 42:1813-20. [PMID: 25059686 DOI: 10.1016/j.jcms.2014.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022] Open
Abstract
The purpose of this study was to assess a piezosurgical device as a novel tool for bony orbital decompression surgery. At a multidisciplinary orbital center, 62 surgeries were performed in 40 patients with thyroid associated orbitopathy (TAO). Within this retrospective case-series, we analyzed the medical records of these consecutive unselected patients. The reduction of proptosis was the main outcome measure. Indications for a two (n = 27, 44%) or three wall (35, 56%) decompression surgery were proptosis (n = 50 orbits, 81%) and optic neuropathy (n = 12, 19%). Piezosurgery enabled precise bone cuts without intraoperative complications. Proptosis decreased from 23.6 ± 2.8 mm (SD) by 3 mm (95% CI: -3.6 to -2.5 mm) after surgery and stayed stable at 3 months (-3 mm, 95% CI: -3.61 to -2.5 mm, p < 0.001, respectively). The effect was higher in those with preoperatively higher values (>24 mm versus ≤ 24 mm: -3.4 mm versus -2.81 mm before discharge from hospital and -4.1 mm versus -2.1 mm at 3 months: p < 0.001, respectively). After a mean long-term follow-up period of 14.6 ± 10.4 months proptosis decreased by further -0.7 ± 2.0 mm (p < 0.001). Signs of optic nerve compression improved after surgery. Infraorbital hypesthesia was present in 11 of 21 (52%) orbits 3 months after surgery. The piezosurgical device is a useful tool for orbital decompression surgery in TAO. By cutting bone selectively, it is precise and reduces the invasiveness of surgery. Nevertheless, no improvement in outcome or reduction in morbidity over conventional techniques has been shown so far.
Collapse
Affiliation(s)
- Katharina A Ponto
- Dept. of Ophthalmology (Head: Prof. Dr. N. Pfeiffer), University Medical Center Mainz, Germany; Center of Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.
| | - Isabella Zwiener
- Dept. of Biostatistics, University Medical Center Mainz, Germany; Center of Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
| | - Bilal Al-Nawas
- Dept. of Maxillofacial Surgery, University Medical Center Mainz, Germany
| | | | - Anna F Otto
- Dept. of Ophthalmology (Head: Prof. Dr. N. Pfeiffer), University Medical Center Mainz, Germany
| | - Julia Karbach
- Dept. of Maxillofacial Surgery, University Medical Center Mainz, Germany
| | - Norbert Pfeiffer
- Dept. of Ophthalmology (Head: Prof. Dr. N. Pfeiffer), University Medical Center Mainz, Germany
| | - Susanne Pitz
- Dept. of Ophthalmology (Head: Prof. Dr. N. Pfeiffer), University Medical Center Mainz, Germany
| |
Collapse
|
33
|
Iatrogenic diplopia [corrected]. Int Ophthalmol 2014; 34:1007-24. [PMID: 24604420 DOI: 10.1007/s10792-014-9927-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/26/2014] [Indexed: 10/25/2022]
Abstract
Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.
Collapse
|
34
|
Effect of Orbital Decompression on Diplopia in Thyroid-Related Orbitopathy. Ophthalmic Plast Reconstr Surg 2014; 30:137-40. [DOI: 10.1097/iop.0000000000000029] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Schiffman JS, Sales-Sanz M, Rebolleda G, Pass AF, Cruz RA, Tang RA. Thyroid orbitopathy. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.13.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
36
|
Abstract
Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.
Collapse
Affiliation(s)
- Kimberly D Tran
- UCSD Shiley Eye Center, Division of Oculofacial Plastic and Reconstructive Surgery , La Jolla, California , USA
| | | | | | | | | |
Collapse
|
37
|
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.
Collapse
Affiliation(s)
- Roberto Rocchi
- Unit of Endocrinology, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Cosmetic orbital inferomedial decompression: quantifying the risk of diplopia associated with extraocular muscle dimensions. Ophthalmic Plast Reconstr Surg 2012; 28:204-7. [PMID: 22581084 DOI: 10.1097/iop.0b013e31824dd8a0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To quantify the risk of new diplopia in inferomedial orbital decompression performed for cosmetic reasons. METHODS Retrospective analysis of 114 patients with Graves orbitopathy who underwent an inferomedial orbital decompression. No patient had diplopia in any of the gaze positions or optic neuropathy. A single coronal slice 9 mm posterior to the lateral orbital rim was employed to quantify the muscular index of the extraocular recti and of the superior complex. A control group of 56 patients imaged for other reasons were also measured. After surgery the oculomotor status of all patients who complained of diplopia and of 51 patients free of diplopia was measured with the prism and cover test in the primary and secondary gaze positions. RESULTS The rate of new-onset diplopia was 14.0% (16 patients). Eye deviations were confirmed in 14 patients. Of these, 10 had significant strabismus that warranted surgical or prism treatment. Most patients had esotropia associated with small vertical deviations. The size of the medial and inferior recti was significantly associated with the development of diplopia. The estimated odds for the appearance of diplopia in patients with muscle enlargement was 12.76 (medial rectus) and 5.21 (inferior rectus). Small-angle deviations were also detected in 27.4% of patients who did not experience diplopia. CONCLUSIONS Medial and inferior recti enlargement is a strong predictor of new-onset diplopia. A large number of patients who do not report diplopia also present with small-angle deviations.
Collapse
|
39
|
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.
Collapse
Affiliation(s)
- Robert H Hill
- Department of Ophthalmology, SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY 13210, USA.
| | | | | |
Collapse
|
40
|
The effect of orbital decompression surgery on refraction and intraocular pressure in patients with thyroid orbitopathy. Eye (Lond) 2012; 26:535-43. [PMID: 22261739 DOI: 10.1038/eye.2011.362] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To investigate the effect of orbital decompression surgery in thyroid orbitopathy (TO) on both refractive status and intraocular pressure (IOP). PATIENTS AND METHODS A prospective, multicentre, consecutive audit of patients undergoing thyroid decompression surgery. Indications for surgery included cosmetically unacceptable proptosis or corneal exposure. Exclusion criteria included the following: previous orbital surgery, glaucoma, corneal disease, steroid use in the preceding 12 months, or an acute optic neuropathy. Automated refraction, keratometry, pachymetry, Hertel exophthalmometry, and IOP were recorded at 1 month pre- and 3 months postoperatively. IOP using the Tono-Pen (mean of three readings) was measured in the primary, upgaze, and downgaze positions. RESULTS Data were collected from 52 orbits of 33 patients (East Grinstead, New York, and Adelaide). There was no significant difference between pre- and postoperative data for sphere, cylinder, or central corneal thickness (CCT). The mean spherical equivalent was -0.43 ± 1.49 D pre-operatively and -0.28 ± 1.52 D postoperatively. The steepest meridian of corneal curvature was 93.1 degrees pre- and 94.2 degrees postoperatively, with no significant difference. Mean IOP significantly decreased when measuring by Goldmann applanation tonometry (GAT) (2.28 mm Hg, (*) P=0.001) and Tono-Pen (3.06 mm Hg, (*) P=<0.0001). IOP measured in upgaze was significantly greater than that in the primary position. Regression analysis between change in IOP and either Hertel exophthalmometry or the number of orbital walls decompressed was non-significant ((*)Student's t-test). CONCLUSION Patients with TO undergoing orbital decompression had, on average, with-the-rule astigmatism not affected by orbital decompression surgery. IOP was significantly reduced by decompression surgery although no relationship between IOP and the degree of decompression was observed.
Collapse
|
41
|
Orbital volume and eye position changes after balanced orbital decompression. Ophthalmic Plast Reconstr Surg 2011; 27:158-63. [PMID: 20940662 DOI: 10.1097/iop.0b013e3181ef72b3] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the changes in eye position and orbital content expansion following medial and lateral orbital wall decompression for thyroid-associated orbitopathy. METHODS The authors used a computer software program (syngo InSpace4D, syngo 3D, syngo fusion, and syngo Volume Evaluation; Siemens AG, Forchheim, Germany) to measure the orbital expansion gained by medial and lateral orbital wall decompression and the change in eye position between the digitized preoperative and postoperative orbital CT scans. RESULTS Twenty patients (16 women and 4 men) with a mean age of 45 years (range, 18-64 years) were enrolled in this study. Of the 20 patients who underwent balanced decompression for thyroid-associated orbitopathy, 18 patients had bilateral medial and lateral orbital wall decompression, and 2 patients had unilateral medial and lateral decompression. The average orbital volume expansion was 3.21 mL (13.51%) of the preoperative orbital volume (2.1 mL [8.98%] gained by medial wall decompression and 1.03 mL [4.53%] by lateral wall decompression). Postoperatively, proptosis decreased by 2.53 mm on average (p < 0.0001). The eyes became closer to each other postoperatively in the horizontal plane by 2.6 mm on average (p < 0.0001). No change in the vertical eye position was detected postoperatively. CONCLUSIONS A significant nasal shift in the eye position was noticed following balanced orbital decompression. Computerized assessment of preoperative and postoperative digitized orbital CT scans helps evaluate the orbital changes in response to different orbital decompression techniques and improve the surgical outcomes in thyroid-associated orbitopathy.
Collapse
|
42
|
Kaminsky J, Ridder GJ, Eckstein A, Metzger M, Beisse F. [Surgical therapy in Graves' orbitopathy]. Ophthalmologe 2011; 108:432-9. [PMID: 21538089 DOI: 10.1007/s00347-010-2188-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Surgical therapy of Graves' orbitopathy comprises orbital decompression as well as strabismus and lid surgery. The former is primarily carried out during active disease, the latter during inactive disease. Orbital decompression abates increased intraorbital pressure and is thus applicable against dysthyroid optic neuropathy and also reduces exophthalmos. The choice of a specific procedure depends mainly on the experience of the respective center. In this article, the pterional transcranial, transnasal transethmoidal, transconjunctival and swinging eyelid approaches are presented. Eye muscle recession relieves the abnormal tension of fibrotic muscles and thus corrects diplopia. Compared to normal strabismus surgery, the dose-response relationship is increased. Lid lengthening surgery is applied to counter upper or lower lid retraction. If several of these operations are necessary the order is chosen in such a way that downstream procedures cannot change specific results of upstream operations.
Collapse
Affiliation(s)
- J Kaminsky
- Neurochirurgie, Sankt-Gertrauden-Krankenhaus, Berlin, Deutschland
| | | | | | | | | |
Collapse
|
43
|
Kent JS, Allen LH, Rotenberg BW. Image-guided transnasal endoscopic techniques in the management of orbital disease. Orbit 2010; 29:328-333. [PMID: 20807018 DOI: 10.3109/01676830.2010.501948] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
PURPOSE To assess the utility of image-guided transnasal endoscopic surgery for a variety of orbital diseases requiring decompression of at least one orbital wall. METHOD A descriptive case series of consecutive orbital procedures requiring decompression of at least one wall. All procedures were performed using a transnasal endoscopic approach and an intraoperative image-guided LandmarX system for anatomical guidance. RESULTS A 3-year review yielded 17 cases, including 6 cases with compressive mucoceles, 4 neoplasms, 4 patients with proptosis secondary to Graves' Ophthalmopathy, 1 case of an intraorbital abscess, 1 fungal mycetoma, and 1 hemangioma. These cases all had improved postoperative clinical status without any serious complications. The LandmarX system was a valuable intraoperative tool in all 17 cases. CONCLUSIONS The endoscopic transnasal approach to orbital decompression surgery allows for good visualization and is minimally invasive. Using this approach in conjunction with the LandmarX image-guided system allows for improved anatomical localization and provided good results in all cases.
Collapse
Affiliation(s)
- Jerrod S Kent
- Department of Ophthalmology, Ivey Eye Institute, University of Western Ontario, London, Ontario, Canada
| | | | | |
Collapse
|
44
|
Abstract
A 68-year-old man with Graves orbitopathy underwent a bilateral swinging eyelid orbital decompression for disfiguring proptosis. A penetrating keratoplasty for keratoconus of the left eye had been performed 13 years earlier. Prior to orbital decompression, biomicroscopy of the left eye showed a partially decompensated sutureless corneal graft with good wound apposition. The corneal stroma appeared edematous, and some epithelial bullae were seen. During orbital wall removal, the corneal wound dehisced for 270 degrees. Swinging eyelid orbital decompression is the technique of choice in the Netherlands for proptosis reduction in Graves orbitopathy. However, spatula pressure on the eye during surgery may cause rupture of the graft-host interface in eyes with previous corneal surgery such as penetrating keratoplasty.
Collapse
|
45
|
Liu GT, Volpe NJ, Galetta SL. Orbital disease in neuro-ophthalmology. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00018-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
46
|
Dickinson J, Perros P. Thyroid-associated orbitopathy: who and how to treat. Endocrinol Metab Clin North Am 2009; 38:373-88, ix. [PMID: 19328417 DOI: 10.1016/j.ecl.2009.01.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Thyroid-associated orbitopathy is the most frequent and troublesome nonthyroidal complication of Graves' disease. It is mandatory to determine whether sight-threatening orbitopathy is present, as this requires prompt and aggressive treatment. Therapies for non-sight-threatening disease range from supportive measures only to medical therapies for active eye disease and surgical rehabilitation for burnt-out disease. Intravenous steroids and orbital radiotherapy are the mainstays of medical therapy. Rehabilitative surgery is frequently a staged process that may involve sequentially: orbital decompression, strabismus surgery, and eyelid procedures. Smoking cessation is recommended at all disease stages. Treatment within a multidisciplinary team consisting of both endocrinologists and ophthalmologists may lead to optimal patient outcomes.
Collapse
Affiliation(s)
- Jane Dickinson
- Department of Ophthalmology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK.
| | | |
Collapse
|
47
|
Chu EA, Miller NR, Lane AP. Selective endoscopic decompression of the orbital apex for dysthyroid optic neuropathy. Laryngoscope 2009; 119:1236-40. [DOI: 10.1002/lary.20240] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
48
|
Barkhuysen R, Nielsen CC, Klevering BJ, Van Damme PA. The transconjunctival approach with lateral canthal extension for three-wall orbital decompression in thyroid orbitopathy. J Craniomaxillofac Surg 2009; 37:127-31. [DOI: 10.1016/j.jcms.2008.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 10/13/2008] [Indexed: 11/30/2022] Open
|
49
|
Abstract
Diplopia following orbital decompression is a common complication in Graves' ophthalmopathy. Strabismus surgery is often required to treat the persistent diplopia. The author presents a successful treatment with botulinum toxin A injection in a case of diplopia following orbital decompression. Treatment with botulinum toxin A in the management of new-onset diplopia following orbital decompression has been suggested in a case that is not amenable to prism treatment and may eliminate strabismus surgery in some cases.
Collapse
Affiliation(s)
- Sorot Wutthiphan
- Department of Ophthalmology, Priest Hospital, Bangkok, Thailand.
| |
Collapse
|
50
|
Limawararut V, Valenzuela AA, Sullivan TJ, McNab AA, Malhotra R, Davis G, Jones N, Selva D. Cerebrospinal Fluid Leaks in Orbital and Lacrimal Surgery. Surv Ophthalmol 2008; 53:274-84. [DOI: 10.1016/j.survophthal.2008.02.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|