Decompression surgery for thyroid-associated orbitopathy--a ten year experience

Surgery around the Orbit: How to Select an Approach

Orbital region pathologies may be safely and effectively treated through a various number of approaches. As the concept of "outcome" and minimally invasive surgery keeps gaining popularity in neurosurgery, these approaches-each with specific indications and limitations-together provide the best surgical options.

Disease-Specific Assessment of Quality of Life after Decompression Surgery for Graves' Ophthalmopathy

Purpose

Graves' ophthalmopathy (GO) is an organ-specific autoimmune disease. Hydrophily of accumulated acidic mucopolysaccharides into bulbar adipose tissue leads to swelling of the eye muscles. Orbital surgical decompression is performed in severe cases of compressive optic neuropathy and severe corneal exposure or failure of steroid therapy. The study was designed to evaluate decompression surgery with respect to the clinical benefit and the patient's satisfaction by means of a disease-specific questionnaire.

METHODS

The 90-item study questionnaire was distributed to 105 patients with GO who underwent orbital decompression surgery at the authors' institution.

Results

A total of 88% of patients stated that decompression had helped them, 80% of the interviewees would undergo decompression again, 78% were content with their eye symptoms, and 71% were satisfied with the cosmetic result of decompression. Furthermore, analysis showed a clinically relevant increase in quality of life after surgery. The correlation between the clinical endpoint proptosis at last examination and the quality of life score proved to be significant (p=0.05).

CONCLUSIONS

The large majority of interviewees were satisfied with the result of the orbital decompression. These results confirmed that disfiguring proptosis is an important indication for decompression surgery.

Neuroimaging of Graves' orbitopathy

Neuroimaging of Graves' orbitopathy (GO) plays an important role in the differential diagnosis and interdisciplinary management of patients with GO. Orbital imaging is required in unclear or asymmetric proptosis, in suspected optic neuropathy and prior to decompression surgery. Especially computed tomography and magnetic resonance (MR) imaging show the actual objective morphological findings, quantitative MR imaging giving additional information concerning the acuteness or chronicity of the disease. Major morphological diagnostic criteria include a spindle like spreading of the rectus muscles without involvement of the tendon, a compression of the optic nerve in the orbital apex (crowded orbital apex syndrome) and the absence of any space occupying intraorbital process. A longer lasting course of the disease may lead to a corresponding impression of the lamina papyracae, the normally parallel configured medial wall of the orbit, similar to a spontaneous decompression.

Is there a relationship between the degree of preoperative motility impairment or the muscle thickness and the outcome of strabismus surgery in patients with graves' orbitopathy after decompression surgery?

There is considerable controversy regarding the performance of strabismus surgery in patients with Graves' orbitopathy (GO). The spectrum of recommendations extends from variable dose-effect correlations for these procedures (Esser, 1994; Mourits et al., 1990; Nguyen et al., 2002) to individualized approaches such as passive intraoperative motility testing and postoperative adjustment of sutures (Lueder et al., 1992; Nguyen et al., 2002), and to local anesthesia for intraoperative assessment of active motility (Kalpadakis et al., 2004). Furthermore, prior decompression surgery is known to contribute to an unpredictable outcome (Eckstein and Esser, 2003; Esser, 1994). We retrospectively analyzed the charts of 34 patients undergoing strabismus surgery for this condition, with the aim to evaluate whether muscle size or preoperative muscle impairment are related to the outcome of surgery.

Orbital pathology

This overview of orbital pathology deals with different kinds of tumors, inflammatory, vascular, and traumatic diseases, which may involve the orbit. Depending on the respective orbital compartment of the globe, the intrakonal, extrakonal and optic nerve the most important and most frequent lesions are presented with their specific clinical symptoms. Their specific presentation on CT- and MR-imaging is discussed in detail, including the most important differential diagnosis.