Long-term outcomes of unilateral orbital fat decompression for thyroid eye disease

Prediction of exophthalmos by body mass index for craniofacial reconstruction: consequences for cold cases

It is inconvenient for a forensic practitioner to gather population-specific data before performing a facial reconstruction. The inconvenience may defeat the point of creating the reconstruction. The objective of this study was to evaluate a non-population-dependent method of determining exophthalmos. The protrusion of the eyeball is known to vary with the contents of the orbital cavity based on bony orbital resorption or increased or decreased fat contents, as well as according to relative eyeball size. Of use are available statistics on body mass index, and this is discussed within the context of eyeball protrusion. A weak positive correlation (0.3263) between the body mass index of the country where the study originated, and the degree of exophthalmos was found. The results suggest that eyeball protrusion rates can be established according to body mass index, and this framework may be more useful considering conventional police practices.

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.

Outcomes of endoscopic orbital decompression for graves' ophthalmopathy

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.

[Orbital decompression : Indications, technique, results]

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

Fat-removal orbital decompression for thyroid associated orbitopathy: The right procedure for the right patient

Orbital decompression is an effective and invaluable procedure for addressing some of the chronic manifestations of Graves’ Ophthalmopathy (GO) such as exophthalmos and orbital congestion. Fat–removal orbital decompression (FROD) started to gain popularity after its introduction in the late 20th century. Among the therapeutic armamentarium of techniques and approaches available for orbital decompression, FROD has proven its efficacy and safety in addition to its ability to reduce proptosis in a relatively predictable manner. In addition, postoperative complications occurring after FROD are generally considered to be less frequent and less serious compared to bone-removal orbital decompression (BROD). Nevertheless, despite of FROD’s high benefit-to-risk ratio, proper selection of patients based on meticulous preoperative assessment, including imaging, is of paramount importance to achieve optimal functional and aesthetic results. Although up till now there is still no consensus regarding the procedure of choice in GO patients, FROD is an important option to consider in this subset of patients.

Long-term outcomes of orbital fat decompression in Graves’ orbitopathy

Purpose

To evaluate the long-term clinical efficacy of orbital fat decompression in treating proptosis in Graves' ophthalmopathy (GO).

Methods

Retrospective review of 1604 eyes of 845 patients with symmetric (1518 eyes) and asymmetric (86 eyes) proptosis who received orbital fat decompression between 2003 and 2014. Changes in Hertel values were evaluated at baseline, 6 months postoperatively and yearly thereafter. Recurrence of proptosis, diplopia and other complications that required additional surgeries were documented and analysed. The surgical outcome was defined as complete success if there was proptosis reduction with no recurrence and improved or no diplopia. Partial success was considered if there was proptosis reduction without recurrence yet persistent or new-onset diplopia. Failure was considered if there was recurrence of proptosis regardless of diplopia. The patient’s quality of life was also evaluated as a long-term outcome.

Results

After follow-up for 37.9±24.4 months, 1365 eyes (85.1%) achieved complete success, 219 eyes (13.7%) achieved partial success and 20 eyes (1.2%) had failure. Newly onset diplopia and secondary decompression occurrence rate remained low at 3.3% and 0.6%, respectively. The total proptosis reduction was 4.1±1.3 mm, which was consistent all through the intermediate and long-term (5–10 years) follow-up. The amount of orbital fat removal (4.5±1.1 mL) played a significant role in the long-term Hertel change. Importantly, the overall quality of life increased significantly for GO patients after undergoing orbital fat decompression.

Conclusions

Orbital fat decompression has a long-term efficacy in correcting disfiguring proptosis with a low complication rate and without the need of secondary decompression procedures. This was also associated with a significant improvement in quality of life.

Orbital decompression for thyroid eye disease

The literature regarding orbital decompression for thyroid eye disease is vast, spanning multiple specialty areas including neurosurgery, head and neck, maxillofacial, and ophthalmic plastic surgery. Although techniques have advanced considerably over the more than 100 years during which this procedure has been performed, the 4 major approaches remain: transorbital, transcranial, transantral, and transnasal. The explosion in literature related to orbital decompression has mostly involved minor technical variations on broader surgical themes. The purpose of this review is to organize the major approaches in terms of bony anatomy and to contextualize variation in transdisciplinary techniques within a common conceptualization.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biometric and refractive changes after orbital decompression in Korean patients with thyroid-associated orbitopathy

PURPOSE

To determine the biometric and refractive changes after orbital decompression in Korean patients with thyroid-associated orbitopathy (TAO).

METHODS

Retrospective, observational study (between October 2012 and September 2014) was performed. Patients with TAO undergoing orbital decompression for stable proptosis received ophthalmic examinations, including Hertel exophthalmometry, A-scan biometry, autorefraction measures, corneal topography, and wavefront aberration measures, before orbital decompression and again 2 months after surgery.

RESULTS

Included in the study were 43 eyes from 23 patients. The mean exophthalmometric value decreased by 4.1 mm 2 months after orbital decompression (P<0.001). On average, axial length (AL) increased significantly by 0.08 mm (P<0.001); specifically, 37 (86%) of the 43 eyes had increased AL. Whereas anterior chamber depth and lens thickness showed no significant changes (P=0.086 and P=0.905, respectively), the mean spherical refraction and spherical equivalent (SE) decreased by 0.35 and 0.48 D, respectively (P=0.008 and P<0.001, respectively). However, cylindrical refraction and axis showed no significant changes (P=0.057 and P=0.218, respectively). The changes in AL and SE were significantly correlated (R=-0.411, P=0.009). Notably, there were no changes in corneal topography or wavefront aberration after orbital decompression.

CONCLUSIONS

TAO patients who underwent orbital decompression showed myopic refractive change via increase in AL. Possible refractive changes should be considered in cases of TAO complaining of decreased visual acuity after orbital decompression.

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.

[Thyroid orbitopathy, an overview with special attention to the role of radiotherapy]

Thyroid orbitopathy is the most prevalent non-thyroid symptom in Graves' syndrome. It has a high incidence and particularly affects young women. Smoking is clearly involved in its development and progress, and in its response to different treatments. This autoimmune condition usually has a benign course, independent from hyperthyroidism, but its severe, progressive forms represent a major therapeutic challenge. Clinical evaluation poses great difficulties, as there is no truly objective rating scale representing disease activity. New molecular or inflammation markers may prove to be useful in this regard. This review reports new findings about its pathophysiology and the different techniques used for treatment over time. Discussion particularly focuses on the immunomodulatory role of radiotherapy, as well as on its role together with corticosteroids.

Graded decompression of orbital fat and wall in patients with Graves' orbitopathy

Purpose

To investigate the results of graded decompression of orbital fat and walls in Graves' orbitopathy (GO) considering the degree of proptosis reduction at surgery and preoperative computed tomography (CT) findings.

Methods

This is a retrospective interventional case series. Graded orbital fat and wall decompression was performed in 90 orbits of 55 patients. In patients with enlarged extraocular muscles and minimal orbital fat proliferation in preoperative CT scans, one- or two-wall decompression of posterior orbit was performed with minimal fat excision. In other cases, the maximal amount of fat tissue was removed from the post-septal area to the apex. If the proptosis was not satisfactorily symmetrically reduced at surgery, one- or two-wall decompression was performed successively. Symmetric reduction of proptosis was consistently confirmed intraoperatively to assure that a desired amount of exophthalmos reduction was achieved.

Results

Four types of decompression were performed: fat only (group 1), fat and one-wall (group 2), fat and two-wall (group 3), and two-wall and minimal fat decompression (group 4). The mean preoperative Hertel value (20.6 ± 2.8 mm) was reduced significantly at six months postoperatively (16.1 ± 2.3 mm). Proptosis significantly decreased with a mean of 4.3 ± 1.7 mm, and the reduction was greatest (5.1 ± 2.1 mm) in group 3. In group 1, a significant correlation between Hertel change and the volume of resected orbital fat was found (r = 0.479). Diplopia was newly developed or aggravated postoperatively in eight patients, and six of these patients were in group 3. With the exception of one patient, visual acuity improved to nearly normal postoperatively in all patients with optic neuropathy.

Conclusions

Graded orbital decompression of orbital fat and bony walls, as assessed by the degree of proptosis reduction during surgery, was effective and predictable with minimal complications in GO patients with vision-threatening or cosmetically disfiguring proptosis.

Semiautomatic regional segmentation to measure orbital fat volumes in thyroid-associated ophthalmopathy. A validation study

This study was designed to validate a novel semi-automated segmentation method to measure regional intra-orbital fat tissue volume in Graves' ophthalmopathy. Twenty-four orbits from 12 patients with Graves' ophthalmopathy, 24 orbits from 12 controls, ten orbits from five MRI study simulations and two orbits from a digital model were used. Following manual region of interest definition of the orbital volumes performed by two operators with different levels of expertise, an automated procedure calculated intra-orbital fat tissue volumes (global and regional, with automated definition of four quadrants). In patients with Graves' disease, clinical activity score and degree of exophthalmos were measured and correlated with intra-orbital fat volumes. Operator performance was evaluated and statistical analysis of the measurements was performed. Accurate intra-orbital fat volume measurements were obtained with coefficients of variation below 5%. The mean operator difference in total fat volume measurements was 0.56%. Patients had significantly higher intra-orbital fat volumes than controls (p<0.001 using Student's t test). Fat volumes and clinical score were significantly correlated (p<0.001). The semi-automated method described here can provide accurate, reproducible intra-orbital fat measurements with low inter-operator variation and good correlation with clinical data.