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Baeg J, Choi HS, Kim C, Kim H, Jang SY. Update on the surgical management of Graves' orbitopathy. Front Endocrinol (Lausanne) 2023; 13:1080204. [PMID: 36824601 PMCID: PMC9941741 DOI: 10.3389/fendo.2022.1080204] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/15/2022] [Indexed: 02/10/2023] Open
Abstract
Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.
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Affiliation(s)
- Joonyoung Baeg
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Han Sol Choi
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Charm Kim
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
- Department of Ophthalmology, AIN Woman`s Hospital, Incheon, Republic of Korea
| | - Hyuna Kim
- Department of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sun Young Jang
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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Zare S, Meidani Z, Ouhadian M, Akbari H, Zand F, Fakharian E, Sharifian R. Identification of data elements for blood gas analysis dataset: a base for developing registries and artificial intelligence-based systems. BMC Health Serv Res 2022; 22:317. [PMID: 35260155 PMCID: PMC8902269 DOI: 10.1186/s12913-022-07706-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/01/2022] [Indexed: 11/23/2022] Open
Abstract
Background One of the challenging decision-making tasks in healthcare centers is the interpretation of blood gas tests. One of the most effective assisting approaches for the interpretation of blood gas analysis (BGA) can be artificial intelligence (AI)-based decision support systems. A primary step to develop intelligent systems is to determine information requirements and automated data input for the secondary analyses. Datasets can help the automated data input from dispersed information systems. Therefore, the current study aimed to identify the data elements required for supporting BGA as a dataset. Materials and methods This cross-sectional descriptive study was conducted in Nemazee Hospital, Shiraz, Iran. A combination of literature review, experts’ consensus, and the Delphi technique was used to develop the dataset. A review of the literature was performed on electronic databases to find the dataset for BGA. An expert panel was formed to discuss on, add, or remove the data elements extracted through searching the literature. Delphi technique was used to reach consensus and validate the draft dataset. Results The data elements of the BGA dataset were categorized into ten categories, namely personal information, admission details, present illnesses, past medical history, social status, physical examination, paraclinical investigation, blood gas parameter, sequential organ failure assessment (SOFA) score, and sampling technique errors. Overall, 313 data elements, including 172 mandatory and 141 optional data elements were confirmed by the experts for being included in the dataset. Conclusions We proposed a dataset as a base for registries and AI-based systems to assist BGA. It helps the storage of accurate and comprehensive data, as well as integrating them with other information systems. As a result, high-quality care is provided and clinical decision-making is improved.
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Affiliation(s)
- Sahar Zare
- Health Information Management Research Center (HIMRC), Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Meidani
- Health Information Management Research Center (HIMRC), Kashan University of Medical Sciences, Kashan, Iran.,Department of Health Information Management & Technology, School of Allied Health Professions, Kashan University of Medical Sciences, Kashan, Iran
| | - Maryam Ouhadian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hosein Akbari
- Department of Epidemiology and Biostatistics, School of Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Anesthesia and Critical Care Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Esmaeil Fakharian
- Department of Neurosurgery, Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Roxana Sharifian
- Health Human Resources Research Center, Department of Health Information Management and Technology, Shiraz University of Medical Sciences, Shiraz, Iran
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The Changes in Optic Nerve after Orbital Decompression Surgery for Thyroid Eye Disease and Case Reports of Ischemic Optic Neuropathy. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4808194. [PMID: 35265712 PMCID: PMC8898798 DOI: 10.1155/2022/4808194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/06/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022]
Abstract
Purpose To demonstrate the changes in the retinal nerve fiber layer (RNFL) after orbital decompression for thyroid eye disease (TED). Methods We retrospectively enrolled 52 surgical TED patients, 30 nonsurgical TED patients, and 30 control subjects. Five surgical TED eyes with disc edema were excluded. The surgical TED patients were classified into the “dysthyroid optic neuropathy (DON)” group (16 eyes) and the “non-DON” group (83 eyes). Optical coherence tomography (OCT) and visual field (VF) examinations were performed preoperatively and 6 months later. The control subjects and nonsurgical TED patients received two OCT examinations at 6-month intervals. The postoperative changes in the RNFL thickness were compared between groups. Three cases with severe postoperative vision loss were presented additionally. Results The changes in the RNFL thickness of the controls (0.5 ± 3.4 μm) and the nonsurgical TED patients (0.3 ± 2.8 μm) were significantly smaller than the surgical TED patients (P < 0.001). The DON group (−9.2 ± 9.2 μm) had greater RNFL thickness reduction than the non-DON group (−3.9 ± 5.4 μm) (P = 0.002). Bone removal decompression was associated with decreased RNFL in the non-DON (P = 0.025; β = −2.49) and DON (P = 0.042; β = −9.43) groups. Three cases who were hard to operate due to extensive fibrosis experienced severe vision loss postoperatively due to anterior ischemic optic neuropathy, posterior ischemic optic neuropathy, and posterior ciliary artery occlusion, respectively. Conclusions TED patients experienced subclinical optic nerve injury and significant RNFL loss after the orbital decompression surgery. Aggressive manipulation during decompression surgery may lead to dreadful vision loss. Tailored surgical plans and delicate manipulation are warranted.
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Suresh R, Soparkar CN, Alford EL. Sinonasal complications associated with endoscopic orbital decompression. Laryngoscope Investig Otolaryngol 2021; 6:71-76. [PMID: 33614932 PMCID: PMC7883623 DOI: 10.1002/lio2.531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Characterize sinonasal complications associated with endoscopic orbital decompression for thyroid eye disease (TED). METHODS Retrospective analysis of patients who underwent endoscopic orbital decompression at Houston Methodist Hospital by two otolaryngologists and one ophthalmologist between May 2016 and February 2020 for TED. Patient ethnicity, age, laterality, operative approach (middle turbinectomy vs middle turbinate sparing), and history of prior sinusitis were collected. RESULTS One hundred and forty-five orbital decompressions met the inclusion criteria. Postoperative obstructive sinusitis where herniated orbital fat caused obstruction of the sinus ostium occurred in 5.5% of operations. Patients who had a prior history of sinusitis were more likely to develop postoperative obstructive sinusitis (P = .02). The middle turbinectomy approach was more likely to show a reduced incidence of postoperative sinusitis (P = .014). CONCLUSION Given the increased difficulty of managing sinonasal complications in the context of a decompressed orbit, efforts should be made to identify factors that might reduce the incidence of postoperative endonasal complications. The current study suggests that resection of the middle turbinate may allow for increased space for orbital fat herniation and lead to a decreased incidence of postoperative obstructive sinusitis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | - Eugene L. Alford
- Houston Methodist Institute for Reconstructive SurgeryHoustonTexasUSA
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Grusha YO, Kochetkov PA, Ismailova DS, Svistushkin VM, Zhorzholadze NV, Spychak VY. [Efficacy of transethmoidal orbital decompression in patients with dysthyroid optic neuropathy]. Vestn Otorinolaringol 2021; 85:52-55. [PMID: 33474918 DOI: 10.17116/otorino20208506152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To estimate efficacy and safety of endoscopic orbital decompression in patients with dysthyroid optic neuropathy (DON). MATERIAL AND METHODS 19 patients aged 54.8±7.1 y.o. with DON were enrolled into the study. RESULTS Visual acuity was from counting fingers till 0.9 (0.4±0.28) before surgery, it increased till 0.7±0.2 (p<0.05) after surgery. The amount of correct Ishihara plates increased from 5.8±7 till 13.3±7.6 (p<0.05). Exophthalmos reduced by 1.7 mm (p<0.05). Significant reduce of orbital inflammation was noted as well. CONCLUSIONS This study is the first study of this kind in Russian Federation. Obtained results showed high efficacy and safety of endoscopic orbital decompression in patients with DON.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovskiy University), Moscow, Russia
| | - P A Kochetkov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovskiy University), Moscow, Russia
| | | | - V M Svistushkin
- I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovskiy University), Moscow, Russia
| | | | - V Y Spychak
- I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovskiy University), Moscow, Russia
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Clarós P, Waląg A, López-Fortuny M, Clarós A. Impact of the ethmoid volume on endoscopic medial wall decompression outcomes in Graves' orbitopathy. Acta Otolaryngol 2020; 140:948-953. [PMID: 32957802 DOI: 10.1080/00016489.2020.1816655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endoscopic orbital decompression is a well-established technique for Graves orbitopathy treatment. AIMS Measurement of the ethmoid volume and its correlation with proptosis reduction in patients undergoing endoscopic orbital decompression for Graves' orbitopathy. METHODS We retrospectively reviewed clinical charts of 209 patients (319 orbits) operated by a surgeon at our institution between 1998 and 2019. RESULTS Average age was 46.9 years. About 83.3% of the patients were female, 54.6% were smokers, 93.8% were euthyroid at the time of decompression, 3.8% were hypothyroid and 2.4% were hyperthyroid. About 77.5% of the patients underwent bilateral surgery, the remainder and unilateral. Subsequent stages included strabismus surgery in 22.5% patients, Müllerectomy 37.8%, with or without canthoplasty (14.8 vs. 23%). Mean proptosis reduction was 4.61 mm. Mean ethmoid volume was 5.57 mm3. Ethmoid volume had a moderate positive correlation with proptosis reduction (r s = 0.49, p < .001). Further investigation, statistically significant moderate correlation was found only in the small (SE) and big (BE) ethmoid groups. CONCLUSION We advise evaluating ethmoid sinus pneumatization on computed tomography before decompression to estimate possible anatomical limitations. Additional wall decompression might be advocated in most severe cases.
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Affiliation(s)
| | - Agnieszka Waląg
- Scholarship at Clínica Clarós, Barcelona, Spain
- Department of Otolaryngology, Rydygier Memorial Hospital, Cracow, Poland
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Endoscopic Orbital Decompression by Oculoplastic Surgeons for Proptosis in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2020; 35:590-593. [PMID: 31162299 DOI: 10.1097/iop.0000000000001406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Orbital decompression is an established surgical treatment option for a range of orbital conditions. Traditionally, Ear, Nose and Throat surgeons have adopted the endoscopic route while ophthalmologists operate via an external approach. The authors report the outcomes of endonasal decompression performed by oculoplastic surgeons experienced in endonasal techniques. METHODS This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to thyroid eye disease across 2 hospital sites between January 2011 and July 2018. Inclusion criteria were patients who had endoscopic decompression for proptosis in inactive thyroid eye disease or active disease without dysthyroid optic neuropathy. Information collected includes patient demographics, diagnosis, surgical details, preoperative and postoperative clinical findings (including, visual acuity, color vision, exophthalmometry readings, palpebral aperture, intraocular pressure, ocular motility, diplopia, and visual field), complications, and further treatment. RESULTS There were 70 cases of endoscopic decompression. The majority of patients had endoscopic medial and posterior medial wall/floor decompression (44.3%; 31/70 cases). Visual acuity remained stable in 98.6% (69/70). There was an average reduction in proptosis of 3.5 ± 1.2 mm (standard deviation [SD]) in the endoscopic medial wall only group, 3.9 ± 0.9 mm (SD) in endoscopic medial wall and posterior medial portion of the floor group, and 7.6 ± 2.1 mm (SD) in the 3-wall decompression group. Motility improved in 11.4% (8/70) and worsened in 2.9% (2/70). There were no significant intraoperative or postoperative complications associated with endoscopic surgery. CONCLUSIONS Oculoplastic surgeons experienced in endonasal techniques can perform endoscopic orbital decompression with outcomes comparable to the literature.The authors report the outcomes of a series of endonasal orbital decompression carried out by oculoplastic surgeons.
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Gladilin E, Hierl T, Sterker I, Hümpfner-Hierl H, Hemprich A, Krause M. Retrospective cohort study of three-wall orbital resection for treatment of endocrine orbitopathy using 3D tomographic data and biomechanical modeling. Clin Biomech (Bristol, Avon) 2020; 71:86-91. [PMID: 31707189 DOI: 10.1016/j.clinbiomech.2019.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 09/28/2019] [Accepted: 10/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical treatment of endocrine orbitopathy can be performed by way of resecting orbital walls, which effectively releases superfluous tissue from the surgically enlarged orbital space allowing the eyeballs to move back. Existing approaches aim to select an optimal surgical strategy based on statistical correlations between the extent of the surgical procedure and the resulting bulbus displacement but do not provide an individual surgery plan or predict surgery outcome. METHODS In this retrospective study, we performed a quantitative analysis of pre- and post-surgery 3D tomographic data of six patients and applied explorative biomechanical modeling of orbital mechanics to dissect factors influencing patient-specific outcome. FINDINGS Our experimental results showed a large variability of the backward eyeball displacement in dependency on the amount of orbital volume flow, which could partially be described by computational simulation. Our detailed analysis revealed that patients with regular fat tissue show a good correlation between bulbus displacement and relative volume of decompressed tissue, which, in turn, correlates with decrease in hydrostatic pressure. In contrast, patients with fibrotic tissue exhibit significantly reduced and computationally less predictable eyeball translation in response to surgical tissue decompression. INTERPRETATION Based on the results of this study we see a great potential for quantitative planning of surgical exophthalmos treatment using 3D biomechanical modeling. Conventional approaches to planning of soft tissue interventions consider, however, only the patient's 3D anatomy and widely disregard individual tissue properties. Further investigations are required to establish reliable procedures for assessment of individual tissue properties and incorporating them into patient-specific models of orbital mechanics.
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Affiliation(s)
- Evgeny Gladilin
- German Cancer Research Center, Div. Bioinformatics and Omics Data Analytics, Mathematikon - Berliner Str. 41, Heidelberg 69120, Germany; University Heidelberg, BioQuant, Im Neuenheimer Feld 267, Heidelberg 69120, Germany.
| | - Thomas Hierl
- Department of Oral and Maxillofacial Plastic Surgery, Helios Vogtlandklinikum Plauen, Roentgenstr. 2, Plauen 08529, Germany
| | - Ina Sterker
- Department of Ophthalmology, Leipzig University Hospital, Liebigstr. 10-14, 04103 Leipzig, Germany
| | - Heike Hümpfner-Hierl
- Department of Oral and Maxillofacial Plastic Surgery, Leipzig University Hospital, Liebigstr. 10-14, Leipzig 04103, Germany
| | - Alexander Hemprich
- Department of Oral and Maxillofacial Plastic Surgery, Leipzig University Hospital, Liebigstr. 10-14, Leipzig 04103, Germany
| | - Matthias Krause
- Department of Oral and Maxillofacial Plastic Surgery, Leipzig University Hospital, Liebigstr. 10-14, Leipzig 04103, Germany
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Dagi LR, Velez FG, Archer SM, Atalay HT, Campolattaro BN, Holmes JM, Kerr NC, Kushner BJ, Mackinnon SE, Paysse EA, Pihlblad MS, Pineles SL, Strominger MB, Stager DR, Stager D, Capo H. Adult Strabismus Preferred Practice Pattern®. Ophthalmology 2020; 127:P182-P298. [DOI: 10.1016/j.ophtha.2019.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022] Open
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Juniat V, McGilligan JA, Curragh D, Selva D, Rajak S. Endoscopic orbital decompression for proptosis in non-thyroid eye disease. Oral Maxillofac Surg 2019; 24:85-91. [PMID: 31853760 DOI: 10.1007/s10006-019-00826-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/06/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE Orbital decompression is an established surgical treatment option for a range of orbital conditions. We report the outcomes of endonasal decompression to recess the globe for conditions and pathologies other than thyroid eye disease. METHODS This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to non-thyroid eye disease orbital pathologies. The procedures were carried out by oculoplastic surgeons across two hospital sites between January 2011 and July 2018. Information collected includes patient demographics, diagnosis, surgical details, pre- and postoperative clinical findings (including visual acuity, exophthalmometry readings, intraocular pressure, ocular motility and diplopia), complications and further treatment. RESULTS There were seven cases of endoscopic decompression, each due to a different pathology. The reasons for decompression were proptosis secondary to optic nerve sheath meningioma (1); sphenoid wing meningioma (1); idiopathic myositis (1); axial myopia (1); chronic third nerve palsy (1); to protuberant keratoprosthesis (1); and Crouzon syndrome with corneal exposure (1). Visual acuity remained stable or improved in all patients postoperatively. There was an average reduction in proptosis of 3.5 ± 1.4 mm (standard deviation - SD). Ocular motility remained stable in 100% (7/7). There were no intraoperative or postoperative complications, including no new cases of postoperative diplopia. CONCLUSIONS Endoscopic orbital decompression can be performed for patients with proptosis associated with a large globe, facial dysplasia or medial and infero-medial orbital lesions.
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Affiliation(s)
- Valerie Juniat
- Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia.
| | - J Anthony McGilligan
- Department of Ears, Nose and Throat, Princess Royal Hospital,, RX16 4EX, Haywards Heath, UK
| | - David Curragh
- Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Dinesh Selva
- Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Saul Rajak
- Department of Ophthalmology, Sussex Eye Hospital, Eastern Road, Brighton, BN2 5BF, UK
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Abstract
Purpose: Vision loss after orbital surgery is one of the most dreaded complications faced by the orbitofacial surgeon. This literature review was conducted in an attempt to determine the risk factors for severe vision loss and discuss the applied anatomy related to various types of orbital surgery - orbital tumor excisions, orbital decompression, and post-traumatic orbital reconstruction.Methods: A literature search was conducted via PubMed and Google Scholar. All cases of vision loss following orbital tumor biopsy or excision, orbital decompression, and orbital trauma reconstruction were reviewed.Results: The incidence of postoperative blindness appears to be more after orbital tumor excisions (4.7%), compared to post-traumatic orbital reconstruction (2.08%) and orbital decompressions for thyroid orbitopathy (0.15%).The causes of vision loss include ischemic optic neuropathy, traumatic optic neuropathy, retinal and ophthalmic artery occlusions, and orbital compartment syndrome.Conclusion: Apart from careful patient selection, proper counseling about the risk of postoperative blindness is of utmost importance. Detailed preoperative treatment planning, meticulous atraumatic intraoperative dissection under direct visualization, with attention to the danger zones and vital structures, close intraoperative and postoperative monitoring, and urgent management of potentially reversible compressive causes of vision loss can improve outcomes.
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Affiliation(s)
- Prerana Kansakar
- Orbit & Oculofacial Surgery, Department of Ophthalmology, National University Hospital Singapore, Singapore.,Department of Ophthalmology, Grande International Hospital, Kathmandu, Nepal
| | - Gangadhara Sundar
- Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore
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Shin KJ, Lee SH, Ha TJ, Shin HJ, Koh KS, Song WC, Paik DJ. Position and size of the sphenoid door jamb in the lateral orbital wall for the orbital decompression. Anat Cell Biol 2019; 52:242-249. [PMID: 31598352 PMCID: PMC6773894 DOI: 10.5115/acb.19.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/13/2019] [Indexed: 01/15/2023] Open
Abstract
The aim of this study was to identify the three-dimensional topography of the sphenoid door jamb (SDJ) in the lateral orbital wall and to propose navigational guidelines for safe deep lateral decompression using surgical landmarks. The 120 orbits and SDJs of 60 subjects were three-dimensionally reconstructed using Mimics software. The mean volumes of the orbit and SDJ were 24.3 mm3 and 2.0 mm3, respectively. The mean distances from the lateral orbital margin (LOM) to the anterior and posterior margins of the SDJ were 13.2 and 36.3 mm, respectively. The mean distances from the superior orbital fissure to the LOM and to the posterior margin of the SDJ were 40.2 mm and 4.6 mm, respectively. The mean distances from the inferior orbital fissure (IOF) to the anterior and posterior margins of the SDJ were 3.8 mm and 20.5 mm, respectively. In the superior approach of the orbit, it can be predicted that the area up to 3 cm posterior from the LOM is safe, while 1 cm posterior from the safe zone could be a dangerous zone. In the inferior approach of the orbit, the safe area will be about 1 cm posterior from the anterior tip of the IOF, and the area up to 1 cm posterior from the safe zone should be approached with extreme care.
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Affiliation(s)
- Kang-Jae Shin
- Department of Anatomy and Cell Biology, Dong-A University College of Medicine, Busan, Korea
| | - Shin-Hyo Lee
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Tae-Jun Ha
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Jin Shin
- Department of Ophthalmology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Ki-Seok Koh
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Wu-Chul Song
- Department of Anatomy, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Doo-Jin Paik
- Department of Medical Education, Hanyang University College of Medicine, Seoul, Korea
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Curragh DS, Selva D. Endoscopic orbital fat decompression for the management of proptosis in Grave's orbitopathy using a laryngeal skimmer blade. Eye (Lond) 2019; 33:1924-1929. [PMID: 31285569 DOI: 10.1038/s41433-019-0519-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 04/17/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUNDS/OBJECTIVES Intraoperative handling and manipulation of orbital fat remains a challenge to orbital surgeons. We present a case series of endoscopic orbital fat decompression with medial orbital wall decompression for proptosis management in Grave's orbitopathy, describing a technique for fat excision using a laryngeal skimmer blade, reporting clinical and surgical outcomes, and complications. SUBJECTS/METHODS All patients who underwent endoscopic orbital fat decompression, with medial orbital wall decompression, for proptosis management in Grave's orbitopathy between 2011 and 2018, under the care of a single surgeon, were included in this retrospective interventional case series. RESULTS Nineteen patients were included in this study. Using a laryngeal skimmer blade, orbital fat was excised endoscopically at the time of medial orbital wall decompression. The mean volume of orbital fat excised was 1.45 ± 0.63 ml and the mean reduction in proptosis was 4.5 ± 1.02 mm. There were no intraoperative complications. CONCLUSIONS In this study, we describe our experience of using a laryngeal skimmer blade as a method of excising orbital fat for orbital decompression in patients with proptosis secondary to Grave's orbitopathy.
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Affiliation(s)
- David S Curragh
- Department of Ophthalmology & Visual Sciences, University of Adelaide, North Terrace, SA, 5000, Australia. .,South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Port Road, SA, 5000, Australia.
| | - Dinesh Selva
- Department of Ophthalmology & Visual Sciences, University of Adelaide, North Terrace, SA, 5000, Australia.,South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Port Road, SA, 5000, Australia
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Oeverhaus M, Copei A, Mattheis S, Ringelstein A, Tiemessen M, Esser J, Eckstein A, Stähr K. Influence of orbital morphology on proptosis reduction and ocular motility after decompression surgery in patients with Graves' orbitopathy. PLoS One 2019; 14:e0218701. [PMID: 31233522 PMCID: PMC6590818 DOI: 10.1371/journal.pone.0218701] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/08/2019] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Orbital decompression surgery is performed in patients with Graves' orbitopathy to treat dysthyroid optical neuropathy (DON) and reduce disfiguring proptosis. The intended proptosis reduction can deviate from the postoperative result and changes of motility with consecutive diplopia can occur. We performed a retrospective study to identify anatomical factors in computed tomography (CT), which influence the surgical effect and postoperative ocular motility and diplopia. METHODS Pre- and postoperative CT-scans of 125 eyes of 68 patients, who mainly underwent a balanced orbital decompression for disfiguring proptosis (≥18mm Hertel Index), have been analyzed. Proptosis, ductions, misalignment and diplopia were assessed before and after surgery. Medial and lateral orbital wall length, conus angle, depth of ethmoidal sinus, orbital surface, length of medial and orbital defect, depth of tissue prolapse and horizontal muscle diameters were analyzed in CT scans before and after surgery. With linear regression and multivariate analyses these parameters have been correlated with postoperative proptosis, abduction deficit, deviation and binocular single vision (BSV). RESULTS Proptosis could be reduced by 5.3±2mm. Patients with <5mm proptosis reduction had significantly less often new onset of diplopia compared to patients with >5mm reduction (13% vs. 56%, p = 0.02). Multiple linear regression showed a significant correlation between tissue prolapse and depth of the ethmoidal sinus as well as age (p<0.001, r = 0.71). Proptosis reduction could not be predicted by tissue prolapse, defect length or depth of ethmoidal sinus. The abduction deficit correlated significantly with tissue prolapse and orbital surface area (p<0.001, r = 0.37) but not with the horizontal muscle diameter. CONCLUSION We were able to show that orbital morphology influences the outcome of balanced orbital decompression surgery in terms of proptosis reduction and motility. However, the rather low coefficients of correlation show that the surgical outcome cannot be predicted with simple CT measurements, although risk factors for postoperative abduction deficit could be found. Therefore, preoperative planning should consider especially the orbital surface area and depth of ethmoidal sinus. Patients should be informed about the higher risk of diplopia with higher proptosis reduction.
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Affiliation(s)
- Michael Oeverhaus
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Anna Copei
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
- Department of Gynecology, University Hospital Oldenburg, Oldenburg, Germany
| | - Stefan Mattheis
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital Essen, Essen, Germany
| | | | - Madeleine Tiemessen
- Department of Radiology and Neuroradiology, Alfried Krupp Hospital Essen, Essen, Germany
| | - Joachim Esser
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Anja Eckstein
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Kerstin Stähr
- Department of Gynecology, University Hospital Oldenburg, Oldenburg, Germany
- * E-mail:
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15
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Woods RSR, Pilson Q, Kharytaniuk N, Cassidy L, Khan R, Timon CVI. Outcomes of endoscopic orbital decompression for graves' ophthalmopathy. Ir J Med Sci 2019; 189:177-183. [PMID: 31203506 DOI: 10.1007/s11845-019-02043-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 05/27/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND/AIMS We assess outcomes of endoscopic orbital decompression for Graves' ophthalmopathy. METHODS A review of endoscopic orbital decompressions of the medial and partial inferior wall between July 2004 and July 2017 was carried out. Outcome was assessed by comparing pre- and post-operative measurements of exophthalmometry and visual acuity. Results were evaluated by repeated measures analysis of variance. RESULTS A total of 41 orbits in 25 patients underwent endoscopic orbital decompression for Graves' ophthalmopathy in the time period; however, six orbits in three patients had insufficient data for inclusion. Eleven patients required concurrent septoplasty to allow access. Measurements were taken at a mean of 11 days, 32 days, and 95 days post-operatively. Reduction in mean proptosis was 2.81 mm at 1-month post-decompression and 3.26 mm at 3 months. There was no significant difference between those treated for compressive optic neuropathy compared with those treated for cosmetic reasons. Colour vision by Ishihara plate improved significantly by a mean score of 2.67 post-operatively. Using LogMAR conversion for visual acuity, measured by a best-corrected Snellen chart, improvement of 0.18 was achieved at 1-month post-decompression, equivalent to approximately two lines on the Snellen chart. There was minimal (0.04) further improvement at 3 months. The improvement in visual acuity was greater in cases treated for compressive optic neuropathy than cosmesis, but this did not reach statistical significance (p = 0.06). Three cases required revision surgery. Diplopia disimproved or developed in four cases and squint surgery was required in three cases. CONCLUSIONS Endoscopic orbital decompression offers an effective, safe and minimally invasive treatment for Graves' ophthalmopathy. There is a trend towards continued improvement in outcomes over the course of 3 months post-operatively.
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Affiliation(s)
- Robbie S R Woods
- Department of Otolaryngology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin, Ireland.
| | - Qistina Pilson
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin, Ireland
| | - Natallia Kharytaniuk
- Department of Otolaryngology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin, Ireland
| | - Lorraine Cassidy
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin, Ireland
| | - Rizwana Khan
- Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin, Ireland
| | - Conrad V I Timon
- Department of Otolaryngology, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin, Ireland
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Park NR, Lee JK. The Clinical Result of Medial Orbital Decompression in Patients with Thyroid-associated Orbitopathy. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.11.1015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Na Ri Park
- Department of Ophthalmology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeong Kyu Lee
- Department of Ophthalmology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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17
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Reply re: "Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy". Ophthalmic Plast Reconstr Surg 2018. [PMID: 29517606 DOI: 10.1097/iop.0000000000001084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Orbital decompression surgery increases the orbital volume. It has rarely been used for proptosis of the large highly myopic globe. However, external decompression surgery carries significant risks because of the large thin-walled globe. The authors report the first use of endoscopic medial wall orbital decompression surgery in this setting to obviate the risk of globe pressure.Endoscopic medial wall decompression brought about a 4 mm reduction of proptosis, correction of exotropia and elimination of retrobulbar ache providing good symmetry with the fellow eye.Endoscopic medial wall orbital decompression can be very effective for correcting the proptosis of high myopia and minimizes the risk of damage to the very large, thin-walled globe.
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Hernández-García E, San-Román JJ, González R, Nogueira A, Genol I, Stoica B, Toledano N, Plaza G. Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves' orbitopathy. Acta Otolaryngol 2017; 137:1183-1187. [PMID: 28741406 DOI: 10.1080/00016489.2017.1354394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND To determine the clinical outcomes and morbidity of endoscopic medial wall combined with transcutaneous lateral orbital wall decompression in Graves' orbitopathy. METHODOLOGY A retrospective noncomparative case series of patients who underwent surgical decompression for Graves' orbitopathy at Hospital Universitario de Fuenlabrada between 2004 and 2014 was performed. We reviewed the patients' charts and analyzed before and after the decompression, the visual acuity (Snellen chart), optic nerve compression (fundoscopy and optic coherence tomography), exophthalmometry (Hertel measurement), ocular motility, diplopia, eyelid surgery needed after decompression and its possible complications. RESULTS A total of 20 patients (36 orbits) were operated. The mean follow-up was 44 months (range 18-84). Vision improved dramatically in all compressive optic neuropathy cases (5 cases). Hertel measurements improved on average 3.5 mm (range 1.5-4.5). Diplopia was cured in eight patients (40%) and nine patients with severe preoperative diplopia required strabismus surgery after decompression. Eyelid surgery was further needed in 13 patients. Hyaluronic acid injection was the most used technique for the treatment of eyelid retraction (6 out of 13 patients). Only two major complications were observed: one case had a major post-operative epistaxis and another a cerebrospinal fluid leak. Both were resolved without further sequelae. CONCLUSIONS These results suggest that endoscopic medial wall combined with transcutaneous lateral wall orbital decompression is an effective and safe treatment for the symptomatic dysthyroid eye disease with important proptosis or compressive optic neuropathy.
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Affiliation(s)
| | - J. Javier San-Román
- Department of Ophthalmology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Ramón González
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada Madrid, Spain
| | - Araceli Nogueira
- Department of Ophthalmology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Ignacio Genol
- Department of Ophthalmology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Bazil Stoica
- Department of Ophthalmology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Nicolás Toledano
- Department of Ophthalmology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Guillermo Plaza
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada Madrid, Spain
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Sobol EK, Rosenberg JB. Strabismus After Ocular Surgery. J Pediatr Ophthalmol Strabismus 2017; 54:272-281. [PMID: 28753216 DOI: 10.3928/01913913-20170703-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 04/18/2017] [Indexed: 11/20/2022]
Abstract
Many types of ocular surgery can cause diplopia, including eyelid, conjunctival, cataract, refractive, glaucoma, retinal, and orbital surgery. Mechanisms include direct injury to the extraocular muscles from surgery or anesthesia, scarring of the muscle complex and/or conjunctiva, alteration of the muscle pulley system, mass effects from implants, and muscle displacement. Diplopia can also result from a loss of fusion secondary to long-standing poor vision in one eye or from a decompensation of preexisting strabismus that was not recognized preoperatively. Treatment, which typically begins with prisms and is followed by surgery when necessary, can be challenging. In this review, the incidence, mechanisms, and treatments involved in diplopia after various ocular surgeries are discussed. [J Pediatr Ophthalmol Strabismus. 2017;54(5):272-281.].
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Ference EH, Sindwani R, Tan BK, Chandra RK, Kern RC, Conley D, Smith SS. Open versus endoscopic medial orbital decompression: Utilization, cost, and operating room time. Am J Rhinol Allergy 2017; 30:360-6. [PMID: 27657902 DOI: 10.2500/ajra.2016.30.4350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The advent of endoscopic sinus surgery has created an exciting interface between rhinology and ophthalmology in the area of orbital and optic nerve decompression Objectives: (1) To study the utilization of open versus endoscopic medial orbital decompression based on geography and indication, (2) to describe the demographics of the patient populations who underwent these different techniques, and (3) to compare outcomes, including mean charges and operating room (OR) times Methods: Cases identified by Current Procedural and Terminology codes were extracted from the California, Florida, Maryland, and New York State Ambulatory Surgery Databases from 2009 to 2011. Patient demographics, diagnoses, mean charge, and OR time were compared. RESULTS A total of 1009 patients underwent orbital decompression; 93.0% of cases involved the medial wall only; 22.9% of medial decompressions were performed endoscopically, 74.5% were open, and 2.6% were via combined approach. Eighty percent of patients had thyroid eye disease. Analyses adjusted for sex, age, race, state, and diagnosis found that surgeries for infection (N = 47) were more likely to be performed endoscopically compared with procedures for other diagnoses (N = 962) (odds ratio 5.27 [2.67-10.40], p < 0.001). Patients in Florida were more likely to undergo endoscopic decompression compared with patients in California (odds ratio 2.35 [1.42-3.62]). The difference in median charge for endoscopic ($13,119) versus open ($11,291; p = 0.085) procedures was not significant on bivariate analysis but was significant on multivariate analysis (p = 0.04). The median OR time for open procedures was, on average, 33 minutes shorter (endoscopic, 132 minutes; open, 98 minutes; p ≤ 0.001) on bivariate analysis but was not significantly different when controlling for covariables (p = 0.08). CONCLUSION In the study sample, endoscopic orbital decompression was performed in 22.9% of patients, with significant variation in surgical technique based on geography and indication. Procedures that used endoscopic compared with open decompression techniques had no significant difference in charge on bivariate analysis. The OR time for open procedures was shorter on bivariate but not on multivariate analysis. Further research is required regarding the relative effectiveness of open versus endoscopic surgical techniques for various indications.
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Affiliation(s)
- Elisabeth H Ference
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Calculation of resected orbital wall areas in the treatment of endocrine orbitopathy. J Craniomaxillofac Surg 2017; 45:485-490. [DOI: 10.1016/j.jcms.2017.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/14/2016] [Accepted: 01/11/2017] [Indexed: 11/19/2022] Open
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Asorey-García A, Martínez-Chico R, Santos-Bueso E, García-Feijoo J. Optic neuropathy after orbital decompression surgery. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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24
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Decompression for thyroid eye disease: An evolving trend of multidisciplinary approach. J Formos Med Assoc 2015; 115:292. [PMID: 26640249 DOI: 10.1016/j.jfma.2015.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 10/22/2015] [Indexed: 11/22/2022] Open
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25
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Learned KO, Nasseri F, Mohan S. Imaging of the Postoperative Orbit. Neuroimaging Clin N Am 2015. [PMID: 26208420 DOI: 10.1016/j.nic.2015.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Imaging evaluation of the postoperative orbit remains challenging even for the expert neuroradiologist. This article provides a simplified framework for understanding the complex postoperative appearances of the orbit, in an attempt to enhance the diagnostic accuracy of postoperative computed tomography and MR imaging of the orbit. Readers are familiarized with the normal appearances of common eye procedures and orbit reconstructions to help avoid interpretative pitfalls. Also reviewed are imaging features of common surgical complications, and evaluation of residual/recurrent neoplasm in the setting of oncologic imaging surveillance.
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Affiliation(s)
- Kim O Learned
- Neuroradiology Division, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at University of Pennsylvania, 219 Dulles Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Farbod Nasseri
- Neuroradiology Division, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at University of Pennsylvania, 219 Dulles Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Suyash Mohan
- Neuroradiology Division, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at University of Pennsylvania, 219 Dulles Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Lv Z, Selva D, Yan W, Daniel P, Tu Y, Wu W. Endoscopical Orbital Fat Decompression with Medial Orbital Wall Decompression for Dysthyroid Optic Neuropathy. Curr Eye Res 2015; 41:150-8. [PMID: 25835075 DOI: 10.3109/02713683.2015.1008640] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Zhigang Lv
- a Department of Ophthalmology , Jinhua Center Hospital , Jinhua , Zhejiang , P.R. China
| | - Dinesh Selva
- b Discipline of Ophthalmology & Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology , Adelaide , Australia
| | - Wentao Yan
- c Department of Orbital & Oculoplastic Surgery , Eye Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , P.R. China and
| | - Pelaez Daniel
- d Bascom Palmer Eye Institute, University of Miami Miller School of Medicine , Miami , FL , USA
| | - Yunhai Tu
- c Department of Orbital & Oculoplastic Surgery , Eye Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , P.R. China and
| | - Wencan Wu
- c Department of Orbital & Oculoplastic Surgery , Eye Hospital of Wenzhou Medical University , Wenzhou , Zhejiang , P.R. China and
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Gulati S, Ueland HO, Haugen OH, Danielsen A, Rødahl E. Long-term follow-up of patients with thyroid eye disease treated with endoscopic orbital decompression. Acta Ophthalmol 2015; 93:178-83. [PMID: 24989709 DOI: 10.1111/aos.12469] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 05/07/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the outcome of endoscopic decompression in a series of patients with thyroid eye disease. METHODS All 46 patients operated at our institution in the period 2001 to 2011 were invited for re-examination. Thirty-seven patients were included in the study and underwent a general otorhinolaryngological and ophthalmological examination. Nasal endoscopy, autoperimetry and a CT scan of the orbits and paranasal sinuses were performed. Preoperative and early postoperative data were obtained from hospital records. Re-examination was performed from 12 months to 9 years postoperatively. Paired t-test was used to evaluate the change in pre- and postoperative data. Image-guided surgery was used in two patients. RESULTS Visual acuity improved from a median value (range) of 0.8 (0.05-1.25) to 1.0 (0.4-1.25) (p=0.006). Intra-ocular pressure (IOP) was reduced from a median value (range) of 18 mmHg (10-27 mmHg) to 14 mmHg (8-24 mmHg) (p<0.001). Median (range) Hertel values were 22.5 mm (14-29 mm) preoperatively and 19 mm (11-26 mm) postoperatively (p<0.001). Mean reduction in proptosis was 4.0 mm. At follow-up, visual fields were normal in 16/37 patients (43%) and with small defects in 12/37 patients (32%). Seventeen patients (46%) had diplopia preoperatively in one or more directions of gaze while 9 (24%) suffered from constant diplopia. After endoscopic decompression, new onset diplopia was seen in seven (19%) individuals, while worsening of diplopia occurred in eight (22%). Impaired motility in abduction and/or elevation was seen in 20 (54%) individuals before decompression and in 23 (62%) after. Strabismus surgery was performed in 22 patients. On final examination 85% of the study population were totally free of diplopia or experienced diplopia only in the peripheral field of gaze. Three patients developed sinusitis. Of these, endoscopic sinus surgery was performed in two patients, and one patient was conservatively treated. Symptoms resolved in all three patients. CONCLUSION Endoscopic medial orbital decompression including removal of the medial floor of the orbit is a safe and effective procedure for treatment of thyroid eye disease. Navigation can be of valuable help to ensure complete resection of the bony walls. However, the majority of patients will need subsequent strabismus surgery, mainly due to significant increase of esotropia.
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Affiliation(s)
- Shashi Gulati
- Department of Otolaryngology, Head and Neck Surgery; Haukeland University Hospital; Bergen Norway
| | - Hans Olav Ueland
- Department of Ophthalmology; Haukeland University Hospital; Bergen Norway
| | - Olav H. Haugen
- Department of Ophthalmology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Arild Danielsen
- Department of Otolaryngology, Head and Neck Surgery; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Eyvind Rødahl
- Department of Ophthalmology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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Wu W, Selva D, Bian Y, Wang X, Sun MT, Kong Q, Yan W. Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy. Am J Ophthalmol 2015; 159:277-84. [PMID: 25448997 DOI: 10.1016/j.ajo.2014.10.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 10/26/2014] [Accepted: 10/27/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Wencan Wu
- Department of Orbital & Oculoplastic Surgery, The Eye Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Dinesh Selva
- Discipline of Ophthalmology & Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Yang Bian
- Department of Orbital & Oculoplastic Surgery, The Eye Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaopeng Wang
- Department of Ophthalmology, Jinhua Center Hospital, Jinhua, China
| | - Michelle T Sun
- Discipline of Ophthalmology & Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia
| | - Qiao Kong
- Department of Ophthalmology, Lihuili Hospital, Ningbo, China
| | - Wentao Yan
- Department of Orbital & Oculoplastic Surgery, The Eye Hospital of Wenzhou Medical University, Wenzhou, China
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Mahoney N, Grant MP, Susarla SM, Merbs S. Computer-Assisted Three-Dimensional Planning for Orbital Decompression. Craniomaxillofac Trauma Reconstr 2014; 8:211-7. [PMID: 26269729 DOI: 10.1055/s-0034-1393731] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 04/21/2014] [Indexed: 01/17/2023] Open
Abstract
Thyroid-associated orbitopathy is the most common cause of unilateral or bilateral proptosis in adults. A mainstay of surgical treatment is orbital decompression utilizing osteotomies to increase the size of the affected bony orbit to accommodate the larger soft tissue volume. Over the past several decades, numerous approaches have been described for orbital decompression. However, given the intricate osseous and soft tissue anatomy within the orbit, orbital decompression is a potentially hazardous intervention. With advances in three-dimensional imaging and virtual planning, extensive orbital decompressions can be performed safely and efficiently. In this report, we describe two cases of three-wall orbital decompressions using three-dimensional planning.
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Affiliation(s)
- Nicholas Mahoney
- Division of Oculoplastic Surgery, Department of Ophthalmology, Wilmen Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael P Grant
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland ; Division of Oculoplastic Surgery, Department of Ophthalmology, Wilmen Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Srinivas Murthy Susarla
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Shannath Merbs
- Division of Oculoplastic Surgery, Department of Ophthalmology, Wilmen Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
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Asorey-García A, Martínez-Chico R, Santos-Bueso E, García-Feijoo J. Optic neuropathy after orbital decompression surgery. Neurologia 2014; 31:62-4. [PMID: 24975348 DOI: 10.1016/j.nrl.2014.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 04/16/2014] [Accepted: 04/29/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- A Asorey-García
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico, San Carlos (IdISSC), Madrid, España.
| | - R Martínez-Chico
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico, San Carlos (IdISSC), Madrid, España
| | - E Santos-Bueso
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico, San Carlos (IdISSC), Madrid, España
| | - J García-Feijoo
- Unidad de Neurooftalmología, Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico, San Carlos (IdISSC), Madrid, España
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Bleier BS, Lefebvre DR, Freitag SK. Endoscopic orbital floor decompression with preservation of the inferomedial strut. Int Forum Allergy Rhinol 2013; 4:82-4. [PMID: 24124099 DOI: 10.1002/alr.21231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 08/20/2013] [Accepted: 09/03/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Medial and inferior orbital decompression is most commonly performed in the setting of dysthyroid orbitopathy. Diplopia represents the most common complication and may be minimized through the preservation of a bony inferomedial strut (IMS). Historically, this has required a transconjunctival approach due to the technical demands of performing an isolated orbital floor decompression using endoscopic instrumentation. Here we describe a novel technique of a purely endoscopic orbital floor decompression with reliable preservation of the IMS. METHODS Description of a novel surgical technique for endoscopic orbital floor decompression with IMS preservation using frontal sinus instrumentation visualized by a 70-degree endoscope. RESULTS We have successfully used this technique in 12 orbits with 100% preservation of the bony inferomedial strut and no complications. The extent of decompression and width of the residual strut may be fine tuned as needed to optimize results. CONCLUSION Orbital floor decompression with IMS preservation may be reliably performed using purely endoscopic techniques. Successful completion of this procedure requires the adaptation of standard frontal sinus instrumentation to the maxillary sinus roof and thus may be readily mastered by any endoscopic surgeon comfortable with frontal sinus techniques.
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Affiliation(s)
- Benjamin S Bleier
- Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
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Antisdel JL, Gumber D, Holmes J, Sindwani R. Management of sinonasal complications after endoscopic orbital decompression for Graves' orbitopathy. Laryngoscope 2013; 123:2094-8. [DOI: 10.1002/lary.23948] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 11/13/2012] [Accepted: 11/27/2012] [Indexed: 11/12/2022]
Affiliation(s)
- Jastin L. Antisdel
- Department of Otolaryngology-Head & Neck Surgery (.); Saint Louis University; Saint Louis, Missouri; Ohio; and the
| | - Divya Gumber
- Department of Otolaryngology-Head & Neck Surgery (.); Saint Louis University; Saint Louis, Missouri; Ohio; and the
| | - Janalee Holmes
- Head and Neck Institute ; Cleveland Clinic Foundation; Cleveland; Ohio; U.S.A
| | - Raj Sindwani
- Head and Neck Institute ; Cleveland Clinic Foundation; Cleveland; Ohio; U.S.A
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Prabhu RS, Liebman L, Wojno T, Hayek B, Hall WA, Crocker I. Clinical outcomes of radiotherapy as initial local therapy for Graves' ophthalmopathy and predictors of the need for post-radiotherapy decompressive surgery. Radiat Oncol 2012; 7:95. [PMID: 22713684 PMCID: PMC3485155 DOI: 10.1186/1748-717x-7-95] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 06/09/2012] [Indexed: 11/11/2022] Open
Abstract
Background The optimal initial local treatment for patients with Graves’ ophthalmopathy (GO) is not fully characterized. The purpose of this retrospective study is to describe the clinical outcomes of RT as initial local therapy for GO and define predictors of the need for post-RT salvage bony decompressive surgery. Methods 91 patients with active GO and without prior surgery were treated with RT as initial local therapy between 01/1999 and 12/2010, with a median follow-up period of 18.3 months (range 3.7 - 142 months). RT dose was 24 Gy in 12 fractions. 44 patients (48.4%) had prior use of steroids, with 31 (34.1%) being on steroids at the initiation of RT. The most common presenting symptoms were diplopia (79%), proptosis (71%) and soft tissue signs (62%). Results 84 patients (92.3%) experienced stabilization or improvement of GO symptoms. 58 patients (64%) experienced improvement in their symptoms. 19 patients (20.9%) underwent salvage post-RT bony decompressive surgery. Smoking status and total symptom score at 4 months were independent predictors of post-RT bony decompression with odds ratios of 3.23 (95% CI 1.03 – 10.2) and 1.59 (95% CI 1.06 – 2.4), respectively. Persistent objective vision loss at 4 months post-RT was the most important symptom type in predicting salvage decompression. Chronic dry eye occurred in 9 patients (9.9%) and cataracts developed in 4 patients (4.4%). Conclusions RT is effective and well tolerated as initial local therapy for active GO, with only 21% of patients requiring decompressive surgery post RT. Most patients experience stabilization or improvement of GO symptoms, but moderate to significant response occurs in the minority of patients. Smoking status and total symptom severity at 4 months, primarily persistent objective vision loss, are the primary determinants of the need for post-RT salvage bony decompression. Patients who smoke or present with predominantly vision loss symptoms should be advised as to their lower likelihood of symptomatic response to RT and their increased likelihood of requiring post-RT decompressive surgery.
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Affiliation(s)
- Roshan S Prabhu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA.
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Moshel YA, Schwartz TH. Multiport minimally invasive skull base surgery: how many ports are too many? World Neurosurg 2010; 73:632-3. [PMID: 20934144 DOI: 10.1016/j.wneu.2010.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Yaron A Moshel
- Neurological Surgery, Division of Neuro-Oncologic Neurosurgery and Stereotactic Radiosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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