Balanced orbital decompression for Graves' ophthalmopathy

The effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid ophthalmopathy

PURPOSE

To evaluate the effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy.

METHODS

This retrospective study enrolled 55 eyes of 33 patients treated in our hospital for restrictive strabismus caused by thyroid-associated ophthalmopathy. We performed muscle recession for the obviously restricted extraocular muscles, with 6 weeks of follow-up. Surgical outcomes were compared between the orbital decompression group (DG, n=15) and non-orbital decompression group (NDG, n=18).

RESULTS

A total of 33 patients with Graves' ophthalmopathy who underwent rectus muscle recession surgery were included. Of these, 15 patients had undergone orbital decompression prior to strabismus surgery, and 18 had not. The two groups did not differ in terms of the preoperative horizontal or vertical ocular deviation, degree of restriction of eye movement, degree of diplopia, or mean number of muscles that underwent surgery (P>0.05). There was no significant difference in the preoperative horizontal or vertical ocular deviation, level of eye movement restriction, degree of diplopia and the success rate of the surgery (P>0.05).

CONCLUSION

Rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy during the quiescent period could improve the ocular deviation and diplopia, and orbital decompression performed before strabismus surgery had no significant effect on surgical technique or outcomes of rectus muscle recession surgery.

Bony Orbital Surgery for Graves' Ophthalmopathy

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.

Therapeutic difference between orbital decompression and glucocorticoids administration as the first-line treatment for dysthyroid optic neuropathy: a systematic review

To assess all available data to compare the efficacy of glucocorticoids treatment and orbital decompression for dysthyroid optic neuropathy (DON). PubMed, EMBASE, the Cochrane Library databases as well as other sources were searched by two independent reviewers followed by extensive hand-searching for the identification of relevant studies. The primary outcomes were the improvement in visual acuity and responder rate. Secondary outcomes were the proptosis reduction, change in diplopia, and clinical activity score (CAS). One randomized controlled trial, three retrospective case series and one prospective case series met the inclusion criteria. They were divided into intravenous high-dose glucocorticoids (ivGC) group and orbital decompression (OD) group. Both groups demonstrated improvement in visual acuity. In addition, the proportion of patients with improved vision in OD group was higher than that in ivGC group (P<0.001). Post-treatment proptosis reduction was also reported in both groups. Overall, weighted mean in proptosis reduction estimated at 1.64 and 5.45 mm in patients treated with ivGC and OD respectively. This study also presented results regarding pre-existing and new-onset diplopia. Apart from diplopia, a wide variety of minor and major complications were noted in 5 included studies. The most common complication in ivGC group and OD group was Cushing's syndrome and epistaxis respectively. The present systematic review shows that both glucocorticoids treatment and OD are effective in treating DON and OD may work better in improving visual acuity and reducing proptosis. However, high-quality, large-sample, controlled studies need to be performed in the future.

Changes in Field of Binocular Single Vision and Ocular Deviation Angle After Balanced Orbital Decompression in Thyroid Eye Disease

PURPOSE

To evaluate influential factors for changes in the binocular single vision (BSV) and ocular deviation angle in the medial direction after bilateral balanced orbital decompression in thyroid eye disease.

METHODS

This retrospective study included 41 patients. The areas of BSV and the angles of medial ocular deviation on the Hess chart were measured. The percentages of pre- and postoperative areas against the normal area (%BSV) and the change in BSV after surgery were calculated. Postoperative change in the angle was calculated by subtraction of the preoperative angle from the postoperative one. Influential factors for the change in BSV and that in the medial deviation angle were evaluated via multivariate linear regression analysis.

RESULTS

The maximum cross-sectional area of the medial rectus muscle, preoperative %BSV, and preoperative medial ocular deviation angle were significant factors of change in BSV (adjusted r2 = 0.449, p < 0.001), although age, history of anti-inflammatory treatment, volume of removed orbital fat, findings on CT images, maximum cross-sectional areas of the other rectus muscles, and presence or absence of a periosteal flap did not affect change in BSV (p > 0.050). On the contrary, all variables did not influence postoperative changes in the medial ocular deviation angle (p > 0.050).

CONCLUSIONS

In balanced orbital decompression, the maximum cross-sectional area of medial rectus muscle, preoperative field of BSV, and medial ocular deviation were significant influential factors for postoperative changes in field of BSV.

Orbital Bone Decompression for Non-Thyroid Eye Disease Proptosis

PURPOSE

To report a multicenter large case series of orbital decompression for non-thyroid eye disease proptosis.

METHODS

Retrospective chart review of cases of orbital decompression performed by 9 experienced orbital surgeons from different countries from 2014 to 2017 for non-thyroid eye disease proptosis. Patients were divided into 3 groups: 1) negative vector (high axial length or shallow orbit), 2) inflammatory, and 3) tumor. Types of orbital decompression and Hertel exophthalmometry (preoperative and minimum 6 months postoperative) were recorded. Charts were also assessed for serious complications. The amount of exophthalmometry improvement was recorded according to the above groups.

RESULTS

The analysis included 41 orbits of 29 patients (14 women and 15 men) with a mean age of 38.9 years (ranging from 9 to 74; standard deviation (SD) 15.66). There were 17 orbits of 11 patients in the negative vector group, 16 orbits of 10 patients in the inflammatory group, and 8 orbits of 8 patients in the tumor group. The mean reduction of proptosis was 2.95 mm in the negative vector group, 2.54 mm in the inflammatory group, and 5.75 mm in the tumor group. There were no serious complications.

CONCLUSIONS

Orbital decompression was safe and effective in reducing proptosis for non-thyroid eye disease indications in this series. The amount of exophthalmometry improvement was less in the inflammatory orbitopathy group compared with other proptosis etiology groups.Orbital decompression may have a role in improving proptosis in non-thyroid eye disease entities.

Deep lateral orbital decompression for Graves orbitopathy: a systematic review

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results

AIM

To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves' ophthalmopathy (GO).

METHODS

Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, medial-lateral (balanced), medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy (DON) were compared between different surgical techniques.

RESULTS

The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values (P<0.005). Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups (P=0.181).

CONCLUSION

The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

Endoscopic and external approaches for orbital decompression: an analysis of trends from a U.S. perspective

BACKGROUND

Although the endoscopic approach has been increasingly utilized for a variety of sinonasal and skull base pathologies, there has been little inquiry into its adoption in the surgical management of orbital disease. Our objective was to evaluate nationwide temporal and geographic trends in approaches for orbital decompression.

METHODS

Data available from the Centers for Medicare and Medicaid Services (CMS) were evaluated, focusing on the use of open and endoscopic approaches for orbital decompression (CPT codes 67414, 67445, 31292, and 31293) among Medicare beneficiaries over a 10-year period. Regional data were also analyzed.

RESULTS

There were 8047 orbital decompressions billed to Medicare from 2007 to 2016. The number of external and endoscopic approaches increased by 73.0% and 29.2%, respectively, while the number of Medicare beneficiaries increased by 29.1%. Endoscopic decompression represented 23.5% of Medicare-billed orbital decompressions in 2016 (221 of 939), down from 29.2% in 2007 (171 of 586). The South had the greatest proportion of decompressions utilizing an endoscopic approach (30.2%).

CONCLUSION

There has not been a clear movement toward the endoscopic approach for orbital decompression, with modest growth when compared with external approaches. Potential explanations include the specialty-exclusive nature of approaches, as well as a lack of consensus; the latter idea is further reinforced by geographic variation. High-quality prospective trials may clarify the role of endoscopic approaches in these patients.

Cutting-edge endonasal surgical approaches to thyroid ophthalmopathy

Objective

Thyroid orbitopathy is a poorly understood extrathyroidal manifestation of Graves' disease that can cause disfiguring proptosis and vision loss. Orbital decompression surgery for Graves' orbitopathy (GO) can address both cosmetic and visual sequelae of this autoimmune condition. Endonasal endoscopic orbital decompression provides unmatched visualization and access to inferomedial orbital wall and orbital apex. This review examines the state of the art approaches employed in endonasal endoscopic orbital decompression for GO.

Methods

Review of literature evaluating novel surgical maneuvers for GO.

Results

Studies examining the efficacy of endonasal endoscopic orbital decompression are heterogenous and retrospective in design; however, they reveal this approach to be a safe and effective technique in the management of GO.

Conclusion

Subtle variations in endoscopic techniques significantly affect postsurgical outcomes and can be tailored to the specific clinical indication in GO making endonasal endoscopic decompression the most versatile approach available.

Level of Evidence

NA.

[Orbital decompression : Indications, technique, results]

Orbital decompression is an effective surgical procedure to reduce intraorbital pressure. Causes may diseases leading to rapid pressure increases, e. g., bleedings, and those causing slower, progressive pressure increases, e. g., tumors or Graves' orbitopathy. During fat tissue decompression, peri- and retrobulbar adipose tissue is removed; in bony decompression, one or more bony orbital walls are removed (one-, two-, or three-wall decompression). In many cases the procedures are combined. Recent developments are the transconjunctival approaches for removing parts of bony orbital walls. Complications include double vision, which occurs in up to 30% of cases depending on the approach, hemorrhage, infections, development of chronic sinusitis, and iatrogenic skull base lesions with consecutive meningitis. In the hands of an experienced rhino- and head and neck surgeon, the intervention has low complication rates.

A Retrospective Review of Orbital Decompression for Thyroid Orbitopathy with Endoscopic Preservation of the Inferomedial Orbital Bone Strut

PURPOSE

To determine incidence of new-onset diplopia, resolution of preexisting diplopia, and impact on proptosis resulting from endoscopic orbital decompression with and without preservation of the inferomedial orbital strut for thyroid orbitopathy.

METHODS

Retrospective review of all patients undergoing endoscopic 2- or 3-wall decompression with or without preservation of the strut for thyroid orbitopathy from January 2012 to June 2015.

RESULTS

Twenty-six patients (45 orbits) were included and divided into 4 primary categories: 2-wall decompression with strut preservation (4 orbits, 8%), 2-wall decompression with strut removal (7 orbits, 16%), 3-wall decompression with strut preservation (27 orbits, 60%), and 3-wall decompression with strut removal (7 orbits, 16%). The incidence of new-onset diplopia was 20% (2/10 patients without preoperative diplopia) overall and 16% in the strut preservation group (1/6 patients without preoperative diplopia). Resolution of diplopia occurred in 4 of 16 patients (25%) with preoperative diplopia, and all 4 had been treated with a 3-wall decompression with strut preservation. Resolution of diplopia in the group treated with strut preservation was 36% (4/11 patients with preoperative diplopia), and 0% of the 5 diplopic patients treated without strut preservation. Reduction in proptosis was statistically greater in those treated with strut removal (p = 0.003).

CONCLUSIONS

This study demonstrates that endoscopic orbital decompression with preservation of the inferomedial bone strut results in a comparable to lower rate of new-onset diplopia compared with other reported techniques. When combined with 3-wall balanced decompression, this technique demonstrates a high rate of resolution of preexisting diplopia.

Image-Guided Endoscopic Orbital Decompression for Graves' Orbitopathy

Objectives: We studied the efficacy and safety of image-guided balanced orbital decompression for Graves' orbitopathy.

Methods: The data of 24 patients (45 orbits) were reviewed for demographics, ophthalmologic outcomes, and complications in regard to image-guided (18 orbits) versus non-image-guided surgery (27 orbits).

Results: Overall, all patients had a reduction in proptosis (mean reduction, 6.2 mm in proptosis) as measured by Hertel exophthalmometry. There was improvement in the visual acuity of all 12 orbits with preoperative acuity of 20/40 or worse and either complete resolution (38%) or improvement (62%) in the 16 orbits with optic neuropathy. These measures reached statistical significance. Despite subjective improvement in surgeon confidence, the use of image guidance did not result in a statistically significant difference in postoperative ophthalmologic outcomes. Medical and sinonasal complications were experienced by 11.1% and 18.5% of patients who underwent image-guided and non-image-guided orbital decompression, respectively.

Conclusions: Image guidance may be a useful adjunct to balanced orbital decompression for Graves' orbitopathy, but it was not associated with a statistically significant improvement in outcomes in this study.

The effect of orbital decompression surgery on interpupillary distance and angle kappa in patients with thyroid-associated orbitopathy

PURPOSE

The purpose was to investigate the effects of orbital decompression surgery on postoperative changes in interpupillary distance (IPD) and angle kappa in patients with thyroid-associated orbitopathy (TAO).

METHODS

In patients with TAO who underwent orbital decompression surgery between January 1, 2014 and February 21, 2016, we measured exopthalmometry, IPD, inner intercanthal distance (IICD) and outer intercanthal distance (OICD) using a computer software program and angle kappa with an ORB scan II. We then analyzed preoperative and 3-month postoperative exophthalmometry, IPD, IICD, OICD and angle kappa to evaluate changes in eye position or rotation of the eyeball following orbital decompression surgery.

RESULTS

Fifty-four patients (35 women and 19 men) with a mean age of 34.59 (range, 16-64 years) were enrolled in this study. After decompression surgery, the IPD was significantly decreased by 1.76 mm (preoperative, 63.14 ± 3.93 mm; postoperative, 61.38 ± 3.84 mm; P < 0.001), but angle kappa, IICD, and OICD did not vary significantly (P = 0.814, P = 0.635 and P = 0.092, respectively).

CONCLUSIONS

A significant decrease in IPD was noted after orbital decompression in patients with TAO. However, there was no significant change in angle kappa. Therefore, the mechanism of change in the IPD is not an inward rotation of the eyeball, but rather an actual dorsal shift causing a wedging of the eye position itself within the orbit.

Minimally invasive surgery for thyroid eye disease

Thyroid eye disease (TED) can affect the eye in myriad ways: proptosis, strabismus, eyelid retraction, optic neuropathy, soft tissue changes around the eye and an unstable ocular surface. TED consists of two phases: active, and inactive. The active phase of TED is limited to a period of 12–18 months and is mainly managed medically with immunosuppression. The residual structural changes due to the resultant fibrosis are usually addressed with surgery, the mainstay of which is orbital decompression. These surgeries are performed during the inactive phase. The surgical rehabilitation of TED has evolved over the years: not only the surgical techniques, but also the concepts, and the surgical tools available. The indications for decompression surgery have also expanded in the recent past. This article discusses the technological and conceptual advances of minimally invasive surgery for TED that decrease complications and speed up recovery. Current surgical techniques offer predictable, consistent results with better esthetics.

Combined Endoscopic Medial and External Lateral Orbital Decompression for Progressive Thyroid Eye Disease

OBJECTIVE: To compare the efficacy of endoscopic medial and lateral orbital wall surgery to 3-wall decompression in patients with thyroid eye disease.

STUDY DESIGN AND SETTING: A retrospective study of patients with thyroid eye disease with severe proptosis, exposure keratitis, or compressive optic neuropathy was conducted.

RESULTS: Mean reduction in proptosis was 4.37 mm in the 2-wall approach and 4.59 mm in the 3-wall group. Seventy-five percent of patients in the 2-wall group demonstrated improved visual acuity; 50% improved after 3-wall decompression. Vertical palpebral fissure height decreased by an average of 2.50 mm in the 2-wall group and by 2.03 mm in the 3-wall group. New onset diplopia was 11.8% and 12.5%, respectively.

CONCLUSIONS: Improvement in the degree of proptosis, visual acuity, and palpebral fissure height was seen in the majority of our patients and compared favorably to our results with 3-wall orbital decompression.

EBM rating: C-4

Orbital Decompression in the Endoscopic Age

Objective

Postoperative diplopia occurs in up to 45% of patients following orbital decompression for exophthalmos associated with Graves’ orbitopathy. We sought to describe outcomes of our balanced orbital decompression strategy that includes the preservation of a modified inferomedial orbital strut (mIOS).

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects and Methods

A total of 115 consecutive orbital decompressions were performed on 73 patients (42 bilateral) with Graves’ orbitopathy. All patients underwent (1) a balanced decompression technique incorporating an endoscopic medial and external lateral decompression and (2) a mIOS technique with preservation of the anterior half of the inferomedial orbital strut. A periorbital periosteal (orbital) sling was utilized in patients (n = 54) without threatened vision loss, proptosis >28 mm, or periorbital disruption to prevent prolapse of the medial rectus muscle.

Results

Utilization of the mIOS technique with or without a sling did not adversely affect the reduction in proptosis (5.1 mm with sling vs 5.0 mm without sling; P = .85).The incidence of new-onset postoperative diplopia was 17% (n = 6). The sling was not associated with postoperative diplopia (odds ratio = 0.54, 95% confidence interval: 0.08-3.40, P = .51), while it was associated with resolution of preexisting diplopia (odds ratio = 6.67, 95% confidence interval: 1.06-42.06, P = .04). No intraoperative complications occurred, and no patients suffered a decrement in visual acuity.

Conclusion

Balanced orbital decompression utilizing a mIOS in patients with Graves’ orbitopathy provides a safe and effective reduction in proptosis with a low rate of new-onset diplopia as compared with historical values. Utilization of an orbital sling may be beneficial in reducing postoperative diplopia in select patients.

Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy

Purpose

To evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO).

Methods

Twenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0).

Results

Forty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 ± 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 ± 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 ± 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 ± 0.8 to 3.8 ± 0.5 mm postoperatively.

Conclusions

The customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.

Use of computed tomography to assess volume change after endoscopic orbital decompression for Graves' ophthalmopathy

BACKGROUND

Orbital decompression is frequently performed in the management of patients with sight-threatening and disfiguring Graves' ophthalmopathy. The quantitative measurements of the change in orbital volume after orbital decompression procedures are not definitively known. Furthermore, the quantitative effect of septal deviation on volume change has not been previously analyzed.

OBJECTIVES

To provide quantitative measurement of orbital volume change after medial and inferior endoscopic decompression and describe a straightforward method of measuring this change using open-source technologies. A secondary objective was to assess the effect of septal deviation on orbital volume change.

METHODS

A retrospective review was performed on all patients undergoing medial and inferior endoscopic orbital decompression for Graves' ophthalmopathy at a tertiary care academic medical center. Pre-operative and post-operative orbital volumes were calculated from computed tomography (CT) data using a semi-automated segmenting technique and Osirix™, an open-source DICOM reader. Data were collected for pre-operative and post-operative orbital volumes, degree of septal deviation, time to follow-up scan, and individual patient Hertel scores.

RESULTS

Nine patients (12 orbits) were imaged before and after decompression. Mean pre-operative orbital volume was 26.99 cm(3) (SD=2.86 cm(3)). Mean post-operative volume was 33.07 cm(3) (SD=3.96 cm(3)). The mean change in volume was 6.08 cm(3) (SD=2.31 cm(3)). The mean change in Hertel score was 4.83 (SD=0.75). Regression analysis of change in volume versus follow-up time to imaging indicates that follow-up time to imaging has little effect on change in volume (R=-0.2), and overall mean maximal septal deviation toward the operative side was -0.5mm. Negative values were attributed to deviation away form the operative site. A significant correlation was demonstrated between change in orbital volume and septal deviation distance site (R=0.66), as well as between change in orbital volume and septal deviation angle (R=0.67). Greater volume changes were associated with greater degree of septal deviation away from the surgical site, whereas smaller volume changes were associated with greater degree of septal deviation toward the surgical site.

CONCLUSION

A straightforward, semi-automated segmenting technique for measuring change in volume following endoscopic orbital decompression is described. This method proved useful in determining that a mean increase of approximately 6 cm in volume was achieved in this group of patients undergoing medial and inferior orbital decompression. Septal deviation appears to have an effect on the surgical outcome and should be considered during operative planning.

Diagnosis, Follow-Up and Treatment Results in Thyroid Ophthalmopathy

Objectives:

To discuss our follow-up and treatment results in thyroid-associated ophthalmopathy (TAO).

Ma­te­ri­als and Met­hods:

The records of 168 TAO cases who were followed at our clinic between October 1998 and October 2013 were reviewed retrospectively. The severity and activity of the disease were evaluated according to the criteria of the European Group on Graves’ Ophthalmopathy (EUGOGO) and Clinical Activity Score (CAS).

Re­sults:

Sixty-three men and 105 women participated in the study. The mean age of the patients was 42.3±12.4 years. Smoking habit was noted in 54.2% of the cases. Graves’ disease was the most common (80.4%) thyroid pathology accompanying TAO. TAO was mild in 64.4%, moderate-to-severe in 33.6% and severe in 2% of the eyes. Male gender was found as an independent risk factor for severity of the disease (p=0.040). TAO was in the active phase in 32.6% of the eyes. Older age and high thyroid receptor antibody titer were correlated with disease activity (P=0.031 and P<0.001, respectively). Thirty-four patients (20%) were treated for ocular findings. The most common treatment was systemic steroid therapy (12%); others included orbital decompression (5%), orbital radiotherapy (2%), and topical application of guanethidine (1%).

Conclusion:

Non-infiltrative phase and mild ocular findings were generally seen in TAO. Therefore, treatment is not recommended for many cases. Systemic steroid therapy is the most commonly used treatment modality in the active phase. However, orbital decompression surgery is necessary in a small number of cases with sight-threatening ocular findings.

Endoscopical Orbital Fat Decompression with Medial Orbital Wall Decompression for Dysthyroid Optic Neuropathy

OBJECTIVE

To describe a novel approach to orbital decompression for dysthyroid optic neuropathy (DON).

METHODS

An augmented endoscopic transethmoid medial orbital wall decompression (ETMOWD) was performed on 43 consecutive patients (72 eyes) with DON in order to access the orbital apex adequately. Concurrently, endoscopic transethmoid fat decompression (ETFD) using a novel aspiration/cutting instrument to remove orbital fat was performed for further reduction of proptosis. All patients were followed up periodically for at least 6 months. Outcomes such as improvement of visual acuity (VA), color vision, degree of proptosis reduction as well as the incidence of surgical induced diplopia were analyzed at the final review.

RESULTS

Sixty-nine out of 72 eyes (95.8%) had a statistically significant improvement in VA from -0.65 ± 0.30 to -0.25 ± 0.22 postoperatively, with a mean improvement of 0.55 ± 0.17 (p < 0.001). Thirty-four out of 45 eyes had an improvement in color vision (p < 0.001). The range of proptosis reduction was 4 to 9 mm (mean 6.2 ± 1.2 mm). Postoperative symmetry was achieved to within 2 mm using an exophthalmometer in 39 of 43 patients (90.7%). Five patients developed diplopia in the postoperative phase, but had complete resolution within 3 months. Two patients had further deterioration in their diplopia following surgery.

CONCLUSION

Our technique of a combined ETFD with ETMOWD appears to be effective in managing patients with DON, with minimal morbidities and a low incidence of postoperative diplopia.

Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy

PURPOSE

To describe the surgical technique for endoscopic medial orbital fat decompression in type 1 (lipogenic) Graves orbitopathy and report outcomes.

DESIGN

Retrospective interventional case review.

METHODS

We reviewed 108 patients (206 orbits) with inactive, type 1 Graves orbitopathy without diplopia, who underwent endoscopic medial orbital fat decompression solely for proptosis reduction. Following endoscopic transethmoid medial orbital wall decompression, extraconal and intraconal orbital fat was removed with a low-suction cutting instrument. All patients were followed up for at least 12 months. Surgical time, preoperative and postoperative Hertel exophthalmometry, incidence of postoperative diplopia within 30-degree visual field in the primary gaze, and other complications were analyzed.

RESULTS

The mean surgical time was 97.7 ± 16.7 minutes (67-136 minutes). The mean follow-up was 16.0 ± 4.2 months (12-24 months). Preoperative and postoperative proptosis values at final review were 21.1 ± 2.3 mm (17-26 mm) and 13.0 ± 0.9 mm (12-15 mm), respectively (P < .001). Median reduction in proptosis was 8.0 mm with mean of 8.2 ± 1.8 mm (4-11 mm). Symmetry to within 2 mm was achieved in 106 of 108 patients (98.1%). Twenty-five of 108 patients (23.1%) had diplopia within 30-degree visual field of the gaze, and 23 of these had complete resolution within 3 months, while the remaining 2 patients required squint surgery.

CONCLUSIONS

Endoscopic medial orbital fat decompression may be an effective technique for proptosis in selected patients with type 1 Graves orbitopathy and is associated with a low rate of surgically induced diplopia.

Iatrogenic diplopia [corrected]

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.

Endoscopic orbital decompression for Graves' orbitopathy

AIM

To study the efficacy of endonasal endoscopic orbital decompression in cases of Graves' orbitopathy.

MATERIAL AND METHODS

A total of 24 orbits in 12 patients underwent endoscopic orbital decompression for graves orbitopathy in the period between October 2002 and December 2010. Indications for surgery included proptosis, corneal exposure, keratitis, and compressive optic neuropathy. Decompression was accomplished by the removal of the medial and part of inferior wall of the orbit and slitting of the orbital periosteum. Pre and postoperative exophthalmometry measurements and visual acuity were recorded and compared.

RESULTS

A mean orbital regression of 3.70 mm was noted following endoscopic decompression. The visual acuity improved significantly in one of two eyes decompressed for failing visual acuity secondary to optic nerve compression. Transient diplopia was invariable following surgery but resolved over the next 8 weeks. One case manifested unilateral frontal sinus obstruction symptoms 4 months postoperatively and responded to medical therapy.

CONCLUSION

Endonasal endoscopic orbital decompression provides for an effective, safe, and minimally invasive treatment for proptosis and visual loss of Graves Orbitopathy. Long-term problems with diplopia were not noted in the endonasal endoscopic approach for orbital decompression.

The diagnosis and treatment of thyroid-associated ophthalmopathy

BACKGROUND

Little is written in the plastic surgery literature about thyroid-associated ophthalmopathy (TAO), a condition that is separate from Graves-Basedow disease and may not be accompanied by hyperthyroidism. Many patients with this disease frequently seek periocular aesthetic reconstruction prior to medical workup.

METHODS

This study presents a comprehensive review of the literature surrounding TAO in order to better understand the prevalence, diagnosis, pathophysiology, and appropriate management of TAO.

RESULTS

TAO is frequently under- or misdiagnosed by health-care providers. Patients seeking blepharoplasty or other oculoplastic procedures may have underlying TAO, and the prevalence of TAO in patients who have had a blepharoplasty is approximately 3%. This condition occurs five times more often in women than in men. As a product of the relatively high prevalence of this disease and its underdiagnosis, TAO patients may experience perioperative and late complications due to surgery.

CONCLUSION

Blepharoplasties performed on TAO patients must be undertaken with care and insight to avoid cosmetic and functional complications.

Orbital volume and eye position changes after balanced orbital decompression

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.

Thyroid-associated orbitopathy

Thyroid-associated orbitopathy (TAO) is usually diagnosed clinically. Early presentation of TAO such as ocular irritation, lid puffiness, and mild retraction may be overlooked and misdiagnosed. Careful clinical evaluation, laboratory investigations, and orbital imaging studies are needed for diagnosing early TAO. Knowing the pathogenesis will open the door for obtaining directed and effective treatment for the inflammatory process in TAO. Most patients with mild to moderate active TAO are treated with observation alone as the available treatment modalities effective in controlling the disease have many potential side effects. Severe active TAO, compressive optic neuropathy, and severe exposure keratopathy are the main indications for treatment with immunosuppressant agents, orbital radiotherapy, or orbital decompression. Surgery remains the final rehabilitation in TAO, which should be done during cicatricial (inactive) TAO when reliable and stable results can be obtained.

Diplopia and strabismus following ocular surgeries

Postoperative diplopia and strabismus may result from a variety of ocular surgical procedures. Common underlying mechanisms include sensory disturbance, scarring, direct extraocular muscle injury, myotoxicity from injections of local anesthesia or antibiotics, and malpositioning of extraocular muscles by implant materials. The most common patterns are vertical and horizontal motility disturbance. Treatment options include prisms, botulinum, occlusion, or surgery.

Functional endoscopic sinus surgery: indications and complications in the ophthalmic field

Functional Endoscopic Sinus Surgery (FESS) is a highly sophisticated type of surgery, which has revolutionized the surgical management of chronic sinus diseases. In the ophthalmic field, FESS plays a crucial role in the management of a few conditions, but not without risks. Ophthalmic complications associated with FESS are well documented. They mainly occur due to the shared common anatomic areas between ophthalmology and otolaryngology. Ophthalmic complications can vary in severity from very trivial cases such as localized hematoma collection, which is not very problematic to very devastating cases, such as optic nerve damage, which can lead to complete blindness. In order to minimize such complications, safety measures need to be considered prio to the surgery, these include; precise knowledge of detailed anatomy, the operating surgeon's ability to interpret precisely the para nasal sinus CT scan and experienced procedural surgical skills.

C-modified osteotomy for bilateral advancement of the orbital rim in Graves orbitopathy: a technical note

The authors present a modification of the classical three-wall orbital decompression for the treatment of Graves' orbitopathy. It consists of two 'C' osteotomies for the bilateral projection of the superolateral, lateral and inferolateral orbital rims, associated with the removal of the lateral orbital walls. This technique is performed following a coronal approach. Ultrasound cutting instruments were used for the osteotomies. They avoided lesion of surrounding soft tissues, such as the duramater and the periorbital tissues. Stabilization of the advanced structure was achieved by interposition of autologous bone graft obtained from the outer cortex of the calvaria. An extreme advancement of the orbital rim with resolution of diplopia, ocular pain and eyelid incompetence was obtained. Using this procedure, a good functional and aesthetic outcome was achieved.

Endoscopic orbital decompression for dyscosmetic thyroid eye disease

Aim:

To document the results of endoscopic orbital decompression performed in a group of patients with thyroid eye disease in order to improve cosmesis.

Methods:

A retrospective case review was performed of all patients who had undergone endoscopic orbital decompression for cosmesis in our departments during the period January 1996 to September 2002. A postal questionnaire was sent to all patients who had undergone the operation, in order to assess patient satisfaction.

Results:

Twenty orbits of 15 patients underwent endoscopic decompression. For all orbits, the reduction in proptosis was 3.7±2.2 mm (mean±standard deviation; t = 6.5, p = 0.001). For 16 of the endoscopic decompressions (89 per cent), patients reported that they were satisfied with the appearance of their eye post-operatively, and all patients reported a reduction in eye prominence post-operatively.

Conclusion:

Endoscopic decompression is an effective procedure for improving cosmesis in patients with inactive thyroid eye disease.

Efficacy and safety of orbital decompression in treatment of thyroid-associated ophthalmopathy: long-term follow-up of 78 patients

OBJECTIVE

To study the long-term results of decompression surgery in patients with thyroid-associated ophthalmopathy (TAO).

DESIGN AND METHODS

Retrospective analysis and clinical re-examination of TAO patients with comparison to healthy controls in Helsinki University Central Hospital.

PATIENTS

Seventy-eight patients who had undergone orbital decompression due to TAO by transantral or endonasal technique between the years 1985 and 2000 were invited for re-examination. For comparison, 79 healthy age- and sex-matched controls underwent a similar examination.

RESULTS

In comparison to the patients' preoperative state, proptosis was reduced by 4.7 (2.6) mm (mean (SD)) in the right and 4.4 (2.9) mm in the left globe (P < 0.0001) but did not reach the level of the controls' globe (P < 0.0001). In the right and left eye of patients, visual acuity improved in 44-55%, remained stable in 27-36% and worsened in 18-20%, but remained significantly worse than in controls (P =0.02-0.001). Prevalence of diplopia was high at the re-examination (N = 39, 50%), but 54% of those patients considered it less difficult than before the surgery. Among patients and controls, maxillary sinusitis and facial neuralgias were equally common. Sensory disturbances were significantly more frequent in patients (P < 0.0001). In assessment of overall satisfaction with present eye status, the median of the visual analogue scale (VAS) was lower for the patients than the controls (P < 0.0001). The majority of the patients considered the operation very helpful regardless of the technique used.

CONCLUSION

For patients with TOA, orbital decompression seems to be an effective and safe treatment.

Endoscopic orbital and optic nerve decompression

The endoscopic transnasal approach is well suited for decompression of both the orbit and optic canal. High-resolution nasal endoscopes provide excellent visualization for bone removal along the orbital apex and skull base. Endoscopic orbital decompression has proved to be safe and effective for the treatment of patients with Graves' orbitopathy; however, the indications and outcomes for endoscopic decompression of the optic nerve remain controversial.

[Initial experience with transpalpebral orbital lipectomy]

PURPOSE

The aim of this study was to evaluate the short-term effectiveness of transpalpebral orbital lipectomy.

METHOD

Using a transpalpebral approach, 2.0-6.5 ml connective tissue was removed from 50 orbits of 33 patients with mild to severe Graves' orbitopathy (25 females, 8 males) over a 5-year period. Indications for surgery comprised cosmetic correction of exophthalmos (27/33 patients), corneal damage (5/33), and rapid bilateral deterioration of visual acuity in 1 patient.

RESULTS

In 27 patients undergoing correction for aesthetic purposes no change in visual acuity ensued; in 4 of 5 keratopathy patients an improvement in visual acuity was detected. Diplopia ceased in 4 of 13 patients, diminished in 3 of 13 cases, and constantly increased in 2 of 13 cases. The high intraocular pressure returned to normal in 8 of 13 patients. The proptosis was reduced at 3.2+/-1.3 mm.

CONCLUSION

Transpalpebral orbital lipectomy is a low-risk, highly effective technique for orbital decompression in both acute and chronic cases of Graves' orbitopathy.

Strabismus after Deep Lateral Wall Orbital Decompression in Thyroid-Related Orbitopathy Patients Using Automated Hess Screen

PURPOSE

To evaluate the effect of deep lateral wall orbital decompression with intraconal fat debulking on strabismus in thyroid-related orbitopathy (TRO) patients using automated Hess screen (AHS).

DESIGN

Prospective nonrandomized clinical study.

PARTICIPANTS

Eleven TRO patients (19 surgeries) operated on at the Jules Stein Eye Institute from January, 2004, through December, 2004.

METHODS

Automated Hess screen testing was performed in all patients before surgery and 3 months after surgery; all patients received surgery in the nonactive phase of the disease.

MAIN OUTCOME MEASURES

Amplitude of horizontal and vertical deviations (prism diopters) in all standard positions of gaze.

RESULTS

Eleven TRO patients (7 females; mean age, 47 years) were included in the study; 8 patients underwent bilateral surgery. After surgery, exophthalmos decreased an average (+/-standard deviation) of 2.7 mm (+/-2.5 mm; P = 0.003). Before surgery, 7 patients (63%) reported primary gaze diplopia, whereas only 2 patients (18%) showed diplopia in primary gaze after surgery (P = 0.03, chi-square analysis). Orbital decompression had no statistically significant effect on horizontal and vertical ocular deviations measured by AHS. Mean amplitude of deviation in primary gaze was 1.2 prism diopters (PD) esotropia and 0.07 PD hypotropia before surgery, and 2.5 PD exotropia with 0.6 PD hypertropia after surgery (delta = 3.7 PD for horizontal deviation and -0.7 for vertical deviation; P = 0.051, paired samples t test for horizontal difference and P not significant for vertical difference). Nonsignificant P values were obtained in all 9 positions of gaze. Most patients had periocular numbness that resolved spontaneously 2 to 6 months after surgery.

CONCLUSIONS

Deep lateral wall orbital decompression with intraconal fat debulking had no statistically significant effect on horizontal and vertical deviations measured by the AHS. Patients may demonstrate small angle exotropia shift, but this finding was not clinically significant.

Endoscopic Orbital and Optic Nerve Decompression

Endoscopic orbital decompression has become the surgical treatment of choice for many patients with orbital manifestations of Graves' disease, including proptosis and optic neuropathy. The unparalleled visualization provided by endoscopic instrumentation allows for a safe and thorough decompression, particularly when operating along the orbital apex and skull base. Although the benefits of and indications for decompression of the orbit are well established, the role of optic nerve decompression remains controversial.

Customized, Single-Incision, Three-Wall Orbital Decompression

PURPOSE

To present the clinical outcome in 55 consecutive patients by using a customized, single-incision, 3-wall orbital decompression.

METHODS

A retrospective chart review was performed of 97 customized, single-incision, 3-wall decompressions in 55 consecutive patients within one surgeon's practice. A standardized surgical technique featuring lateral small-incision, 3-wall decompression with specific "strut" preservation was used in all patients. Success of the procedure was assessed on the basis of the amount of proptosis reduction achieved, as measured by the difference in Hertel exophthalmometry measurements, and by improvement in or preservation of preoperative visual acuity and color vision in the setting of compressive optic neuropathy. Subjective diplopia was recorded before and after surgery, as was the presence of extraocular muscle restriction.

RESULTS

A total of 97 orbital decompressions in 55 consecutive patients were reviewed. The majority of surgeries were performed for disfiguring proptosis with some degree of exposure-related symptoms (81%), with other indications including compressive optic neuropathy (17%), and pain (2%). The average amount of proptosis reduction achieved at 3 months was 5 mm (range, 1 to 11 mm). Visual acuity in patients with compressive optic neuropathy improved an average of 2 lines on the standard Snellen chart testing (range, 1 to 5). Color vision improved an average of 5 Ishihara plates (range, 0 to 13). Seventy-one percent of patients had subjective diplopia before surgery; 21% of these patients reported improvement or complete resolution of diplopia after surgery. Of the 29% of patients without preoperative subjective diplopia, all but one (1.8 of total patients) remained symptom free.

CONCLUSIONS

We find that a customized, single-incision, 3-wall orbital decompression provides adequate decompression and proptosis reduction while minimizing postoperative strabismus and providing an aesthetically desirable result.