Thyroid-associated orbitopathy: a clinicopathologic and therapeutic review

“Influence of Clinically Active Graves’ Ophthalmopathy on Spherical Equivalent and Visual Acuity”

Purpose

Clinical experience regarding the fluctuations of the refractive error of the eye during the different stages of Graves’ ophthalmopathy observed through outpatient clinic frequent check-ups points towards an underestimated and often overlooked problem. Published data about it are sparse. The clinical manifestations of Graves’ ophthalmopathy can be understood from the perspective of “compartment syndrome” and literature implies how such changes can affect the refractive error and consequently, the visual acuity. The purpose of the study was to explore how the clinical activity score of Graves’ ophthalmopathy affects refractive error and visual acuity.

Patients and Methods

The study was prospective and observational, including 60 eyes of 30 patients with clinically active Graves’ ophthalmopathy. All the patients were monitored and evaluated over a period of 36 months by the clinical activity score, spherical equivalent and visual acuity. All the observed parameters were statistically analyzed.

Results

The mean values of spherical equivalent and visual acuity throughout the observed period showed continuous fluctuation. Repeated measure analysis of variance showed statistically significant differences in visual acuity and spherical equivalent over the observed period. There was a statistically significant positive correlation between visual acuity and clinical activity score. The correlation between spherical equivalent and clinical activity score was also positive but not statistically significant.

Conclusion

A decrease in the clinical activity score is either the result of a spontaneously resolving course of Graves’ ophthalmopathy or a consequence of treatment, so lowering in fluctuation of refractive error and improved visual acuity may be associated with a reduction in orbital inflammation.

A generative adversarial network approach to predicting postoperative appearance after orbital decompression surgery for thyroid eye disease

PURPOSE

Orbital decompression for thyroid-associated ophthalmopathy (TAO) is an ophthalmic plastic surgery technique to prevent optic neuropathy and reduce exophthalmos. Because the postoperative appearance can significantly change, sometimes it is difficult to make decisions regarding decompression surgery. Herein, we present a deep learning technique to synthesize the realistic postoperative appearance for orbital decompression surgery.

METHODS

This data-driven approach is based on a conditional generative adversarial network (GAN) to transform preoperative facial input images into predicted postoperative images. The conditional GAN model was trained on 109 pairs of matched pre- and postoperative facial images through data augmentation.

RESULTS

When the conditional variable was changed, the synthesized facial image was transferred from a preoperative image to a postoperative image. The predicted postoperative images were similar to the ground truth postoperative images. We also found that GAN-based synthesized images can improve the deep learning classification performance between the pre- and postoperative status using a small training dataset. However, a relatively low quality of synthesized images was noted after a readout by clinicians.

CONCLUSIONS

Using this framework, we synthesized TAO facial images that can be queried using conditioning on the orbital decompression status. The synthesized postoperative images may be helpful for patients in determining the impact of decompression surgery. However, the quality of the generated image should be further improved. The proposed deep learning technique based on a GAN can rapidly synthesize such realistic images of the postoperative appearance, suggesting that a GAN can function as a decision support tool for plastic and cosmetic surgery techniques.

Electrophysiological Studies in Thyroid Associated Orbitopathy: A Systematic Review

Dysthyroid optic neuropathy (DON) is the commonest cause of blindness in thyroid associated orbitopathy (TAO). While diagnosis remains clinical, objective tests for eyes with early or equivocal findings are lacking. Various electrophysiological studies (EPS) have been reported, yet the types and parameters useful for DON remain inconclusive. We performed a systematic literature search in MEDLINE, EMBASE and the Cochrane databases via the OVID platform up to August 20, 2017. 437 records were identified for screening and 16 original studies (1327 eyes, 787 patients) were eligible for review. Pattern visual evoked potential (pVEP) was the most frequently studied EPS. Eyes of TAO patients with DON showed delayed P100 latencies, decreased P100 amplitudes or delayed N75 latencies during pVEP, compared to those without or healthy controls. Due to study heterogeneity, no quantitative analysis was possible. This review highlights the most common type (pVEP) and useful parameters (P100 latency and amplitude) of EPS, and supports further research on them using standardized testing conditions.

The role of rectus muscle myectomy in the management of large-angle strabismus for Graves' ophthalmopathy

PurposeRetrospective noncomparative case series to investigate the role of rectus muscle myectomy for the treatment of large-angle strabismus in patients with Graves' ophthalmopathy.Patients and methodsData from 47 consecutive patients with Graves' ophthalmopathy who underwent complete myectomy for large-angle strabismus (strabismus greater than 25 prism diopters (PDs)) were collected retrospectively. Pre- and postoperative deviations in primary and reading position were measured in PDs. Postoperative deviation of <5 diopters in primary gaze and functional binocular vision in central 30° field were considered as successful surgical outcomes.ResultsPatients undergoing complete myectomy of the restricted muscles in large-angle strabismus achieved a 78.7% success rate after the first surgery. Reoperation performed on seven patients resulted in 85.7% success rate in reoperation group. The overall success rate was 91.5%. The mean efficacy of the isolated rectus muscle myectomy was 34.3±7.7 PDs.ConclusionsThe complete rectus muscle myectomy technique is effective and predictable in the treatment of large-angle strabismus in patients with Graves' ophthalmopathy.

Effect of botulinum toxin A on the intraocular pressure and the retina in an animal model

OBJECTIVE

The purpose of our study was to investigate the effect of an inadvertent intravitreal injection of botulinum toxin A (BTA) on the intraocular pressure (IOP) and the retina in an animal model.

METHODS

BTA was injected intravitreally in normotensive rats. IOP was measured preoperatively as well as 1, 2, and 4 weeks postoperatively. Retinas were stained in vivo using a retrograde labelling technique and the density of retinal ganglion cells (RGCs) was determined. Immunohistochemistry was performed for rhodopsin and retinal glial fibrillary acidic protein (GFAP).

RESULTS

Significant temporary IOP elevation occurred in all groups in the immediate postoperative period (ANOVA, p < 0.05). IOP changes in the intermediate period were not statistically significant (ANOVA, p > 0.05). The differences in the density of RGCs after BTA injection were not statistically significant (ANOVA, p > 0.05). All retinas displayed the same immunostaining pattern for rhodopsin and GFAP.

CONCLUSION

Our findings indicate that BTA has probably no severe impact on IOP and the retina after an inadvertent intravitreal injection. However, temporary rise of IOP may possibly occur in the immediate postoperative period due to a volume-effect.

Evaluation of multifocal visual evoked potentials in patients with Graves' orbitopathy and subclinical optic nerve involvement

Dysthyroid optic neuropathy is the most serious, although infrequent (8-10 %) complication in Graves' orbitopathy (GO). It is known that early stages of compressive optic neuropathy may produce reversible visual field defects, suggesting axoplasmic stasis rather than ganglion cell death. This observational, cross-sectional, case-control study assessed 34 consecutive patients (65 eyes) with Graves' hyperthyroidism and longstanding GO and 31 age-matched control subjects. The patients' multifocal visual evoked potentials (mfVEP) were compared to their clinical and psychophysical (standard automated perimetry [SAP]) and structural (optic coherence tomography [OCT]) diagnostic test data. Abnormal cluster defects were found in 12.3 % and 3.1 % of eyes on the interocular and monocular amplitude analysis mfVEP probability plots, respectively. As well, mfVEP latencies delays were found in 13.8 and 20 % of eyes on the interocular and monocular analysis probability plots, respectively. Interestingly, 19 % of patients with GO had ocular hypertension, and a strong correlation between intraocular pressure measured at upgaze and mfVEP latency was found. MfVEP amplitudes and visual acuity were significantly related to each other (P < 0.05), but not with the latencies delays. However, relationships between the interocular or monocular mfVEP amplitudes and latencies analysis and SAP indices or OCT data were not statistically significant. One-third of our patients with GO showed changes in the mfVEP, indicating significant subclinical optic nerve dysfunction. In this sense, the mfVEP may be a useful diagnostic tool in the clinic for early diagnosis and monitoring of optic nerve function abnormalities in patients with GO.

Clinical profile and visual outcomes after treatment in patients with dysthyroid optic neuropathy

PURPOSE

To report the clinical data and visual outcomes after treatment of patients with dysthyroid optic neuropathy (DON).

METHODS

We retrospectively reviewed the medical records and orbital images of 40 patients (65 eyes) with DON and analyzed the visual outcomes after treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression.

RESULTS

The study included 21 men and 19 women, with 10 (25%) being diabetic patients. Visual field test results revealed defects in 88.7% of DON eyes; afferent pupillary defects in 63.2%; reduced color vision in 78.5%; and abnormal visual evoked potentials in 84%. Orbital imaging showed moderate to severe apical crowding in 95% of the orbits and intracranial fat prolapse in 24.2%. Median best corrected visual acuity improved from 0.4 to 1.0 after one year of treatment (p < 0.001). We noted more improvement in vision with the use of decompressive surgery than with non-surgical methods (p < 0.05). Recurrences occurred in 7 patients who had not received orbital radiotherapy.

CONCLUSIONS

Visual field defects and apical crowding seen on orbital imaging were the most sensitive indicators for the detection of DON. Treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression effectively improved visual outcomes in cases of DON.

The evaluation and treatment of graves ophthalmopathy

Optimum care of the patient with Graves ophthalmopathy (GO) is achieved through teamwork between the endocrinologist and ophthalmologist, with input from ancillary specialists as needed. Clinical evaluation should include determination of both the severity and the activity of the disease. It is important to assess early in the evaluation the impact of the disease on the patient's quality of life and their priorities and expectations regarding management. Once this information has been gathered, careful discussion between patient and physicians can define the management plan. This article reviews the pathophysiology, epidemiology, evaluation, and management of GO.

Assessment of visual acuity, refraction changes, and proptosis in different ages of patients with thyroid diseases

Objective. The aim of the study was to assess visual acuity, refractive status, and eye proptosis in children and young adults with Graves' disease. Material and Methods. We have done investigations of visual acuity, refraction, and eye proptosis in 16 children, 14 teenagers, and 49 adults with Graves' disease at Eye Clinic of Lithuanian University of Health Sciences Medical Academy. Data were compared with 14 children, 14 teenagers, and 35 adults of similar age without the same diseases (control group). Results. In the present study we observed a significant decrease of visual acuity in teenagers (0.73 ± 0.18, P = 0.001) and adults (0.7 ± 0.16, P = 0.001) with Graves' disease. Myopia was ascertained more frequent in teenagers (42.8 percent) and adults (44.9 percent) with Graves' disease. In our study exophthalmometer values were higher in children (15.94 ± 1.98 mm, P = 0.003), teenagers (17.28 ± 2.99 mm, P = 0.01), and adults (18.05 ± 2.91 mm, P = 0.001) in comparison with the controls. Conclusions. The data we have found suggest that Graves' disease in children, teenagers, and adults has influence on vision acuity, refraction, and eye proptosis.

Anatomy-based surgical concepts for individualized orbital decompression surgery in graves orbitopathy. I. Orbital size and geometry

PURPOSE

To analyze orbital morphological parameters that potentially could influence the effect of decompression surgery on exophthalmos reduction in Graves orbitopathy, thus making decompression surgery more predictable.

METHODS

To generate a reference database, a CT-based study was performed in 140 orbits obtained from adult patients with unaffected orbits in a European white ethnicity. The following parameters were chosen: orbital volume, globe volume, globe to orbital volume ratio, and orbital cone angle. Volumes were measured on postprocessed CT data using morphometric techniques. To define the cone angle, a 3-dimensional approach was chosen using the program Amira.

RESULTS

Significant interindividual variation was found in orbital volume from 18.9 to 33.4 ml and in globe volume from 6.0 to 10.1 ml. The globe to orbital volume ratio showed a relatively broad variation from 0.25 to 0.4. Differences in the orbital cone angle from 39.7° to 65.7° were observed.

CONCLUSION

The experienced large variations in orbital morphology might significantly influence the degree of exophthalmos reduction, which can be obtained by standardized decompression procedures. Based on our results, a prospective clinical study will be conducted to test our hypothesis.

Thyroid eye disease: honing your skills to improve outcomes

Thyroid eye disease affects the eyelids, orbital compartment, and extraocular muscles, resulting in a highly variable degree of chemosis and enlargement of the preorbital fat pads, eyelid retraction, proptosis, restrictive strabismus, torticollis, and, rarely, compressive or congestive optic neuropathy. Although most patients with thyroid eye disease are best treated conservatively, those more severely affected may benefit from orbital decompression, strabismus surgery, or eyelid retraction repair after stabilization has occurred. Botulinum A toxin, high-dose intravenous corticosteroids, and radiation treatment are therapeutic options in select cases. Compressive or congestive optic neuropathy and severe corneal exposure warrant consideration of surgical intervention on an urgent basis without waiting for stabilization. Epidemiology and risks and benefits of high-dose steroids and radiation therapy are reviewed along with recommendations to improve conservative as well as surgical management of this disease. Strategies to manage strabismus and optimize outcomes are provided.

The role of intravenous methylprednisolone immunosuppression in the management of active thyroid eye disease

PURPOSE

To analyze the efficacy of intravenous methylprednisolone (IVMP) immunosuppression in the management of active thyroid eye disease (TED).

METHODS

This is a consecutive case series of 36 patients treated with 1 g of IVMP over 3 days, between January 2000 and January 2008. The indications for this treatment were moderate to severe active TED with or without optic nerve compression.

RESULTS

There were 32 hyperthyroid, 2 hypothyroid, and 2 euthyroid patients in this series. Nine patients presented with optic nerve compromise, 3 had severe active TED and 24 had moderately active TED. Twenty-seven patients received one course of IVMP and nine patients received two courses. All patients had tapering oral prednisolone over 1 month following the IVMP. The mean improvement in proptosis was 1.31 mm (range = 0-3 mm). Optic nerve function improved in seven of nine patients (77.8%). Extra ocular muscle movement improved in 18 patients (50%). Overall benefit from IVMP was seen at 1/12 in 27 patients (75%) and at 3/12 in 30 patients (83%). After IVMP one patient underwent radiotherapy and three patients had nonsteroidal immunosuppression.

CONCLUSIONS

 IVMP immunosuppression is effective in 83% of patients. The effect lasts from 3 months to 8 years, with a mean of 15 months in 30.5%. It remains a useful modality of treatment especially when the optic nerve or cornea is threatened because of moderate to severe active TED. We encountered no severe side effects of pulsed IVMP and 3 g over 3 days is a safe dose.

A step towards individualized, anatomy-based surgical concepts for orbital decompression in Graves' orbitopathy

The surgical armamentarium for orbital decompression in Graves'orbitopathy (GO) includes techniques for orbital wall resection using local incisions, but also techniques for orbital rim advancement or resection of the greater sphenoid wing, which require a coronal or even transcranial approach. Up to now the choice of technique rather depends on the surgeon;s preference than on objective criteria. The goal of our CT-based research project is to define morphological orbital parameters which potentially could influence the result of a given technique for orbital decompression in thyroid eye disease. Based on the results individualized, anatomy-based surgical concepts could be established.

Dysthyroid optic neuropathy: atypical initial presentation and persistent visual loss

PURPOSE

Dysthyroid Optic Neuropathy (DON) can lead to irreversible visual loss. We report risk features correlated with poor visual recovery despite an intensive treatment in a series of patients with DON.

DESIGN

Retrospective analysis of a non-comparative interventional series.

METHODS

Between 1997 and 2007, 300 consecutive patients with Graves' orbitopathy were seen at the Rothschild Foundation (Paris). Medical records of all consecutive patients who developed a DON were reviewed. Demographic, clinical features and visual function were collected at the time of the first onset, one month follow-up after medical and sometime surgical treatment and at the last examination. Statistical analysis (reflected as p values) gathered the significant observations into detrimental visual recovery prognostic factors for DON.

RESULTS

Fifty-six eyes of 29 patients developed a DON. Sixteen eyes (28%) did not improve vision despite usual treatment (intravenous steroids and surgical decompression when necessary). An inferior altitudinal visual field defect (AVF, p=0.0004) and/or a lack of response to intravenous steroids boluses (p= 0.011) were related to a poor recovery.

CONCLUSION

DON prognosis is highly variable. Our results suggest that a non-inflammatory element, probably vascular could be involved in atypical DONs. An earlier recognition could prompt to rapid surgical treatment for these patients.

Thyroid eye disease

Introduction

Thyroid eye disease (TED), also known as Graves opthalmopathy is the most common orbital disease and affects 25–50% of patients with Graves' disease (Kuryan et al 2008). Most patients are only mildly affected, suffering ocular irritation with redness and watering, ‘staring eyes' due to retraction of the eyelids, exophthalmos (protrusion of the eyeballs) and periorbital swelling (Figure 1). A minority of patients (around 28%) will develop ocular motility problems, leading to diplopia (double vision), exposure/damage to the cornea and optic neuropathy (Kumar & Clarke 2002, Forbes & Jackson 2003, Meyer 2006).

Development and validation of a patient symptom questionnaire to facilitate early diagnosis of thyroid-associated orbitopathy in graves' disease

BACKGROUND

To construct a patient-based symptom questionnaire to facilitate early referral of thyroid-associated orbitopathy (TAO) in Graves' hyperthyroidism (GH).

METHODS

Phase I of our study involved developing a symptomatology-based questionnaire for the self-reporting of TAO symptoms in patients recently diagnosed with GH. Phase II involved administering the questionnaire along with a standard ophthalmic examination to a screening cohort of patients newly diagnosed with GH. Symptoms highly associated with the clinical diagnosis of TAO were used to construct a tool with the highest possible sensitivity. Phase III involved validation of this tool in a new cohort of patients recently diagnosed with GH. For each patient, the diagnosis of TAO was made by both a standardized orbital ophthalmic exam and the questionnaire. Results from the questionnaire were then compared to the clinical examination.

RESULTS

The questionnaire was compared to the standardized examination and found to have a sensitivity of 0.76 and a specificity of 0.82 in the validation phase of the study.

INTERPRETATION

This questionnaire may be a useful tool in clinical practice to allow identification of patients with TAO secondary to GH. Future studies using this questionnaire are needed to determine whether earlier identification and management of these patients is associated with reduced morbidity from TAO.

Role of botulinum toxin A in diplopia following orbital decompression

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.

Exophthalmometry values of Turkish adult population and the effect of age, sex, refractive status, and Hertel base values on Hertel readings

PURPOSE

To establish normal exophthalmometry values in the adult Turkish population, and the impact of age, gender, interpupillary distance, Hertel base selection, and refractive status on globe position.

METHODS

Exophthalmometry measurements and refractive status of 2477 subjects were conducted in one tertiary and five primary health care centers. Change of globe position by age, intersex differences in terms of globe position, correlations of Hertel base with exophthalmometry results, and interpupillary distance (IPD) were evaluated. Multiple linear regression analysis was performed to test determination effect of each variable on final Hertel reading.

RESULTS

Median Hertel reading was 13 mm, and 95% of the population had an upper limit of 17 mm for both eyes. There was a negative correlation between spherical equivalent of refractive status and exophthalmometry results and a weak positive correlation between IPD and exophthalmometry result. Mean Hertel value was found to decrease significantly after the third decade. Hertel base value was found to have moderate linear correlation with Hertel results. A weak correlation was detected with Hertel base/IPD ratio with final Hertel results. Multiple linear regression analysis was performed and only 13% and 20% of change in Hertel values bilaterally were found to be determined by other variables (age, IPD, refractive status, and Hertel base value) for females and males.

CONCLUSIONS

Normative dataset for exophthalmometry results of the Turkish population is established to be used in clinical practice and research. Only 13% to 20% of change in Hertel values was detected to be determined by age, IPD and Hertel base values.

Double vision in a patient with thyroid disease: what's the big deal?

A 70-year-old woman with a 46-year history of Graves disease had significant thyroid related orbitopathy (TRO) requiring previous bilateral orbital decompressions and one previous strabismus procedure for an exotropia of 60 PD. At the initial neuro-ophthalmology assessment, she had an exotropia of 20 PD and was scheduled for further surgery, but at the time of a second assessment a few weeks later, her strabismus had markedly changed. Accordingly, the patient underwent a neostigmine bromide test that demonstrated evidence of co-existing myasthenia gravis.

Management of Graves' ophthalmopathy

Management of Graves' ophthalmopathy is preferably done in a multidisciplinary setting. Smoking is associated with worse disease outcome. (131)I therapy for hyperthyroidism can also worsen ophthalmopathy, especially if administered during active disease or to patients who smoke or have severe hyperthyroidism, or those with high levels of TSH-receptor-binding inhibitory immunoglobulins. Coadministration of steroids and (131)I therapy is recommended for such high-risk patients. (131)I therapy is safe for patients with inactive Graves' ophthalmopathy. Subtotal thyroidectomy and antithyroid drugs show no benefit or harm to eye changes. There is no good evidence that total thyroid ablation has additional benefit. Artificial teardrops, dark glasses and prisms are very helpful. Dysthyroid optic neuropathy is best treated with intravenous pulsed methylprednisolone; if visual functions do not recover, urgent surgical decompression is indicated. A wait-and-see policy is recommended in mild Graves' ophthalmopathy because the natural history of this condition reveals a tendency to resolve spontaneously. Active, moderately severe Graves' ophthalmopathy qualifies for immunosuppression: intravenous pulsed methylprednisolone is more efficacious and has fewer side effects than oral steroids. Once the disease is inactive, rehabilitative surgery has much to offer. Quality of life is seriously limited in patients with Graves' ophthalmopathy, and remains restricted even after all treatments. Consequently, there is an urgent need for improved treatment modalities, and antibody therapy has shown promise in this respect.

Optic Neuropathy Associated With Botulinum A Toxin in Thyroid-related Orbitopathy

PURPOSE

To report the development of optic neuropathy after botulinum A toxin injection for restrictive myopathy from thyroid-related orbitopathy (TRO).

METHODS

We retrospectively reviewed the records of three patients with TRO who underwent botulinum A toxin injection for restrictive myopathy and subsequently developed optic neuropathy. Development of optic neuropathy was measured by visual acuity, color vision testing, visual field testing, and relative afferent pupillary testing.

RESULTS

At 3 week follow-up after botulinum A toxin injection, three patients were noted to have clinical signs and symptoms of optic neuropathy in the ipsilateral eye following injection of botulinum A toxin for restrictive myopathy. Treatment with oral steroids followed by orbital wall decompression reversed the optic neuropathy.

CONCLUSIONS

To our knowledge, this is the first report of optic neuropathy associated with botulinum A toxin injection in TRO. Clinicians should be aware of this potential vision threatening complication.

Clinical features of dysthyroid optic neuropathy: a European Group on Graves' Orbitopathy (EUGOGO) survey

BACKGROUND

This study was performed to determine clinical features of dysthyroid optic neuropathy (DON) across Europe.

METHODS

Forty seven patients with DON presented to seven European centres during one year. Local protocols for thyroid status, ophthalmic examination and further investigation were used. Each eye was classified as having definite, equivocal, or no DON.

RESULTS

Graves' hyperthyroidism occurred in the majority; 20% had received radioiodine. Of 94 eyes, 55 had definite and 17 equivocal DON. Median Clinical Activity Score was 4/7 but 25% scored 3 or less, indicating severe inflammation was not essential. Best corrected visual acuity was 6/9 (Snellen) or worse in 75% of DON eyes. Colour vision was reduced in 33 eyes, of which all but one had DON. Half of the DON eyes had normal optic disc appearance. In DON eyes proptosis was > 21 mm (significant) in 66% and visual fields abnormal in 71%. Orbital imaging showed apical muscle crowding in 88% of DON patients. Optic nerve stretch and fat prolapse were infrequently reported.

CONCLUSION

Patients with DON may not have severe proptosis and orbital inflammation. Optic disc swelling, impaired colour vision and radiological evidence of apical optic nerve compression are the most useful clinical features in this series.

Cosmetic orbital surgery

PURPOSE

Current indications for orbital surgery primarily aimed at improving cosmesis are considered in the context of subspecialist orbital practice by an ophthalmologist.

SCOPE

Thyroid eye disease, orbital vascular anomalies, and dermolipomas are common orbital diseases in which the symptoms can be purely cosmetic. Accurate anatomical awareness, preoperative scanning, control of medical factors including smoking and thyroid status, and endoscopic techniques have all contributed to the aesthetic outcome of orbital surgery. The threshold for performing reconstructive orbital surgery has also been lowered by public demand.

CONCLUSIONS

Orbital surgeons can therefore offer the familiar techniques, such as orbital decompression, for pure cosmesis. Sensitive history taking and awareness of the psychological element are of paramount importance for the orbital surgeon who develops a cosmetic practice.