Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy

Teprotumumab and Orbital Decompression for the Management of Proptosis in Patients With Thyroid Eye Disease

PURPOSE

To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence.

METHODS

Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects.

RESULTS

One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up ( p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone.

CONCLUSIONS

Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone.

Orbital Decompression: Conceptual Approach for Orbital Volume Expansion

PURPOSE

To review the advances in the surgical techniques of orbital decompression.

METHODS

A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression.

RESULTS

In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed.

CONCLUSION

A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms.

Factors Predicting the Success of Combined Orbital Decompression and Strabismus Surgery in Thyroid-Associated Orbitopathy

To evaluate the safety and efficacy of orbital decompression combined with strabismus surgery in thyroid-associated orbitopathy (TAO) and identify factors leading to surgical success. A retrospective comparative case series was conducted on 52 patients who were treated with combined orbital decompression and strabismus surgery. Outcome measurements included perioperative Hertel exophthalmometry and strabismus measurements. Surgical success was defined as binocular single vision (BSV) in the primary and reading positions within 5 prism diopters (PDs). As a result, the average reduction in proptosis was 3.23 mm, with a mean preoperative Hertel measurement of 22.64 mm. Forty-four patients (84.6%) achieved the success criterion and composed the success group. In addition to sex and underlying hyperthyroidism, symmetry of orbitopathy, interocular exophthalmos difference of more than 2 mm, predominant esotropia type, mixed type strabismus, baseline horizontal deviations, baseline vertical deviations, and combination with one-wall decompression surgery were significantly different between the success and failure groups. All complications were mild and temporary. Orbital decompression combined with strabismus surgery produced satisfactory outcomes in selected patients with efficacy and safety. Symmetry between the two eyes with relatively simple strabismus and proptosis ensured surgical success. With experienced surgeons, advanced techniques, and selected patients, this method can serve as an alternative treatment option to minimize the number of surgeries, medical costs and recovery period.

Strategies in Surgical Decompression for Thyroid Eye Disease

Surgical management of thyroid eye disease- (TED-) associated morbidity has been plagued by the complex interplay of different operative techniques. Orbital decompression is the well-recognized procedure for disfiguring exophthalmos and dysthyroid optic neuropathy (DON). There are numerous published techniques described for the removal of the orbital bone, fat, or a combination. The diverse studies are noncomparative as they include different indications, stages of disease, and methods of evaluation. Thus, it is difficult to conclude the most efficient decompression technique. To obtain effective and predictable results, it is therefore important to propose a logical and acceptable clinical guideline to customize patient treatment. Herein, we developed an algorithm based on the presence of DON, preoperative existing diplopia, and severity of proptosis which were defined by patient's disabling symptoms together with a set of ocular signs reflecting visual function or cosmesis. More specifically, we aimed to assess the minimal but effective surgical technique with acceptable potential complications to achieve therapeutic efficacy. Transcaruncular or inferomedial decompressions are indicated in restoring optic nerve function in patients with DON associated with mild or moderate to severe proptosis, respectively. Inferomedial or fatty decompressions are effective to treat patients with existing diplopia associated with mild or moderate to severe proptosis, respectively. Fatty or balanced decompressions can improve disfiguring exophthalmos in patients without existing diplopia associated with mild to moderate or severe proptosis, respectively. Inferomedial or 3-wall decompressions are preferred to address facial rehabilitation in patients associated with very severe proptosis but without preoperative diplopia.

Surgical Outcomes of Endoscopic Medial Orbital Wall Decompression

STUDY DESIGN

Retrospective chart review.

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease

OBJECTIVE

To examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED).

METHODS

Data on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests.

RESULTS

145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ² test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ² test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ² test, p = 0.004).

CONCLUSIONS

To the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients' characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.

Minimally invasive surgery for thyroid eye disease

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

Analysis of Lid Contour in Thyroid Eye Disease With Upper and Lower Eyelid Retraction Using Multiple Radial Midpupil Lid Distances

PURPOSE

The aim of this study was to analyze upper and lower eyelid contours in adult patients with thyroid eye disease (TED) and normal adults using a software program that measures multiple radial midpupil lid distance (MPLD).

METHODS

Analysis targeted 61 eyes from 61 normal adults who had never undergone eyelid surgery or ophthalmic surgery and 63 eyes from 63 patients with TED. Digital pictures of primary gaze were analyzed using custom software. Conventional MPLD (90°, 270°) and 12 oblique MPLDs were collected every 15° across the temporal (105°, 120°, 135°, 150°, 165°, 180°) and nasal (75°, 60°, 45°, 30°, 15°, 0°) sectors of the upper eyelid. For lower eyelid contours, 9 oblique MLPDs in the temporal sector (255°, 240°, 225°, 210°, 195°) and nasal sector (285°, 300°, 315°, 330°) of the lower eyelid were analyzed.

RESULTS

From all angles, the MPLD of patients with TED was larger than that of the control group. The mean difference between the 2 groups was larger for the upper eyelid (0° ∼ 180°) than the lower eyelid (195° ∼ 330°). When comparing symmetry by dividing into each angle, the ratio of 90°/270° (MRD1/MRD2) demonstrated greater in patients with TED (P = 0.000). Temporal/nasal eyelid contour symmetry in the upper eyelid, investigated using the distance ratio of the nasal sector/temporal sector (15°/165°, 30°/150°, 45°/135°, 60°/120°, 75°/105°), was significantly smaller in patients with TED (P < 0.05). However, there was no significant difference between the 2 groups regarding temporal/nasal eyelid contour symmetry of the lower eyelid (330°/210°, 315°/225°, 300°/240°, 285°/255°).

CONCLUSIONS

Radial MPLD is effective for analyzing eyelid contour. In our study, lateral flare of upper lid retraction and flat appearance of lower lid retraction were distinct characteristics in patients with TED. Consideration of eyelid contour in patients with TED may improve corrective surgery for eyelid retraction.

Surgical Outcomes of Balanced Deep Lateral and Medial Orbital Wall Decompression in Korean Population: Clinical and Computed Tomography-based Analysis

Purpose

To evaluate the clinical outcomes of balanced deep lateral and medial orbital wall decompression and to estimate surgical effects using computed tomography (CT) images in Korean patients with thyroid-associated ophthalmopathy (TAO).

Methods

Retrospective chart review was conducted in TAO patients with exophthalmos who underwent balanced deep lateral and medial orbital wall decompression. Exophthalmos was measured preoperatively and postoperatively at 1 and 3 months. Postoperative complications were evaluated in all study periods. In addition, decompressed bone volume was estimated using CT images. Thereafter, decompression volume in each decompressed orbital wall was analyzed to evaluate the surgical effect and predictability.

Results

Twenty-four patients (48 orbits) with an average age of 34.08 ± 7.03 years were evaluated. The mean preoperative and postoperative exophthalmos at 1 and 3 months was 18.91 ± 1.43, 15.10 ± 1.53, and 14.91 ± 1.49 mm, respectively. Bony decompression volume was 0.80 ± 0.29 cm³ at the medial wall and 0.68 ± 0.23 cm³ at the deep lateral wall. Postoperative complications included strabismus (one patient, 2.08%), upper eyelid fold change (four patients, 8.33%), and dysesthesia (four patients, 8.33%). Postsurgical exophthalmos reduction was more highly correlated with the deep lateral wall than the medial wall.

Conclusions

In TAO patients with exophthalmos, balanced deep lateral and medial orbital wall decompression is a good surgical method with a low-risk of complications. In addition, deep lateral wall decompression has higher surgical predictability than medial wall decompression, as seen with CT analysis.

Surgical effects of various orbital decompression methods in thyroid-associated orbitopathy: computed tomography-based comparative analysis

OBJECTIVES

To evaluate the surgical effects of orbital fat decompression and bony decompression in each orbital wall using computed tomography (CT) in thyroid-associated orbitopathy (TAO).

METHODS

In 27 TAO patients (48 orbits) with exophthalmos who underwent orbital wall decompression combined with fatty decompression, we recorded the resected orbital fat volume intraoperatively and estimated the decompression volume of the orbital wall in the deep lateral, medial and inferior walls using postoperative orbit CT images. Then, the correlation between exophthalmos reduction by Hertel reading and decompression volume in each area was analyzed to validate the surgical predictability, surgical efficiency and contribution level to total exophthalmos reduction.

RESULTS

The decompression volume in orbital fat and the deep lateral wall showed relatively high correlation with exophthalmos reduction (surgical predictability) compared to medial and inferior wall. The surgical efficiency was highest at deep lateral wall (2.704 ± 0.835 mm/cm(3)), followed by medial wall (0.892 ± 0.527 mm/cm(3)), orbital fat (0.638 ± 0.178 mm/cm(3)) and inferior wall (0.405 ± 0.996 mm/cm(3)). The actual contribution level to total exophthalmos reduction was highest in fatty decompression, followed by deep lateral decompression.

CONCLUSION

In TAO patients with exophthalmos, orbital fat and deep lateral orbital wall are more predictable and contributory surgical targets for postsurgical exophthalmos reduction.

Iatrogenic diplopia [corrected]

Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.

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.

Indications for orbital decompression for patients undergoing keratoprosthesis surgery

INTRODUCTION

Optimizing the ocular surface and achieving acceptable cosmesis are important considerations in the rehabilitation of patients with keratoprosthesis (KPro). In osteo-odonto-KPro and type 1 Boston KPro surgery, it is important to ensure a healthy ocular surface to increase the chance of functional success.

MATERIALS AND METHODS

The authors present 2 patients with KPros undergoing orbital decompression surgery. This series highlights a novel indication for orbital decompression surgery for patients, who are usually 1-eyed, undergoing KPro surgery. It illustrates the importance of globe position to either optimize the ocular surface or allow a cosmetic shell to be worn. To the authors' knowledge, such indications for orbital decompression have not been reported to date.

RESULTS

Two-wall and intraconal fat orbital decompression surgery achieved globe retroplacement of 6 mm and 7 mm, allowing fitting of a cosmetic shell over the osteo-odonto-KPro and reducing lagophthalmos and corneal exposure in patients 1 and 2, respectively.

CONCLUSION

Indications for orbital decompression exist in patients undergoing osteo-odonto-KPro or KPro to reduce pseudoproptosis or exposure.

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

BACKGROUND

The aim of this study was to evaluate the long-term outcomes after unilateral orbital fat decompression in patients with thyroid eye disease.

DESIGN

Retrospective, comparative, cross-sectional study

PARTICIPANTS

Thirty-three orbits of 33 patients were included in this study. Of the 33 patients, 13 underwent fat decompression (group A), and the other 20 had bony decompression (group B).

METHODS

The medical records of patients who underwent orbital decompression to reduce proptosis for thyroid eye disease were retrospectively reviewed. The degrees of proptosis were measured by Hertel exophthalmometry preoperatively and over a follow-up period of more than 3 years. We evaluated the change in proptosis after surgery.

MAIN OUTCOME MEASURES

Postoperative change in exophthalmos.

RESULTS

A recurrence in proptosis from fat decompression was seen in ten patients (76.9 %) in group A and in only two patients (10 %) in group B. The amount of regression due to surgery after 3 years was 2.3 ± 1.4 mm and 0.7 ± 0.9 mm in groups A and B respectively. The tendency of regression was more prominent in group A than in group B.

CONCLUSION

The long-term effect of unilateral orbital fat decompression for the reduction of proptosis in patients with thyroid eye disease may be weak, leading to regression. Care should be taken when determining the extent of fat decompression with consideration for this tendency.

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

PURPOSE

To quantify the risk of new diplopia in inferomedial orbital decompression performed for cosmetic reasons.

METHODS

Retrospective analysis of 114 patients with Graves orbitopathy who underwent an inferomedial orbital decompression. No patient had diplopia in any of the gaze positions or optic neuropathy. A single coronal slice 9 mm posterior to the lateral orbital rim was employed to quantify the muscular index of the extraocular recti and of the superior complex. A control group of 56 patients imaged for other reasons were also measured. After surgery the oculomotor status of all patients who complained of diplopia and of 51 patients free of diplopia was measured with the prism and cover test in the primary and secondary gaze positions.

RESULTS

The rate of new-onset diplopia was 14.0% (16 patients). Eye deviations were confirmed in 14 patients. Of these, 10 had significant strabismus that warranted surgical or prism treatment. Most patients had esotropia associated with small vertical deviations. The size of the medial and inferior recti was significantly associated with the development of diplopia. The estimated odds for the appearance of diplopia in patients with muscle enlargement was 12.76 (medial rectus) and 5.21 (inferior rectus). Small-angle deviations were also detected in 27.4% of patients who did not experience diplopia.

CONCLUSIONS

Medial and inferior recti enlargement is a strong predictor of new-onset diplopia. A large number of patients who do not report diplopia also present with small-angle deviations.

Transcaruncular medial wall orbital decompression: an effective approach for patients with unilateral graves ophthalmopathy

Purpose. To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. Methods. Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. Results. The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). Conclusions. Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results.

Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated orbitopathy: a new technique and results of a case series

PURPOSE

To describe a new technique for deep lateral (single) wall orbital decompression surgery, developed by Mr. Geoffrey Rose, for proptosis in patients with thyroid-associated orbitopathy and to analyse the results achieved in our series.

METHODS

The study is an interventional, retrospective, non-comparative case series. Twenty-one eyes of seventeen patients underwent the described technique of deep lateral wall orbital decompression for thyroid-associated orbitopathy. All patients had controlled thyroid functions and underwent surgery for cosmetic rehabilitation, with analysis of the reduction in proptosis, changes in visual acuity and post-operative complications. The surgery involved removing the lateral orbital wall whilst preserving the lateral rim, the lateral wall being approached through a horizontal skin incision placed lateral to the lateral canthus. After reflecting the periosteum, most of the bone (deep lateral wall) between the skull base and inferior orbital fissure is removed.

RESULTS

A mean reduction in proptosis of 4.81 mm ± 1.23 (SD) (p < 0.0001) with a median of 5.0 mm (range 3-7 mm) was achieved and the best-corrected visual acuity was maintained in all patients. There were no complications during surgery, and post-operative complications included worsening of pre-existing diplopia in one patient (6%) and transient cheek/temple numbness seen in three patients (18%).

CONCLUSIONS

This technique of deep lateral wall orbital decompression developed by Mr. Rose is a safe and effective procedure for patients with mild to moderate proptosis. It carries a low risk of morbidity and avoids complications associated with decompressing the floor and medial wall, including new onset of motility disorders.

Correlation of retrobulbar volume change with resected orbital fat volume and proptosis reduction after fatty decompression for Graves ophthalmopathy

PURPOSE

To evaluate the correlation of retrobulbar volume change, resected orbital fat volume, and proptosis reduction after fatty decompression.

DESIGN

Cross-sectional and prospective study.

METHODS

Twenty-two patients (44 orbits) with Graves ophthalmopathy underwent fatty decompression. Preoperative orbital computed tomography (CT) imaging with a 2-mm cut was compared with postoperative imaging carried out 6 months after fatty decompression. The relationship of retrobulbar volume change, resected orbital fat volume, and proptosis reduction was analyzed by Pearson correlation. Linear regression was performed using resected fat volume or proptosis reduction as independent variables and retrobulbar volume change as a dependent variable to validate the effect of fatty decompression.

RESULTS

Mean proptosis reduction was 4.1 ± 0.9 mm. Mean volume of resected orbital fat was 4.4 ± 1.2 mL. Mean retrobulbar volume change in computed tomographic imaging was 3.2 ± 1.0 cm(3). The change in retrobulbar volume was correlated strongly with proptosis reduction and volume of resected orbital fat. Linear regression revealed the following equation for Retrobulbar volume change: 0.546 × Hertel change + 0.945 or 0.293 × Volume of resected orbital fat + 1.917.

CONCLUSIONS

Fatty decompression can reduce proptosis for patients with disfiguring Graves ophthalmopathy. Because of the close correlation of retrobulbar volume change with volume of resected orbital fat and proptosis reduction, we propose that orbital fat removal may be accompanied by decreased retrobulbar volume after fatty decompression. Evidence of decreased retrobulbar volume may result in effective proptosis reduction.

Torsional diplopia after orbital decompression and strabismus surgery

PURPOSE

To investigate diplopia after orbital decompression in patients with thyroid-related orbitopathy.

METHODS

We retrospectively analyzed medical records of 45 consecutive patients who had undergone orbital decompression surgery (DS) and a subgroup of 10/45 patients who underwent disinsertion of the inferior oblique (IO) muscle during DS. Diplopia was assessed before DS and 1 and 3 months after DS. Residual strabismus defects were treated surgically approximately 3 months after DS with follow-up visits 1 week, 3 months, and 6 months postoperatively. Patients with horizontal or vertical diplopia were evaluated using the alternate prism-and-cover test and torsional diplopia (TD) using a double Maddox rod test to quantitate their strabismus.

RESULTS

Strabismus surgery was effective in treating the horizontal and vertical diplopia (13/40 cases with residual deviations required prism glasses), but did not resolve the TD. None of the patients with IO disinsertion during DS complained of TD before strabismus surgery. However, after strabismus surgery, TD occurred in all 10 patients with IO disinsertion vs 8/30 patients without IO disinsertion (p<0.001, Fisher exact test). Overall, TD was induced in 18/45 (40%) of the DS cohort.

CONCLUSIONS

Patients with IO disinsertion during DS may be at increased risk of developing TD postoperatively. We recommend sparing or reattaching the IO muscle during DS when possible to reduce the risk of developing untreatable TD.

Endoscopic endonasal approach to the orbital apex and medial orbital wall: anatomic study and clinical applications

OBJECTIVE

The objective of this study was to recognize the endoscopic anatomy of the orbital apex and medial orbital wall to understand the pure endoscopic endonasal approaches to this region and their clinical applications. These basic information will facilitate our surgical procedures and decrease the rate of surgical complications.

MATERIAL AND METHODS

Five fresh adult cadavers were studied bilaterally (N = 10). We used Karl Storz 0- and 30-degree 4-mm, 18-cm, and 30-cm rod-lens rigid endoscopes in our dissections. After cadaver specimen preparation, we approached each orbital apex and medial orbital wall through each nostril. After resection of medial orbital wall, an endoscopic intraorbital approach was performed.

RESULTS

The orbita could be exposed by using 0- and 30-degree endoscopes. We preferred to start the approach from the sphenoid sinus instead of transethmoidal approaches that are less familiar to the neurosurgeons. The posterior and anterior ethmoidal arteries are in close relation to the supralateral wall of ethmoid sinus, thus care must be taken not to injure these arteries during dissection. In this way, we can safely expose the whole medial wall of the orbita. Optic canal decompression can be safely done by bone resection starting from the optic nerve toward the optic canal. We continued bone resection from the posterior to the anterior of the medial orbital wall, thus we can perform medial orbitotomy. The intraorbital approach can be done medially by introducing the endoscope between the medial and inferior rectus muscles.

CONCLUSIONS

Our anatomic study offered the facility to learn the endoscopic anatomy of the orbital apex and the medial wall of the orbita and understand the appropriate approaches (such as medial orbitotomy and optic canal decompression) to some pathologic lesions of this region. With skilled and experienced hands, it can superimpose many traditional orbital approaches with minimal invasiveness and less postoperative complications.

[Basedow exophthalmos]

Dysthyroid orbitopathy is a disease that is edematous and inflammatory, generally chronic, sometimes subacute or acute, and is characterized by exophthalmos in the majority of cases, retraction of the lid, restrictive strabismus with diplopia, corneal ulceration, ocular hypertension, and compressive optic neuropathy. Proptosis is the cardinal sign. Exophthalmos is frequently axial and is bilateral in 85%-90% of cases. Displacement of the globe in the vertical and horizontal axes is not rare, particularly when intense enlargement of an extraocular muscle produces a mass effect. Proptosis stems from a conflict for the space in the orbital cavity. The infiltration of the fat, muscles, and lacrimal gland by lymphocytes, plasma cells, and mucopolysaccharides, which are very hydrophilic, all contribute to the orbitopathy. The majority of patients with minimal exophthalmos do not require special treatment since they tend to improve spontaneously. In severe forms, it is important to evaluate the activity for steroid use to eliminate the inflammation in the soft tissues and to make rehabilitative surgery possible under better conditions. When a good response is not obtained, radiotherapy is evaluated. The surgical treatment by bone orbital decompression and sometimes lipectomy is indicated in inactive forms, disfiguring exophthalmos, certain particular cases such as dysthyroid optic neuropathy, ocular hypertension, corneal exposition.

Strabismus following endoscopic orbital decompression for thyroid eye disease

Endoscopic orbital decompression may be used to treat disfiguring proptosis or sight threatening optic nerve compression in patients with thyroid eye disease. Strabismus is common in thyroid eye disease and frequently follows decompression surgery. We retrospectively reviewed patients undergoing endoscopic decompression for thyroid eye disease, by a single surgeon, from 1994 to 2000. Twenty-three patients (21 female, 2 male) were identified with a mean age of 47.5 years. At presentation, 21 patients had proptosis, 8 optic nerve compression (2 without proptosis) and 11 strabismus (9 complained of diplopia) with a mean BSV score of 24.5 before decompression. Forty orbits were decompressed with a mean decrease in proptosis of 3.3 mm. Following decompression, the mean BSV score was 25, and 17 patients had manifest strabismus in primary gaze (3 at near only) of whom 10 had pre-existing strabismus. Five patients had new diplopia (22%). Eleven patients ultimately required strabismus surgery of whom 8 had manifest strabismus before decompression. Following strabismus surgery, the mean BSV score was 37. The final BSV score for those not requiring strabismus surgery was 29. Mean follow-up was 28 months. Endoscopic orbital decompression can effectively treat disfiguring proptosis. Diplopia is a common complication, but pre-existing diplopia may improve.

Role of botulinum toxin A in diplopia following orbital decompression

Diplopia following orbital decompression is a common complication in Graves' ophthalmopathy. Strabismus surgery is often required to treat the persistent diplopia. The author presents a successful treatment with botulinum toxin A injection in a case of diplopia following orbital decompression. Treatment with botulinum toxin A in the management of new-onset diplopia following orbital decompression has been suggested in a case that is not amenable to prism treatment and may eliminate strabismus surgery in some cases.

Advances in surgical rehabilitation in thyroid eye disease

BACKGROUND

Surgery has evolved over the past 20 years. Conceptual and technical advances have helped improve the surgical rehabilitation of Graves' orbitopathy. A historical comparison of methods and approaches has shown clear progress.

SUMMARY

Surgical rehabilitation of Graves' orbitopathy is traditionally staged: orbital decompression, extraocular muscle surgery, eyelid repositioning, and the soft tissue volume and redraping. Improvements in techniques have evolved from the problems that historical methods have presented, and an evaluation of each will help appreciate the improvements that have been made for patient care.

CONCLUSION

Incremental improvements in surgery for thyroid eye disease have been made over the past 20 years. However, thyroid-related orbitopathy will always be limited by fibrotic and structural changes that may be camouflaged by surgery, but never cured. Future advances in medical management will be derived from the laboratory.

Results and predictability of fat-removal orbital decompression for disfiguring graves exophthalmos in an Asian patient population

PURPOSE

To evaluate proptosis reduction by fat-removal orbital decompression (FROD), to determine the incidence of postoperative diplopia, and to assess predictability of proptosis reduction per volume of resected orbital fat.

DESIGN

Cross-sectional study.

METHODS

One hundred and twenty patients (31 men; 89 women) with Graves ophthalmopathy were treated with FROD via the transforniceal approach on 222 orbits between April 2003 and April 2006. Fifteen (12.5%) patients exhibited preoperative diplopia; 105 (87.5%) were without diplopia; mean follow-up +/- standard deviation (SD) was 10.9 +/- 5.1 months (range, six to 37 months). Univariate and multivariate analyses were used to evaluate Hertel change with FROD by linear regression. The setting was thyroid eye disease special clinics at National Taiwan University Hospital.

RESULTS

Mean Hertel values +/- SD decreased from 20.3 +/- 1.8 mm (range, 16.5 to 26.0 mm) to 16.8 +/- 1.4 mm (range, 13.5 to 21.0). Mean proptosis reduction +/- SD was 3.6 +/- 1.0 mm (range, 1.5 to 7.5 mm). Mean volume of resected orbital fat +/- SD was 3.6 +/- 1.0 ml (range, 1.2 to 6.5 ml). New-onset diplopia was noted for 2.8% of patients after FROD. The final predictive equation for Hertel change is shown as: 0.72 x removal of intraconal fat (ml) - 0.001 x age (yrs) - 0.22 x gender (male, 1; female, 0) - 0.19 x preoperative diplopia (yes, 1; no, 0) + 1.02.

CONCLUSIONS

FROD can achieve reasonable proptosis reduction and can reduce incidence of new-onset diplopia for patients with disfiguring Graves exophthalmos. The volume of resected orbital fat correlates with mean Hertel value change. The amount of resected orbital fat may predict proptosis reduction.

The influence of previous orbital irradiation on the outcome of rehabilitative decompression surgery in graves orbitopathy

PURPOSE

To investigate whether orbital irradiation influences the outcome of decompression surgery in Graves orbitopathy.

DESIGN

Retrospective, comparative case series.

METHODS

The medical records of all the patients with Graves orbitopathy treated with a three-wall orbital decompression through a coronal approach at our institution between January 1, 1990 and December 31, 2000 were reviewed. Only patients who underwent bilateral surgery for aesthetic rehabilitation, without preoperative diplopia, and who, in the active phase of the disease, had received orbital radiotherapy alone (20 Grays (Gy) in 10 daily fractions of two Gy over a period of two weeks; group R), systemic glucocorticoids alone (daily administration for more than three months independently from the dosage; group G), or both radiotherapy and glucocorticoids (group RG) were selected. Groups were compared for demographics, smoking habits, preoperative characteristics, and surgical outcome (mean reduction of exophthalmos, reduction of lid retraction, persistence of periorbital swelling requiring cosmetic eyelid surgery, onset of diplopia within 20 degrees of the central position of gaze, and variations in the peripheral field of diplopia).

RESULTS

Sixty-one of 376 patients were selected for this study. There were no differences between group R (n=29), group G (n=15), and group RG (n=17) with respect to demographics or predecompression characteristics, whereas the number of smokers was significantly greater in group RG (P=.019). We could not find differences in surgical outcome by comparing the three groups.

CONCLUSIONS

The total radiation dose, fraction size, and irradiated volume commonly used to treat active Graves orbitopathy do not adversely interfere with the outcome of rehabilitative decompression surgery.

Recognizing the protruding eye

It is currently unknown how much exophthalmos may be noticeable to an observer. The authors determined the threshold for detection of exophthalmos may be 4 millimeters.

PURPOSE

To determine the threshold for detection of exophthalmos by an observer.

METHODS

The Massachusetts Eye and Ear Infirmary Ophthalmic Plastics imaging database was used to select 28 photographs of patients with unilateral exophthalmos measuring between 1 to 11 mm for the study group and 28 photographs of patients without exophthalmos for the control group. One hundred ophthalmology attendings, residents, medical students, and technicians reviewed each photograph. Participants commented on whether the patient appeared "normal" or "abnormal."

RESULTS

Eighty-one percent of the control patients were correctly identified as "normal." In comparison, 60% of patients with 1 mm of exophthalmos (p < 0.001), 53% of patients with 2 mm of exophthalmos (p < 0.001), 46% of patients with 3 mm of exophthalmos (p < 0.001), 35% of patients with 4 mm of exophthalmos (p < 0.001), and 40% of patients with 5 mm of exophthalmos (p < 0.001) were identified as "normal." The vast majority of patients (91.9%, p < 0.001) with 6 mm of exophthalmos were identified as "abnormal," and almost all patients (97.9%, p < 0.001) with more than 6 mm of exophthalmos were also described as having an "abnormal" appearance.

CONCLUSIONS

Greater than half of the patients with 1-2 mm of exophthalmos appear as "normal" as the control patients. In comparison, the majority of patients with 4-5 mm of exophthalmos and nearly all the patients with 6 mm of exophthalmos and greater appear "abnormal." Our data suggests that the point at which exophthalmos becomes clinically perceptible to the majority of observers is 4 mm. There may be patients with 3 mm of exophthalmos and greater with orbital pathology being "missed" on cursory external examinations by general ophthalmologists, optometrists, and general practitioners.

Cosmetic orbital surgery

PURPOSE

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

SCOPE

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

CONCLUSIONS

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