Orbital decompression for endocrine ophthalmopathy: the endonasal approach

Endoscopic orbital decompression for Graves' orbitopathy

AIM

To study the efficacy of endonasal endoscopic orbital decompression in cases of Graves' orbitopathy.

MATERIAL AND METHODS

A total of 24 orbits in 12 patients underwent endoscopic orbital decompression for graves orbitopathy in the period between October 2002 and December 2010. Indications for surgery included proptosis, corneal exposure, keratitis, and compressive optic neuropathy. Decompression was accomplished by the removal of the medial and part of inferior wall of the orbit and slitting of the orbital periosteum. Pre and postoperative exophthalmometry measurements and visual acuity were recorded and compared.

RESULTS

A mean orbital regression of 3.70 mm was noted following endoscopic decompression. The visual acuity improved significantly in one of two eyes decompressed for failing visual acuity secondary to optic nerve compression. Transient diplopia was invariable following surgery but resolved over the next 8 weeks. One case manifested unilateral frontal sinus obstruction symptoms 4 months postoperatively and responded to medical therapy.

CONCLUSION

Endonasal endoscopic orbital decompression provides for an effective, safe, and minimally invasive treatment for proptosis and visual loss of Graves Orbitopathy. Long-term problems with diplopia were not noted in the endonasal endoscopic approach for orbital decompression.

The sphenoidal sinus in optic nerve decompression

Surgical decompression of the orbit may be necessary in dysthyroid patients with compressive optic neuropathy. Two-wall decompression with a trans-antral or a trans-conjunctival approach is commonly used. However, in some patients the initial improvement following this surgical procedure is not maintained. Although this may be due to disease progression, a variant of orbital anatomy can contribute to sub-optimal decompression. We report three cases in which recurrence of compressive optic neuropathy occurred following two-wall decompression. The sphenoidal sinus was placed anteriorly in these patients. Further decompression which included the lateral wall of the sphenoidal sinus resulted in improvement. An endoscopic approach provides superior access and visibility for decompression of the optic nerve into the sphenoidal sinus, and this approach may be the surgical treatment of choice in these cases.

Orbital decompression for thyroid eye disease: a comparison of external and endoscopic techniques

The results of orbital decompression for thyroid eye disease are presented in a cohort of 33 patients. It was performed by an external Patterson approach in 21 individuals and in 13 by an endonasal endoscopic approach. The endoscopic approach was entirely comparable in respect of improvement in axial proptosis, giving a mean improvement of 4.4 mm as compared with a mean of 3.8 mm for the external approach, and produced a demonstrable improvement in visual acuity and perception of colour in three individuals, where this was compromised, and was associated with fewer complications.

Effects of bilateral orbital decompression by an endoscopic endonasal approach in dysthyroid orbitopathy

AIMS

The efficacy of endoscopic endonasal orbital decompression in dysthyroid orbitopathy was analysed.

METHODS

In 21 consecutive cases of bilateral operation short term (10 (SD 6) days after operation) and long term (156 (12) days after operation) results were recorded.

RESULTS

Short term results showed that vision of the more affected eye improved from a mean of 0.35 to 0.59; vision improved in all but one eye which remained unchanged. In the fellow eyes mean visual acuity improved from 0.6 to 0.7; three of these eyes showed a decrease. Mean proptosis returned from 23.0 mm to 20.0 mm. As to motility the mean abductive capacity decreased from 5.5 mm to 4.0 mm of monocular excursion, whereas adduction increased from 7.5 mm to 8.5 mm. Upgaze and downgaze did not show any major change. The mean angle of horizontal squint shifted from 7.5 degrees of convergence to 15.5 degrees while no significant vertical or cyclorotational deviation was induced. These immediate postoperative results proved to be stable for the period of long term follow up with only slight changes. No significant bleeding or specific otorhinolaryngological complication without resolve occurred intraoperatively or perioperatively.

CONCLUSION

This method is believed to be superior to non-endoscopic techniques because it avoids external scars and antral pain. With regard to the relief of intraorbital pressure, the technique gives good results for visual acuity improvement, but in proptosis reduction the method is not as efficient as external or combined procedures. There seems to be no difference when compared with other approaches in induction of horizontal squint. The method has a protective long term effect against the recurrence of compressive optic neuropathy.