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?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).     

Effect of prior orbital decompression on outcome of strabismus surgery in patients with thyroid ophthalmopathy.

PURPOSE: To compare strabismus surgery outcomes of patients who have had prior orbital decompression for thyroid ophthalmopathy with those of patients who have not had decompression. METHODS: The records of all patients operated on by the author for strabismus related to thyroid ophthalmopathy were retrospectively reviewed. RESULTS: Fifty patients were included in this study. Seventeen patients had previously undergone orbital decompression, and 33 patients had not. Seventy-six percent of patients who had had orbital decompression had a good or excellent outcome compared with 91% of those who had not had orbital decompression. Patients in the orbital decompression group had an average of 1.4 operations compared with 1.2 in the no-decompression group. The average numbers of muscles operated on were 3.1 in the decompression group and 1.9 in the no-decompression group. Patients who had been decompressed were more than 4 times as likely to require surgery for both a horizontal and vertical deviation than patients who had not been decompressed. CONCLUSIONS: Patients with thyroid ophthalmopathy who have had orbital decompression have a lower success rate of surgery for strabismus, more frequently need correction for both horizontal and vertical deviations, and have more muscles operated on than patients who have not had orbital decompression. The need for orbital decompression in patients with Graves' disease is reflective of a worse degree of orbitopathy. In addition, ocular changes from decompression surgery may interfere with a successful result from strabismus surgery.     

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

PurposeTo 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).MethodsRetrospective 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.ResultsTwenty-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.ConclusionsIn 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.     

Ocular motility problems after orbital decompression for dysthyroid ophthalmopathy

Ocular motility problems of 50 consecutive patients following orbital decompression for dysthyroid (Graves') ophthalmopathy were analyzed retrospectively. No significant relationship to the development of postoperative diplopia was seen in the amount of retrodisplacement of the globe, the anatomical approach for orbital decompression, or the indication for decompression. Several clinical observations were made. Patients whose indication for orbital decompression was a vision-threatening ophthalmopathy were more likely (although not statistically significantly) to develop postoperative strabismus. Patients who developed changes in preoperative strabismus were more likely to develop increased esotropia and/or restrictive hypertropia. Of 32 patients who were orthotropic in the primary position before operation, 11 developed postoperative strabismus in the primary position. Only five patients had normal versions and ductions before operation. All five of these patients had normal versions and ductions after operation.     

Orbital decompression: a comparison between trans-fornix/transcaruncular inferomedial and coronal inferomedial plus lateral approaches

PURPOSE: To compare two techniques of orbital decompression for Graves orbitopathy, that is, the inferomedial transfornix/transcaruncular approach and the inferomedial plus lateral coronal approach. METHODS: Comparative interventional case series. A retrospective review of 53 patients (94 orbits) with Graves orbitopathy operated on over a 9-year period was performed. Forty-nine orbits were decompressed by the transfornix-transcaruncular approach and 45 by the coronal approach. Data obtained for all patients included computed tomography scans of the orbits, Snellen visual acuity measurements, visual fields, Hertel exophthalmometry, color vision testing, subjective testing for diplopia in the cardinal positions of gaze, and direct ophthalmoscopic or biomicroscopic examination of the optic disc. RESULTS: The mean proptosis reduction was 4.37 mm with the transfornix/transcaruncular approach and 5.76 mm with the 3-wall coronal approach. The rate of optic neuropathy reversal was similar with both techniques (90%). Induction of new diplopia occurred in 13.6% patients operated by the transfornix/transcaruncular approach and in 16.6% patients who underwent decompression by the coronal approach. CONCLUSIONS: The two techniques have similar effects on visual function and ocular motility. For the vast majority of patients with Graves who need orbital decompression, the coronal approach is unnecessary; the transconjunctival approach allows the same exposure to the medial, inferior, and lateral walls.     

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 3.3mm. 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.     

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.     

Balanced orbital decompression combined with fat removal in Graves ophthalmopathy: do we really need to remove the third wall?

PURPOSE: To compare the reduction of proptosis and the incidence of new-onset diplopia after 3-wall (medial, lateral, and inferior) orbital decompression versus balanced medial and lateral wall decompression combined with orbital fat excision in patients with Graves ophthalmopathy. METHODS: Three-wall orbital decompression including medial, inferior, and lateral walls was performed in 13 eyes of 7 patients (group 1), and balanced medial and lateral wall decompression combined with fat removal was performed in 18 eyes of 11 patients (group 2). A transnasal endoscopic approach was used for medial wall removal. A lateral canthotomy incision combined with a short upper eyelid incision was used for extended lateral wall removal, and this was combined with an inferior conjunctival fornix incision when floor decompression was performed. RESULTS: The mean reduction of proptosis was 6.9+/-1.6 mm and 6.5+/-1.3 mm in the first and second groups, respectively; the difference was not statistically significant (P=0.37). After 3-wall decompression, 57.1% of the patients had permanent new-onset diplopia (group 1), whereas none of the patients had permanent postoperative diplopia after balanced medial and lateral wall decompression combined with fat removal (group 2). The difference in permanent new-onset postoperative diplopia between two groups was statistically significant (P<0.001). CONCLUSIONS: Balanced medial and lateral wall decompression combined with orbital fat removal provides an effective reduction in proptosis and reduces the incidence of postoperative permanent diplopia when compared with 3-wall decompression. This technique may eliminate the need for orbital floor excision.     

The effect of orbital decompression surgery on refraction and intraocular pressure in patients with thyroid orbitopathy

Purpose

To investigate the effect of orbital decompression surgery in thyroid orbitopathy (TO) on both refractive status and intraocular pressure (IOP).

Patients and methods

A prospective, multicentre, consecutive audit of patients undergoing thyroid decompression surgery. Indications for surgery included cosmetically unacceptable proptosis or corneal exposure. Exclusion criteria included the following: previous orbital surgery, glaucoma, corneal disease, steroid use in the preceding 12 months, or an acute optic neuropathy. Automated refraction, keratometry, pachymetry, Hertel exophthalmometry, and IOP were recorded at 1 month pre- and 3 months postoperatively. IOP using the Tono-Pen (mean of three readings) was measured in the primary, upgaze, and downgaze positions.

Results

Data were collected from 52 orbits of 33 patients (East Grinstead, New York, and Adelaide). There was no significant difference between pre- and postoperative data for sphere, cylinder, or central corneal thickness (CCT). The mean spherical equivalent was −0.43±1.49 D pre-operatively and −0.28±1.52 D postoperatively. The steepest meridian of corneal curvature was 93.1 degrees pre- and 94.2 degrees postoperatively, with no significant difference. Mean IOP significantly decreased when measuring by Goldmann applanation tonometry (GAT) (2.28 mm Hg, ^* P=0.001) and Tono-Pen (3.06 mm Hg, ^* P=<0.0001). IOP measured in upgaze was significantly greater than that in the primary position. Regression analysis between change in IOP and either Hertel exophthalmometry or the number of orbital walls decompressed was non-significant (^*Student''s t-test).

Conclusion

Patients with TO undergoing orbital decompression had, on average, with-the-rule astigmatism not affected by orbital decompression surgery. IOP was significantly reduced by decompression surgery although no relationship between IOP and the degree of decompression was observed.     

Superior oblique muscle involvement in thyroid ophthalmopathy.

BACKGROUND: Rectus muscle involvement in thyroid ophthalmopathy is well documented. The inferior rectus is the most frequently involved, followed by the medial, superior, and infrequently the lateral rectus. This study reports involvement of the superior oblique muscle as a contributory cause of restrictive strabismus in patients with thyroid ophthalmopathy. METHODS: This is a retrospective review of four patients with known thyroid ophthalmopathy who presented with incomitant vertical strabismus, A-pattern, overdepression in adduction, underelevation in adduction, and incyclotorsion. All patients underwent preoperative orbital imaging. Two of the four patients had previous orbital decompressions. All patients underwent surgery on the SO muscle. RESULTS: Preoperative scans showed enlargement of one or both SO muscles in all patients and intraoperative forced duction testing revealed restriction to elevation in adduction in all cases. Preoperative A-pattern ranged from to 6 to 22 prism diopters. All subjects had preoperative incyclotorsion, ranging from 2 and 14 degrees. Improvement of the versions, hypertropia, and cyclotorsion followed surgical weakening procedures on the SO muscle. CONCLUSION: Thyroid ophthalmopathy may involve the SO muscle. Clinical manifestations include preoperative A-pattern strabismus, incyclotorsion, and restrictive limitation to elevation in adduction. Orbital imaging documents SO muscle enlargement. Awareness of SO involvement in thyroid ophthalmopathy assists the surgeon to develop a more precise surgical strategy to correct the hypotropia.     

Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno

AIMS: A modified surgical technique is described to perform a one, two, or three wall orbital decompression in patients with Graves' ophthalmopathy. METHODS: The lateral wall was approached ab interno through a "swinging eyelid" approach (lateral canthotomy and lower fornix incision) and an extended periosteum incision along the inferior and lateral orbital margin. In addition, the orbital floor and medial wall were removed when indicated. To minimise the incidence of iatrogenic diplopia, the lateral and medial walls were used as the first surfaces of decompression, leaving the "medial orbital strut" intact. During 1998, this technique was used in a consecutive series of 19 patients (35 orbits) with compressive optic neuropathy (six patients), severe exposure keratopathy (one patient), or disfiguring/congestive Graves' ophthalmopathy (12 patients). RESULTS: The preoperative Hertel value (35 eyes) was on average 25 mm (range 19-31 mm). The mean proptosis reduction at 2 months after surgery was 5.5 mm (range 3-7 mm). Of the total group of 19 patients, iatrogenic diplopia occurred in two (12.5%) of 16 patients who had no preoperative diplopia or only when tired. The three other patients with continuous preoperative diplopia showed no improvement of double vision after orbital decompression, even when the ocular motility (ductions) had improved. In the total group, there was no significant change of ductions in any direction at 2 months after surgery. All six patients with recent onset compressive optic neuropathy showed improvement of visual acuity after surgery. No visual deterioration related to surgery was observed in this study. A high satisfaction score (mean 8.2 on a scale of 1 to 10) was noted following the operation. CONCLUSION: This versatile procedure is safe and efficacious, patient and cost friendly. Advantages are the low incidence of induced diplopia and periorbital hypaesthesia, the hidden and small incision, the minimal surgical trauma to the temporalis muscle, and fast patient recovery. The main disadvantage is the limited exposure of the posterior medial and lateral wall.     

Hypoglobus following orbital decompression for dysthyroid ophthalmopathy

Hypoglobus following orbital decompression is not a rare complication. Hypoglobus requiring surgery to elevate the globe following orbital decompression is considered clinically significant hypoglobus. A retrospective analysis of 157 consecutive patients who had their orbits expanded by removing the medial wall and floor of the orbit found seven patients (4.5%) who required further surgery to elevate the globe. The seven patients who developed clinically significant hypoglobus following orbital decompression all developed a set of distinct clinical signs. These included a "setting sun" appearance of the globe, eyelid malposition, orbital volume loss, and strabismus. These clinical signs can be explained by the inferior movement of the globe and the orbital contents following the loss of support structures on the orbital floor. A two-wall orbital decompression performed on a cadaver reproduced the physical signs of hypoglobus. The dissection suggested that the periorbita is the most important structure supporting the globe in the orbit.     

Balanced orbital decompression in Graves' orbitopathy: Upper eyelid crease incision for extended lateral wall decompression

INTRODUCTION . This study reports on the results and complications detected in patients with Graves' orbitopathy who underwent balanced medial and lateral wall orbital decompression through concealed incisions. MATERIALS AND METHODS . The medial and lateral orbital walls of nine consecutive patients (14 eyes) were removed. A transnasal endoscopic spheno-ethmoidectomy was performed for the medial wall decompression. A lateral wall decompression was performed via an upper eyelid crease incision which was extended laterally in a relaxed skin tension line. The lateral aspect of the orbit was sculpted with a high-speed surgical drill from the inferior orbital fissure inferiorly and frontal bone of the lacrimal fossa superiorly to the orbital apex posteriorly, including the thick bone of the greater wing of the sphenoid. RESULTS . The decompression was performed for cosmetic purposes in seven patients (10 orbits) and for exposure keratopathy and restrictive myopathy in the remaining two patients (4 orbits). The average follow-up period was 13.6 months. The mean reduction of proptosis was 4.8 mm. The preoperative diplopia in two cases demonstrating restrictive myopathy worsened during the postoperative period. New onset diplopia was not detected in seven cases operated on for cosmetic purposes. All patients were satisfied with their eye status, visual rehabilitation and cosmetic appearance. CONCLUSIONS . The transnasal endoscopic approach for medial wall and extended lateral wall decompression with hidden eyelid crease incision provides a favorable cosmetic and physiologic outcome with proper retroplacement of the globe.     

Orbital decompression for Graves' ophthalmopathy by inferomedial, by inferomedial plus lateral, and by coronal approach

To test the efficacy and safety of orbital decompression for Graves' ophthalmopathy, the authors studied the records of 60 consecutive patients who were operated on for dysthyroid optic neuropathy or for rehabilitative purposes. Patients decompressed for neuropathy were older, had less proptosis, and a shorter duration of eye disease than patients operated on for disfigurement. The authors compared the results of three surgical procedures including the inferomedial, the inferomedial plus lateral, and the coronal approach. Regarding improvement of visual function, no difference was found between the three techniques. Patients in whom vision failed to recover had a high prevalence of diabetes mellitus. Proptosis reduction varied from 1 to 9 mm, depending on the number of walls decompressed. There was no net change in the prevalence of diplopia. Persistent complications were seen in less than 5% of all decompressions. The authors conclude that orbital decompression for Graves' ophthalmopathy is safe and efficacious, regardless of surgical procedure. However, the coronal approach gives the best cosmetic results.     

Deep lateral wall orbital decompression following strabismus surgery in patients with Type II ophthalmic Graves’ disease

Purpose: Surgical management of ophthalmic Graves’ disease traditionally involves, in order, orbital decompression, followed by strabismus surgery and eyelid surgery. Nunery et al. previously described two distinct sub-types of patients with ophthalmic Graves’ disease; Type I patients exhibit no restrictive myopathy (no diplopia) as opposed to Type II patients who do exhibit restrictive myopathy (diplopia) and are far more likely to develop new-onset worsening diplopia following medial wall and floor decompression. Strabismus surgery involving extra-ocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with Type II patients who have already undergone medial wall and floor decompression and strabismus surgery found, when additional decompression is necessary, deep lateral wall decompression (DLWD) appears to have a low rate of post-operative primary-gaze diplopia.

Methods: A case series of four Type II ophthalmic Graves’ disease patients, all of whom had already undergone decompression and strabismus surgery, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with DLWD. Institutional Review Board approval was granted by the University of Kansas.

Results: None of the four patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following DLWD.

Conclusions: While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Graves’ disease, for proptosis following consecutive strabismus surgery, DLWD appears to be effective with a low rate of recurrent primary-gaze diplopia.     

Balanced orbital decompression in Graves' orbitopathy: Upper eyelid crease incision for extended lateral wall decompression

INTRODUCTION. This study reports on the results and complications detected in patients with Graves' orbitopathy who underwent balanced medial and lateral wall orbital decompression through concealed incisions. MATERIALS AND METHODS. The medial and lateral orbital walls of nine consecutive patients (14 eyes) were removed. A transnasal endoscopic spheno-ethmoidectomy was performed for the medial wall decompression. A lateral wall decompression was performed via an upper eyelid crease incision which was extended laterally in a relaxed skin tension line. The lateral aspect of the orbit was sculpted with a high-speed surgical drill from the inferior orbital fissure inferiorly and frontal bone of the lacrimal fossa superiorly to the orbital apex posteriorly, including the thick bone of the greater wing of the sphenoid. RESULTS. The decompression was performed for cosmetic purposes in seven patients (10 orbits) and for exposure keratopathy and restrictive myopathy in the remaining two patients (4 orbits). The average follow-up period was 13.6 months. The mean reduction of proptosis was 4.8 mm. The preoperative diplopia in two cases demonstrating restrictive myopathy worsened during the postoperative period. New onset diplopia was not detected in seven cases operated on for cosmetic purposes. All patients were satisfied with their eye status, visual rehabilitation and cosmetic appearance. CONCLUSIONS. The transnasal endoscopic approach for medial wall and extended lateral wall decompression with hidden eyelid crease incision provides a favorable cosmetic and physiologic outcome with proper retroplacement of the globe.     

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.     

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.     

Surgical treatment of the sequelae of Basedow's ophthalmopathy

Functional and cosmetic ophthalmic complications of Graves' disease are exophthalmos, eyelid retraction and oculomotor disturbances. This paper describes and takes over the surgical procedures used when these complications are associated. In severe exophthalmos, we used an orbital decompression of the orbital floor sometimes combined with the medial wall by an anterior approach. In eyelid retraction, we perform a recession of the levator muscle with scleral graft implantation. In incomitant strabismus, surgery is usually limited to recessions of the involved muscles, most of the surgery is directed to the inferior rectus and medial rectus, as these are the most commonly affected muscles. The indications depend on the status of the patient at the time of referral. For severe exophthalmos with true retraction of the upper eyelid, we begin at the first stage by treatment of the retraction and if it is not sufficient, we perform an orbital decompression at the second stage. For severe exophthalmos with oculomotor disturbances, we perform at the first stage the orbital decompression and at the second stage the strabismus surgery. For oculomotor disturbances with eyelid retraction, we perform the strabismus surgery at the first stage and the eyelid retraction at the second stage. When there is the association of exophthalmos, eyelid retraction and oculomotor disturbances, the indication and the choice of treatment are difficult and depend on numerous factors. If an orbital decompression is indicated, it will be done first, followed by the strabismus surgery and at a later stage, the eyelid retraction. If only the eyelid retraction is treated, it will be done after the strabismus surgery. The chronology of the treatment depends on the modification we observed on the other components of the ophthalmopathy when one stage treatment is performed on one component: for example orbital decompression can modify the oculomotor disturbance and oculomotor surgery can modify eyelid retraction.