Cosmetic orbital inferomedial decompression: quantifying the risk of diplopia associated with extraocular muscle dimensions

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.

Extraocular muscle expansion after deep lateral orbital wall decompression: influence on proptosis reduction and its predictive factors

PURPOSE

To examine the relationship between extraocular muscle expansion and proptosis reduction (Δproptosis) in patients with thyroid eye disease who underwent deep lateral orbital wall decompression and to analyze the factors that contribute to extraocular muscle expansion.

METHODS

This retrospective, observational study included 133 sides from 77 patients with thyroid eye disease. The cross-sectional areas of the greater wing of the sphenoid bone (trigone), extraocular muscles, and superior ophthalmic vein were measured on computed tomographic images. Variables influencing Δproptosis were analyzed using multivariate linear regression analyses with stepwise variable selection. Predictive factors for the rate of postoperative increase in the cross-sectional extraocular muscle areas (Δextraocular muscle) were analyzed using the same statistical method.

RESULTS

The amount of orbital fat removed (P < 0.001) and rate of Δlateral rectus muscle (P < 0.001) were positively and negatively correlated with Δproptosis, respectively (r = 0.425; adjusted r² = 0.168; P < 0.001). The cross-sectional trigone area (P < 0.001) was positively correlated with the rate of Δlateral rectus muscle, whereas the preoperative cross-sectional lateral rectus muscle area (P < 0.001) and amount of orbital fat removed (P = 0.036) were negatively correlated with the rate of Δlateral rectus muscle (r = 0.551; adjusted r² = 0.288; P < 0.001).

CONCLUSION

Lateral rectus muscle expansion was negatively correlated with proptosis reduction and proved to be predictable before surgery. The results of this study will help predict proptosis reduction after deep lateral orbital wall decompression and to preoperatively plan additional orbital bony and fat decompression.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES

To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.

METHODS

Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.

RESULTS

Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).

CONCLUSIONS

IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Effect of orbital radiotherapy on the outcome of surgical orbital decompression for thyroid-associated orbitopathy (TAO): a retrospective study in 136 patients

PURPOSE

In patients with moderate to severe thyroid-associated orbitopathy (TAO), orbital radiation therapy (ORT) can prevent disease progression. In the sequelae stage, orbital decompression surgery can be useful in case of functional discomfort. The aim of this study was to evaluate the effect of orbital ORT on the outcomes of decompression surgery.

METHODS

In this retrospective study, we included 136 patients who had had bilateral orbital decompression between 1995 and 2016. Before surgery, 38 patients received Radiation Therapy (RT+) while 98 did not (RT-). All RT+ patients and 20 RT- patients had systemic corticosteroid treatment. In both groups surgical outcome was evaluated by exophthalmos reduction (mm), palpebral fissure (mm), distance between the lid margin and the corneo-scleral limbus (mm), existence of conjunctival hyperemia and diplopia.

RESULTS

In both RT+ and RT- groups, surgery improved the proptosis, significantly greater in RT+(3.66 ± 1.79 mm) than in RT- group (2.85 ± 1.80 mm) (p < 0.019). No significant differences were noted in the palpebral fissure, the distance from the lid margin to the corneo-scleral limbus. After surgery, only one patient (5%) in the RT+ group presented with new-onset diplopia, whereas in the RT- group there were 14 (36%) patients (p < 0.007). After orbital decompression, the number of conjunctival hyperemia decreased by 6 (21%) in the RT+ group versus 21 (60%) in the RT- group (p < 0.006).

CONCLUSION

Orbital radiotherapy during the inflammatory phase enhances the outcomes after orbital decompression in TAO. After surgery we observed a greater improvement in proptosis and in diplopia for RT+ versus RT- patients.

MicroRNA-27 inhibits adipogenic differentiation in orbital fibroblasts from patients with Graves' orbitopathy

Background

To investigate the role of microRNA (miR)-27a and miR-27b in adipogenesis in an in vitro model of Graves’ orbitopathy (GO).

Methods

Orbital fat tissues were harvested from GO and non-GO participants for primary orbital fibroblast cultures. The expression levels of miR-27a and miR-27b between GO and non-GO orbital fat tissues were compared. During adipogenesis of GO orbital fibroblasts, the expression levels of miR-27a and miR-27b were determined, and the effects of mimics of miR-27a and miR-27b transfection on adipogenesis of GO orbital fibroblast were investigated.

Results

Real time-polymerase chain reaction showed significantly more decreases in miR-27a and miR-27b levels in orbital fat tissues in GO participants than in non-GO participants (p < 0.05). The expression of both miR-27a and miR-27b was highest in orbital fibroblasts at day 0 and declined gradually after the induction of adipogenic differentiation. The expression levels of PPARγ, CCAAT/enhancer binding protein (C/EBP)α and C/EBPβ were decreased and Oil Red O-stained lipid droplets were lower in GO orbital fibroblasts transfected with miR-27a and miR-27b mimics than in negative controls.

Conclusions

Our results indicated that miR-27a and miR-27b inhibited adipogenesis in orbital fibroblasts from GO patients. Further studies are required to examine the potential of miR-27a and miR-27b as targets for therapeutic strategies.

Surgical Outcomes of Endoscopic Medial Orbital Wall Decompression

STUDY DESIGN

Retrospective chart review.

PURPOSE

The aim of this study was to evaluate the surgical outcomes and complications after endoscopic medial orbital wall decompression.

METHOD

From November 2016 to July 2017, we retrospectively reviewed 40 eyes of 20 patients who had undergone orbital decompression because of thyroid ophthalmopathy and other causes of proptosis.The eyes were classified into 2 groups: orbits which received only endoscopic medial wall decompression, and orbits which received both endoscopic medial wall decompression and transconjunctival inferior wall decompression. Statistical analysis was performed for all data generated. The preoperative and 3-month postoperative follow-up examinations for all patients were assessed by Hertel ophthalmometry, interpalpebral fissure, marginal reflex distance 1, Goldmann applanation tonometry, diplopia test, and Grave ophthalmopathy specific quality of life survey.

RESULTS

Endoscopic medial wall decompression was performed in 17 of the total 40 eyes, and endoscopic medial wall decompression and transconjunctival inferior wall decompression was performed in the remaining 23 eyes. Proptosis improved from 20.4 ± 1.16 mm preoperatively to 16.8 ± 1.02 mm postoperatively in the endoscopic medial wall approach group, and from 20.8 ± 1.75 mm preoperatively to 14.8 ± 1.79 mm postoperatively in the endoscopic medial wall and transconjunctival inferior wall approach group. Postoperative complications occurred in 2 patients who displayed periphery diplopia, in the endoscopic medial wall and transconjunctival inferior wall approach group. A survey to assess the level of cosmetic satisfaction was significantly improved in both groups after surgery.

CONCLUSION

Endoscopic medial wall decompression is an approach that achieves sufficient orbital decompression while minimizing complications.

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.

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.

[Diagnosis and treatment of dysthyroid orbitopathy: a multidisciplinary disease]

Graves' disease is a common autoimmune disorder that can be complicated, especially in smokers, by an orbitopathy which can sometimes jeopardize vision and result in functional sequelae affecting quality of life of these patients. Although the diagnosis of dysthyroid orbitopathy is usually obvious, clinical evaluation must specify the stage of progression (clinical activity score) and severity according to the European Group EUGOGO classification. At first, rapid restoration of the euthyroid state, smoking cessation and simple symptomatic ophthalmic treatment are suggested. In the case of severe or active orbitopathy, oral or intravenous corticosteroid therapy with or without orbital radiation therapy (and even emergency orbital surgery in the case of compressive optic neuropathy) should be implemented. Ultimately, orbital surgery (orbital decompression in cases of exophthalmos), oculomotor surgery (diplopia) or eyelid surgery (retraction) may be required depending on the severity of sequelae. A multidisciplinary approach involving ophthalmologist, endocrinologist and orbital surgeon should facilitate an overall diagnosis and treatment plan for these patients.