Primary-gaze diplopia in patients with thyroid-related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome

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.

Update on the surgical management of Graves' orbitopathy

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.

Lateral Wall Implant as an Adjunct to Lateral Wall Orbital Decompression in Severe Thyroid Eye Disease

PURPOSE

To describe the use of a lateral wall implant as an adjunct in lateral orbital wall decompression in severe thyroid eye disease.

METHODS

This study is a retrospective review of 6 patients who underwent prior orbital decompression but had persistent proptosis. These patients underwent lateral wall decompression with adjunct lateral wall implant placement with a manually vaulted 0.6-mm polyethylene-coated titanium mesh implant. Data collection included: visual acuity, intraocular pressure, exophthalmometry, ocular motility, eyelid position, and complication rates.

RESULTS

Eight orbits in 6 patients underwent maximal lateral wall decompression and reconstruction using the polyethylene-coated titanium implant. Four males and 2 females were included with ages ranging from 25 to 73 years. Visual acuity improved an average of 2.4 lines (range 0-5 lines). Intraocular pressure improved an average of 7.5 mm Hg (2-13 mm Hg). There was reduction of proptosis by 3.4 mm on average (1-7 mm). Upper eyelid retraction improved on average by 1.8 mm (0-5 mm). Horizontal eye movements improved by 11% on average (-3.1% to +25%). Excellent cosmesis was achieved with no visible temple deformity, trismus, conjunctival scarring, orbital hemorrhage, or vision loss.

CONCLUSIONS

The amount of volume created in lateral wall decompression is limited by the amount of native bone present and the temporalis muscle. In severe or recalcitrant cases, the authors propose the placement of a lateral wall implant as an adjunct to laterally displace the temporalis muscle and create additional volume. This technique accomplishes further reduction of proptosis in patients who have undergone prior orbital decompression.

Endoscopic Transconjunctival Deep Lateral Wall Decompression for Thyroid-associated Orbitopathy: A Minimally Invasive Alternative: Transconjunctival Endoscopic with Wall Decompression for TAO

PURPOSE

To investigate the feasibility, efficacy, and safety of endoscopic transconjunctival transorbital deep lateral wall decompression for thyroid-associated orbitopathy (TAO).

DESIGN

Prospective single-surgeon interventional case series.

METHODS

Twenty-two patients (39 orbits) diagnosed with thyroid-associated orbitopathy without dysthyroid optic neuropathy were enrolled in this study. All patients underwent endoscopic transconjunctival transorbital deep lateral wall decompression for proptosis reduction. The data, including measurement on exophthalmometry, volumetric change on computed tomography, and surgery-related complications, were analyzed.

RESULTS

We observed a proptosis reduction (mean, 3.42 ± 0.87 mm; range, 2.10-5.52 mm) and a corresponding decrease in the bony volume of the greater wing of the sphenoid bone (mean, 1.89 ± 0.81 cm³; range, 0.56-3.79 cm³) postoperatively. Preexisting diplopia improved in 5 patients (22.73%). Transient zygomaticotemporal hypoesthesia developed in all patients, and cerebrospinal fluid leakage occurred in 1 orbit (2.56%). No patient complained of temporal hollowing, oscillopsia, or new-onset or worsening diplopia during follow-up.

CONCLUSIONS

Endoscopic transconjunctival transorbital deep lateral wall decompression is an effective and minimally invasive treatment for proptosis reduction in patients with thyroid-associated orbitopathy. The surgery-related complications with this technique were fewer compared with traditional approaches.

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.

Risk Factors for New Onset Diplopia After Graduated Orbital Decompression

PURPOSE

The aim of the study was to identify possible risk factors for new onset diplopia in 20° of primary position (NOD PP) after orbital decompression. A predisposition for NOD has been established for patients with pre-existing diplopia in secondary gaze; therefore, the authors focused on patients without preoperative diplopia.

METHODS

Retrospective chart review of patients who underwent balanced orbital decompression between 2012 and 2019 due to Graves orbitopathy at the authors' institution. Exclusion criteria were incomplete clinical data set, revision surgery, and medial or lateral decompression only. The following clinical parameters were evaluated preoperatively and postoperatively: Hertel exophthalmometry, objective measurement of misalignment using the prism-cover-test, assessment of the field of binocular single vision, and measurement of monocular excursions. In addition, the diameter of the extraocular eye muscles was measured in all preoperative CT scans.

RESULTS

We included 327 patients (612 orbits), 126 patients (242 orbits) had no preoperative diplopia. In patients with NOD PP (34%, n = 43/126), enlargement of the medial rectus muscle and restriction of abduction and elevation were significantly more frequent than in patients with no NOD PP. The degree of exophthalmos decrease positively correlated with postoperative squint angle.

CONCLUSION

We were able to identify the diameter of the medial rectus muscle, restriction of abduction, and elevation as well as an extensive reduction of exophthalmos as risk factors for NOD PP in patients with no preoperative diplopia.

Proposing a surgical algorithm for graduated orbital decompression in patients with Graves' orbitopathy

PURPOSE

To determine the outcome after orbital decompression using a graduated technique, adapting the surgical technique according to individual patients' disease characteristics.

METHODS

We retrospectively examined the postoperative outcome in patients treated with a graduated balanced orbital decompression regarding reduction of proptosis, new onset diplopia and improvement in visual function. 542 patients (1018 orbits) were treated between 2012 and 2020 and included in the study. Clinical examinations including visual acuity, exophthalmometry (Hertel) and orthoptic evaluation were performed preoperatively and at minimum 6 weeks postoperatively. Mean follow-up was 22.9 weeks.

RESULTS

Mean proptosis values have significantly decreased after surgery (p < 0.01). In 83.3% of the patients Hertel measurement normalized (≤ 18 mm) after surgery, New onset diplopia within 20° of primary position occurred in 33.0% of patients, of whom 16.0% had preoperative double vision in secondary gaze. Patients suffering from dysthyroid optic neuropathy (DON) had a significant increase in visual acuity (p < 0.01).

CONCLUSION

We demonstrated that individually adapted graduated orbital decompression successfully improves key disease parameters of Graves' orbitopathy with low morbidity.

Changes in Field of Binocular Single Vision and Ocular Deviation Angle After Balanced Orbital Decompression in Thyroid Eye Disease

PURPOSE

To evaluate influential factors for changes in the binocular single vision (BSV) and ocular deviation angle in the medial direction after bilateral balanced orbital decompression in thyroid eye disease.

METHODS

This retrospective study included 41 patients. The areas of BSV and the angles of medial ocular deviation on the Hess chart were measured. The percentages of pre- and postoperative areas against the normal area (%BSV) and the change in BSV after surgery were calculated. Postoperative change in the angle was calculated by subtraction of the preoperative angle from the postoperative one. Influential factors for the change in BSV and that in the medial deviation angle were evaluated via multivariate linear regression analysis.

RESULTS

The maximum cross-sectional area of the medial rectus muscle, preoperative %BSV, and preoperative medial ocular deviation angle were significant factors of change in BSV (adjusted r2 = 0.449, p < 0.001), although age, history of anti-inflammatory treatment, volume of removed orbital fat, findings on CT images, maximum cross-sectional areas of the other rectus muscles, and presence or absence of a periosteal flap did not affect change in BSV (p > 0.050). On the contrary, all variables did not influence postoperative changes in the medial ocular deviation angle (p > 0.050).

CONCLUSIONS

In balanced orbital decompression, the maximum cross-sectional area of medial rectus muscle, preoperative field of BSV, and medial ocular deviation were significant influential factors for postoperative changes in field of BSV.

Oscillopsia After Isolated Lateral Wall Decompression Versus Balanced or 3-Wall Decompression

PURPOSE

To assess the incidence of postoperative masticatory oscillopsia after orbital decompression, comparing results between isolated lateral wall and balanced or 3-wall orbital decompression.

METHODS

An observational retrospective study was performed, involving 161 consecutive patients who underwent orbital decompression between 2008 and 2018. Patients' clinical data were registered, and archives were revised for data compilation. Patients were divided into 2 groups according to the type of surgery: "lateral" group included patients who underwent isolated lateral wall decompression and "lateral plus" group involved patients with balanced or 3-wall decompression. Exclusion criteria were secondary decompressions, those not including lateral wall and asymmetrical surgeries, so analysis was performed among 131 remaining patients. Oscillopsia was self-reported and was registered as present or not. Diplopia was evaluated according to Paridaens grading system.

RESULTS

Statistical analysis among the 131 patients with lateral wall decompression (isolated or in combination) was performed. Seven patients referred oscillopsia, 5 among "lateral" group, while 2 reported oscillopsia on "lateral plus" group (p = 0.001). The authors found no differences on new-onset or worsening of diplopia between groups (p = 1).

CONCLUSIONS

Oscillopsia was significantly higher after isolated lateral wall decompression than after balanced or 3-wall decompression, while no differences were found between groups according to diplopia status. Transmission of temporal muscle contraction to the orbit seems to be the cause of the oscillopsia. The authors postulate that the absence of orbital floor or medial wall may act as a dampener for the temporalis muscle contractions, allowing the orbital contents to be expanded through them, and avoiding oscillopsia.

[Orbital decompression in Graves' orbitopathy-Experiences and results]

Hintergrund

Die endokrine Orbitopathie ist die häufigste extrathyreoidale Manifestation des Morbus Basedow und tritt bei schätzungsweise 25–50 % der betroffenen Patienten auf. Krankheitsbedingt kommt es zu einer entzündlichen Schwellung der Orbitaweichteile. Die Behandlung erfolgt meist konservativ. Bei schweren Fällen mit beeinträchtigendem Exophthalmus oder akuter, steroidrefraktärer Visusbedrohung kann eine chirurgische Orbitadekompression die Beschwerden der Patienten lindern oder das Sehvermögen erhalten. Ein wesentlicher Aspekt der Versorgungsqualität besteht in der Vermeidung postoperativer Doppelbilder.

Ziel der Arbeit

Erfahrungs- und Ergebnisbericht von 100 chirurgischen Orbitadekompressionen bei 62 Patienten an einem interdisziplinären Orbitazentrum. Patienten mit Kompression der Orbitaspitze wurden mittels pterionaler Dekompression behandelt. Patienten ohne Hinweise auf Orbitaspitzenbeteiligung wurden mittels tiefer lateraler Wandresektion oder pterionaler Dekompression behandelt.

Methodik

Retrospektive Datenanalyse.

Ergebnisse

Die mittlere Exophthalmusreduktion betrug 2,9 mm. Augen mit visusbedrohendem Schweregrad gewannen im Mittel 2,2 Zeilen an Sehschärfe, der Visus bei rehabilitativer Indikation blieb stabil. Die Komplikationsrate betrug 4 %. Neue Doppelbilder wurden nach 2 Eingriffen beobachtet. Bei einem Patienten kam es zu einer Visusminderung von 0,8 auf 0,1. In 9 Fällen führte die Operation zu einem vollständigen Rückgang zuvor beklagter Doppelbilder.

Diskussion

Visusgewinn, Exophthalmusreduktion und Komplikationsrate sind in diesem Kollektiv vergleichbar mit zuvor publizierten Arbeiten. Diese Studie bestätigt die Rolle der Orbitadekompression bei visusbedrohender und schwer beeinträchtigender endokriner Orbitopathie.

Correlation between uniocular deviation and duction changes following different decompression surgeries in thyroid eye disease

Background

Postoperative ocular imbalance is an important problem for orbital decompression surgery in thyroid eye disease (TED). The aim of this study was to evaluate the changes in unilateral ocular deviation and duction following orbital decompression and discuss the biomechanics of ocular imbalance.

Methods

Fifty-four TED patients who underwent unilateral orbital decompression were included. Fifteen patients underwent 1-wall (deep lateral wall) decompression, 18 patients underwent 2-wall (deep lateral and medial wall) decompression and 21 patients underwent 3-wall (deep lateral, medial and inferior wall) decompression. Objective and subjective deviation of the operated eyes were evaluated using the prism test and synoptophore, respectively. Ocular ductions were measured using Hirschberg’s method. The diameters of the extraocular rectus were measured by computed tomography.

Results

Ocular deviation and duction showed no significant difference after 1-wall decompression (p = 0.25–0.89). Esotropia increased after 2-wall decompression (p = 0.001–0.02), and hypotropia increased after 3-wall decompression (p = 0.02). Adduction increased but abduction decreased following 2-wall and 3-wall decompression (p < 0.05). Infraduction increased following 3-wall decompression (p < 0.001). Additionally, the increase in esotropia was significantly correlated with the increase in adduction and with the decrease in abduction (r = 0.37–0.63, p < 0.05). There were significant correlations between the diameter of the medial rectus and the increase in esotropia, the increase in adduction and the decrease in abduction postoperatively (r = 0.35–0.48, p < 0.05).

Conclusions

The changes in ocular deviation and duction were different after 1-wall, 2-wall and 3-wall orbital decompression. The increased contractile force of the rectus may be an important reason for strabismus changes after orbital decompression surgery.

Comparison of 2-wall versus 3-wall orbital decompression against dysthyroid optic neuropathy in visual function: A retrospective study in a Chinese population

To compare visual function of 2-wall (medial and lateral) versus 3-wall (medial, lateral, and inferior) orbital decompression in patients with dysthyroid optic neuropathy (DON).A total of 52 eyes of 37 patients underwent orbital decompression for DON between 2013 and 2019 were retrospectively reviewed. Two- or 3-wall decompression was performed in 31 eyes of 23 patients and 21 eyes of 14 patients, respectively. We examined best-corrected visual acuity (BCVA), visual field mean deviation (MD) and pattern standard deviation (PSD), pattern-reversed visual evoked potential (PVEP) for P100 latency and amplitude at 60 and 15 arcmin stimulation checkerboard size, as well as proptosis using Hertel exophthalmometry.Whether 2-wall or 3-wall decompression, all parameters of visual function were improved after surgery (all P < .05). The improvement in BCVA, MD, and PSD was not statistically significant between groups (all P > .05). Proptosis reduction was higher after 3-wall decompression (P = .011). Mean increase in P100 amplitude after 3-wall decompression was statistically higher than that of after 2-wall decompression at 60 and 15 arcmin (P = .045 and .020, respectively), while the mean decrease in P100 latency was similar between the groups (P = .821 and .655, respectively). Six patients (66.67%) had persistent postoperative diplopia and 1 patient (20%) had new-onset diplopia in 3-wall decompression group, which were higher than in 2-wall decompression group (46.15% persistent postoperative diplopia and no new-onset diplopia).Both 2-wall and 3-wall decompression can effectively improve visual function of patients with DON. Three-wall decompression provides better improvement in P100 amplitude and proptosis, however new-onset diplopia is more common with this surgical technique.

Deep lateral orbital decompression for Graves orbitopathy: a systematic review

PURPOSE

To systematically review the literature on the deep lateral orbital decompression (DLD).

METHODS

The authors searched the MEDLINE, Lilac, Scopus, and EMBASE databases for all articles in English, Spanish, and French that used as keywords the terms orbital decompression and lateral wall. Two articles in German were also included. Data retrieved included the number of patients and orbits operated, types of the approach employed, exophthalmometric and horizontal eye position changes, and complications. The 95% confidence intervals (CI) of the mean Hertel changes induced by the surgery were calculated from series with 15 or more data.

RESULTS

Of the 204 publications initially retrieved, 131 were included. Detailed surgical techniques were analyzed from 59 articles representing 4559 procedures of 2705 patients. In 45.8% of the reports, the orbits were decompressed ab-interno. Ab-externo and rim-off techniques were used in 25.4% and 28.8% of the orbits, respectively. Mean and 95% CI intervals of Hertel changes, pooled from 15 articles, indicate that the effect of the surgery is not related to the technique and ranges from 2.5 to 4.5 mm. The rate of new onset of diplopia varied from zero to 8.6%. Several complications have been reported including dry eye, oscillopsia, temporal howling, lateral rectus damage, and bleeding. Unilateral amaurosis and subdural hematoma have been described in only one patients each.

CONCLUSIONS

The low rate of new-onset diplopia is the main benefit of DLD. Prospective studies are needed to compare the rate of complications induced by the 3 main surgical techniques used.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy

Purpose

To describe the results of thyroid-related orbitopathy (TRO) treated by ultrasonic deep lateral wall bony decompression with partial rim sparing (DLW-PRS).

Methods

A review was carried out, from January 2015 to September 2017, of all patients treated with ultrasonic DLW-PRS decompression using a SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator, using a lateral, small triangle flap incision for access. The primary outcome was the change in proptosis (measured by the difference in Hertel exophthalmometry measurements). Other secondary outcomes were changes in visual acuity (VA) (using Snellen scale, decimal fraction), presence of lagophthalmos, eyelid retraction (measured by upper eyelid margin distance to the corneal reflex (MRD₁) and lower eyelid margin distance to the corneal reflex (MRD₂), and presence of exposure keratopathy).

Results

A total of 58 orbital decompressions in 35 patients were reviewed, with 23 patients (65.7%) having bilateral decompressions. There was a female preponderance with 26 patients (74.2%), and the mean age ± standard deviation was 52.6 ± 13.9 years. Mean proptosis was 24.51 ± 1.76 mm preoperatively, reduced to 19.61 ± 1.27 mm in final follow-up. The mean reduction was 4.9 ± 1.54 mm. VA improved from 0.8 ± 0.14 to 0.9 ± 0.12, p=0.039. 5 of 13 patients (38.4%) with preoperative diplopia reported improvement or complete resolution after surgery. MRD₁ was reduced from 5.25 ± 0.88 mm to 4.49 ± 0.7 mm. MRD₂ was also reduced from 6.3 ± 0.88 mm to 5.0 ± 0.17 mm. Presence of lagophthalmos was reduced from 35 eyes (60.3%) to five (8.6%); the presence of epiphora was also reduced from 20 patients (57.1%) to 3 (8.5%) following decompression. Complications of the surgery included zygomatic hypoaesthesia in 14 (40%) patients in the early postoperative period and chewing alterations in 10 (28.5%) of the patients. All of these complications were resolved at the 6-month follow-up visit. We noted no surgical complications such as ocular or soft tissue damage, infection, inflammation, or visual loss.

Conclusions

The SONOPET® ultrasonic bone curette can be used safely and effectively for DLW orbital decompression surgery. The main benefits were good visualization and handling of tissues and speed and ease of use of the equipment. This trial is registered with ClinicalTrials.gov identifier: NCT04025034.

Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results

AIM

To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves' ophthalmopathy (GO).

METHODS

Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, medial-lateral (balanced), medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy (DON) were compared between different surgical techniques.

RESULTS

The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values (P<0.005). Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups (P=0.181).

CONCLUSION

The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

Original endoscopic orbital decompression of lateral wall through hairline approach for Graves' ophthalmopathy: an innovation of balanced orbital decompression

Background

Orbital decompression is an important surgical procedure for treatment of Graves’ ophthalmopathy (GO), especially in women. It is reasonable for balanced orbital decompression of the lateral and medial wall. Various surgical approaches, including endoscopic transnasal surgery for medial wall and eye-side skin incision surgery for lateral wall, are being used nowadays, but many of them lack the validity, safety, or cosmetic effect.

Patients and methods

Endoscopic orbital decompression of lateral wall through hairline approach and decompression of medial wall via endoscopic transnasal surgery was done to achieve a balanced orbital decompression, aiming to improve the appearance of proptosis and create conditions for possible strabismus and eyelid surgery afterward. From January 29, 2016 to February 14, 2017, this surgery was performed on 41 orbits in 38 patients with GO, all of which were at inactive stage of disease. Just before surgery and at least 3 months after surgery, Hertel’s ophthalmostatometer and computed tomography (CT) were used to check proptosis and questionnaires of GO quality of life (QOL) were completed.

Findings

The postoperative retroversion of eyeball was 4.18±1.11 mm (Hertel’s ophthalmostatometer) and 4.17±1.14 mm (CT method). The patients’ QOL was significantly improved, especially the change in appearance without facial scar. The only postoperative complication was local soft tissue depression at temporal region. Obvious depression occurred in four cases (9.76%), which can be repaired by autologous fat filling.

Interpretation

This surgery is effective, safe, and cosmetic. Effective balanced orbital decompression can be achieved by using this original and innovative surgery method. The whole manipulation is safe and controllable under endoscope. The postoperative scar of endoscopic surgery through hairline approach is covered by hair and the anatomic structure of anterior orbit is not impacted.

Surgical Anatomy of the Deep Lateral Orbital Wall

PURPOSE

To determine the exact anatomic location and volume of the thickest section of the greater wing of the sphenoid bone (trigone), which is removed during deep lateral orbital wall decompression.

METHODS

Eighteen dried skulls were used to determine the exact anatomic location and computed tomography (CT) images of 20 patients (10 male, 10 female) were used for volumetric calculations.

RESULTS

Mean values were 14.5 mm for the orbital rim to inferior orbital fissure distance, 23.3 mm for rim to trigone distance, 13.0 mm for width of the trigone base, 5.8 mm for trigone to orbital apex distance, and 12.3 mm for trigone height. The width of the narrowest section of the trigone was 5.2 mm. The trigone was found to have a lower segment (0.92 cc) neighboring the inferior orbital fissure, and an upper segment (0.32 cc) adjoining the thick substance of frontal bone. The narrowest part between these two segments was located just at the superior border of the lateral rectus muscle.

CONCLUSIONS

The authors recommend avoiding the thin rectangular portion located in the inter-fissural area adjacent to the superior orbital fissure. A high intersubject variability underscores the need for individualized preoperative analysis by imaging studies.

[Management of moderate and severe dysthyroid orbitopathy: about 22 cases]

Décrire la prise en charge thérapeutique des orbitopathies dysthyroidiennes modérées et sévères et évaluer par une étude statistique les facteurs associés à la neuropathie optique ainsi que les facteurs de mauvais pronostic visuel. Nous avons mené une étude rétrospective sur 22 patients présentant une ophtalmopathie dysthyroidienne modérée à sévère sur au moins un oeil, hospitalisés au service d'ophtalmologie du CHU Farhat Hached Sousse, sur une période s'étalant de 1998 à 2015. Les indications thérapeutiques sont basées sur les critères d'activité et de sévérité de l'Eugogo ainsi que l'évaluation des facteurs de mauvais pronostic visuel. L'âge moyen de nos patients était de 40 ans avec une légère prédominance masculine (54.5%). 68.2% des patients étaient en euthyroidie, 18.2% étaient tabagique. Le facteur le plus associé significativement à la neuropathie est la compression au niveau de l'apex orbitaire (P = 0.03). Le traitement était basé sur la corticothérapie intraveineuse et/ou la décompression orbitaire en fonction de l'activité et la sévérité de la maladie. L'évolution globale après traitement a été marquée par une amélioration des signes inflammatoires, réduction de l'exophtalmie. Le pronostic visuel était plus mauvais chez les patients plus âgés (P = 0.0001), de sexe masculin (P = 0.03) et traités par irathérapie (P = 0.04). Dans les limites d'une étude rétrospective, nos résultats étaient globalement concordants avec la littérature. L'orbitopathie dysthyroidienne reste une maladie dont l'évaluation et la prise en charge thérapeutique sont non encore bien élucidées. Des études de cohortes, probablement multicentriques, sont à envisager pour améliorer la prise en charge.

Postoperative Changes in Strabismus, Ductions, Exophthalmometry, and Eyelid Retraction After Orbital Decompression for Thyroid Orbitopathy

INTRODUCTION

Surgical rehabilitation of thyroid orbitopathy involves reducing proptosis, treating strabismus, lengthening the eyelids, and managing aesthetic changes. Not all are necessary in each patient; however, they often are. The current investigation intends to describe postdecompression changes that may influence the staging of these procedures.

METHODS

In this retrospective cohort study, records of 169 patients who underwent orbital decompression between 1983 and 2001 were reviewed. A single orbital specialist confirmed all measurements. Time to follow up was defined as the most recent follow up after decompression and prior to any secondary procedures. No strabismus or eyelid surgery was performed at the time of decompression. Strabismus was measured with alternating prism cover test. Ductions were estimated utilizing Hirschberg's method. Exophthalmometry was measured with Hertel. Eyelid positions were defined relative to the pupillary light reflex. Strabismus data were analyzed within eye pairs. Ductions, exophthalmometry and eyelid position were analyzed for each eye. T-test for paired data was utilized to compare means pre- and postoperatively.

RESULTS

The study population was on average 45 years old and 73.4% women. Average length of follow up was 1.2 years. Esotropia was significantly increased after decompression by an average of 8.1 prism diopters (p < 0.01). Exotropia and vertical deviations were not significantly altered. Ductions decreased by >5 degrees in at least one meridian for 68.1% of the population. Upper eyelid retraction remained unchanged; however, lower eyelid retraction improved by 50% from 1.4 mm to 0.7 mm (p < 0.01). Exophthalmometry improved from 23.5 mm to 19.7 mm (p < 0.01), and this result was correlated with the number of walls removed (Pearson r = -0.302, p < 0.01).

CONCLUSIONS

On average, esotropia and ductions tend to worsen with decompression surgery. This result supports the clinical dictum to avoid strabismus surgery until after decompression. The improvement in lower eyelid retraction suggests that at least lower eyelid-lengthening surgery should be reserved for after decompression, as there may be significant spontaneous improvement, while the same may not be true for upper eyelid retraction, which does not tend to change with decompression.

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.

Geriatric patients are predisposed to strabismus following thyroid-related orbital decompression surgery: A multivariate analysis

Geriatric patients (age ≥ 65) are prone to complications after surgery and are at risk for severe thyroid eye disease (TED). In this study, we aim to identify preoperative demographic and TED patterns associated with geriatric patients who underwent decompression surgery, to examine the effect of age on postoperative strabismus rates, and to identify factors that may contribute to postoperative strabismus in the geriatric subgroup. We retrospectively reviewed patients who underwent thyroid-related orbital decompression surgery at the Kellogg Eye Center, University of Michigan, between 1999 and 2014. Primary outcome was postoperative strabismus requiring palliation with prisms and/or strabismus surgery. Descriptive, univariate, and multivariable logistic regression analyses were used to define association of geriatric age with postoperative strabismus and determine predictors of postoperative strabismus. Of 241 patients, 41 (17.0%) were geriatric. They were less likely to undergo bilateral decompression (P = 0.012), less likely to be current smokers at time of decompression (P = 0.002), and more likely to have preoperative primary gaze diplopia (P = 0.001). Postoperative strabismus rates for geriatric patients (≥ 65 years of age), ages 50-65, 30-50, and < 30, were 73.2%, 41.3%, 31.9%, and 15.8%, respectively (P = 0.002). On multivariable analysis, geriatric age remained an independent risk factor for postoperative strabismus when compared to each age group (P ≤ 0.001). Among geriatric patients in subgroup multivariable analysis, balanced as opposed to lateral wall decompression (P = 0.038) and shorter TED duration (P = 0.031) were independently predictive of postoperative strabismus.

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.

Combined Endoscopic Medial and External Lateral Orbital Decompression for Progressive Thyroid Eye Disease

OBJECTIVE: To compare the efficacy of endoscopic medial and lateral orbital wall surgery to 3-wall decompression in patients with thyroid eye disease.

STUDY DESIGN AND SETTING: A retrospective study of patients with thyroid eye disease with severe proptosis, exposure keratitis, or compressive optic neuropathy was conducted.

RESULTS: Mean reduction in proptosis was 4.37 mm in the 2-wall approach and 4.59 mm in the 3-wall group. Seventy-five percent of patients in the 2-wall group demonstrated improved visual acuity; 50% improved after 3-wall decompression. Vertical palpebral fissure height decreased by an average of 2.50 mm in the 2-wall group and by 2.03 mm in the 3-wall group. New onset diplopia was 11.8% and 12.5%, respectively.

CONCLUSIONS: Improvement in the degree of proptosis, visual acuity, and palpebral fissure height was seen in the majority of our patients and compared favorably to our results with 3-wall orbital decompression.

EBM rating: C-4

Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy

Purpose

To evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO).

Methods

Twenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0).

Results

Forty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 ± 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 ± 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 ± 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 ± 0.8 to 3.8 ± 0.5 mm postoperatively.

Conclusions

The customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.

Critical Appraisal on Orbital Decompression for Thyroid Eye Disease: A Systematic Review and Literature Search

INTRODUCTION

Orbital decompression is the indicated procedure for addressing exophthalmos and compressive optic neuropathy in thyroid eye disease. There are an abundance of techniques for removal of orbital bone, fat, or a combination published in the scientific literature. The relative efficacy and complications of these interventions in relation to the specific indications remain as yet undocumented. We performed a systematic review of the current published evidence for the effectiveness of orbital decompression, possible complications, and impact on quality of life.

METHODS

We searched the current databases for medical literature and controlled trials, oculoplastic textbooks, and conference proceedings to identify relevant data up to February 2015. We included randomized controlled trials (RCTs) comparing two or more interventions for orbital decompression.

RESULTS

We identified only two eligible RCTs for inclusion in the review. As a result of the significant variability between studies on decompression, i.e., methodology and outcome measures, we did not perform a meta-analysis. One study suggests that the transantral approach and endonasal technique had similar effects in reducing exophthalmos but the latter is safer. The second study provides evidence that intravenous steroids may be superior to primary surgical decompression in the management of compressive optic neuropathy requiring less secondary surgical procedures.

CONCLUSION

Most of the published literature on orbital decompression consists of retrospective, uncontrolled trials. There is evidence from those studies that removal of the medial and lateral wall (balanced) and the deep lateral wall decompression, with or without fat removal, may be the most effective surgical methods with only few complications. There is a clear unmet need for controlled trials evaluating the different techniques for orbital decompression. Ideally, future studies should address the effectiveness, possible complications, quality of life, and cost of each intervention.

Characterization and outcomes of repeat orbital decompression for thyroid-associated orbitopathy

Orbital decompression for thyroid-associated orbitopathy (TAO) is commonly performed for disfiguring proptosis, congestion, and optic neuropathy. Although one decompression typically achieves goals, a small percentage requires repeat decompression. We performed a 10-year retrospective chart review of all orbital decompressions for TAO at a single tertiary referral institution. Four-hundred and ninety-five orbits (330 patients) were decompressed for TAO, with 45 orbits (37 patients) requiring repeat decompression. We reviewed the repeat cases for indications, clinical activity scores, approach, walls decompressed, and outcomes. Nine percent of orbits required repeat decompression for proptosis (70%), optic neuropathy (25%) or congestion (45%). Sixty-four percent were for recurrence of disease, 36% were for suboptimal decompression. Three incisional approaches were used: lateral upper eyelid crease, inferior transconjunctival, and transcaruncular, with inferior transconjunctival being most common. Of the three walls removed, deep lateral, inferior, and medial, the deep lateral wall was most common (51%). A repeat lateral decompression was the most frequent pattern. Of 37 patients requiring repeat decompression, 40% had diplopia prior to repeat, and an additional 24% developed diplopia after the repeat. Whereas previous studies published by our group cited only 2.6% of deep lateral wall orbital decompressions leading to new-onset primary gaze diplopia, repeat orbital decompressions have a much higher rate of post-operative diplopia. The new onset primary gaze diplopia after repeat decompression group had a higher average preoperative CAS (3.3 vs. 2.4, p < 0.01), higher mean blood loss (56 vs. 19 mL, p = 0.04), more frequent medial wall decompressions (47% vs. 29%, p = 0.33), and greater proptosis reduction (2.4 vs. 1.7 mm, p = 0.24).

Results after En Bloc Lateral Wall Decompression Surgery with Orbital Fat Resection in 111 Patients with Graves' Orbitopathy

Purpose. To evaluate the effect of en bloc lateral wall decompression with additional orbital fat resection in terms of exophthalmos reduction and complications. Methods. A retrospective, noncomparative case series study from 1999 to 2011 (chart review) in Graves' orbitopathy (GO) patients. The standardized surgical technique involved removal of the lateral orbital wall including the orbital rim via a lid crease approach combined with additional orbital fat resection. Exophthalmos, diplopia, retrobulbar pressure sensation, and complications were analyzed pre- and postoperatively. Results. A total of 111 patients (164 orbits) with follow-up >3 months were analysed. Mean exophthalmos reduction was 3.05mm and preoperative orbital pressure sensation resolved or improved in all patients. Visual acuity improved significantly in patients undergoing surgery for rehabilitative or vision threatening purposes. Preoperative diplopia improved in 10 patients (9.0%) but worsened in 5 patients (4.5%), necessitating surgical correction in 3 patients. There were no significant complications; however, one patient had slight hollowing of the temporalis muscle around the scar that did not necessitate revision, and another patient with a circumscribed retraction of the scar itself underwent surgical correction. Conclusions. The study confirms the efficiency of en bloc lateral wall decompression in GO in a large series of patients, highlighting the low risk of disturbance of binocular functions and of cosmetic blemish in the temporal midface region.

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.

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.

Surgical treatment of Graves' ophthalmopathy

The aims of surgical treatment in Graves's orbitopathy (GO) are improvement of function and appearance. Since antiinflammatory treatment of GO rarely results in a complete resolution of symptoms, surgical treatment is very important for patients well being. Rehabilitative surgery includes orbital decompression, squint correction, lid lengthening and blepharoplasty and these procedures have to be performed in centres of expertise. Various techniques have been developed for orbital decompression which allow now a graded approach to proptosis reduction and optic nerve decompression in emergency situations. Extraocular muscle recessions can be successfully performed to treat most of the patients with diplopia. Only large or complex squint angles are difficult to treat and step by step procedures are recommended in these patients. Lid lengthening procedures are performed most often in GO patients and should be performed under local anaesthesia to get a good result. Serious complications are rare.

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.

Comparison of lateral and medial orbital decompression for the treatment of compressive optic neuropathy in thyroid eye disease

PURPOSE

To compare the efficacy of lateral orbital decompression with medial orbital decompression for the treatment of compressive optic neuropathy (CON) caused by thyroid eye disease (TED).

METHODS

A retrospective review of all patients undergoing orbital decompression for TED-associated CON between 2003 and 2008 was conducted. Clinical outcome measures included visual acuity, mean deviation on Humphrey visual field, Ishihara color plate testing, afferent pupillary defect, and Hertel exophthalmometry. A composite CON score was also calculated for each patient based on the 3 visual outcome measures, with a higher CON score reflecting greater disease severity.

RESULTS

Twenty-eight eyes of 17 patients were included in the study. Ten orbits underwent lateral wall decompression, and 18 orbits underwent medial decompression. Both groups showed a significant postoperative improvement in visual acuity, Humphrey visual field testing, and color testing at 3 months following the initial surgery. The composite CON score improved 9.04 ± 9.97 points after lateral decompression (p = 0.02) and 9.03 ± 10.84 points after medial decompression (p = 0.003). There was no significant difference in the degree of improvement in any of the visual outcome measures between the lateral and medial groups. There was a statistically significant difference in the amount of proptosis reduction resulting from lateral decompression compared with medial decompression (6.3 versus 3.1 mm, respectively, p < 0.0001).

CONCLUSIONS

Lateral orbital decompression and medial orbital decompression are both efficacious for the treatment of TED-associated CON. Lateral decompression also results in a greater proptosis reduction than medial decompression.

Orbital decompression in the treatment of proptosis due to high axial myopia

PURPOSE

To report the results of orbital decompression surgery for proptosis due to high axial myopia.

METHODS

The clinical records and imaging of 8 consecutive patients with high axial myopia who underwent orbital decompression surgery to treat disfiguring proptosis were reviewed. Data collected included preoperative and postoperative best-corrected visual acuity, Hertel exophthalmometry, ocular motility examination findings, and surgical complications.

RESULTS

Eight patients (6 women) with a median presenting age of 53 years (range, 41-78 years) underwent unilateral bony orbital decompression surgery to treat proptosis due to unilateral or asymmetric high axial myopia. Indications for surgery were disfigurement in all patients and exposure keratopathy in 4 patients. All patients had more than 12 diopters of myopia on the operated side and axial lengths between 27.5 and 34.7 mm. Preoperative visual acuity was reduced in all patients owing to amblyopia and/or myopic retinal degeneration. In addition, 2 patients had mild symmetrical thyroid-related orbitopathy. After orbital decompression surgery, Hertel exophthalmometry measurements on the operated side were within 2 mm of the other side in all patients. The mean reduction in proptosis was 2.3 mm after deep lateral orbital wall decompression (3 patients), 4.3 mm after medial and lateral wall decompression (3 patients), and 5 mm after 3-wall decompression (2 patients). Five patients had a hypotropia on the operated side, and inferior rectus recession was performed in 4. Two patients underwent additional eyelid procedures. No surgical complications were observed.

CONCLUSIONS

Orbital decompression to reduce proptosis in patients with unilateral or asymmetric high axial myopia can improve cosmesis with low morbidity.

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.