Piezoelectric surgery versus mechanical drilling for orbital floor decompression: effect on infraorbital hypoaesthesia

Purpose: To compare efficacy and safety of mechanical drill and piezoelectric technology in the prevention of infraorbital nerve hypoaesthesia during orbital floor decompression.

Methods: Single-centre, non-randomized prospective, interventional case series. We enrolled 24 patients who underwent 3-wall orbital decompression. A total of 13 patients underwent floor decompression using 5-mm diamond dusted Piezoelectric tip (Synthes GmbH, Oberdorf, Germany), whereas 11 patients underwent conventional mechanical decompression of the floor using Stryker Core handpiece with 5-mm diamond dusted tip (Stryker, USA) and a Kerrison’s bone ronguer. All surgeries were performed by a single surgeon (MNN) using standard surgical technique. The infraorbital nerve hypoesthesia was measured pre-operatively, and post-operatively on day 1, at 1 week, 6 weeks, 3 months, and final follow-up by an independent observer. Hypoaesthesia was graded on a simple numerical scale: 0 defined as “normal”, 1 defined as “minimally reduced”, 2 defined as “grossly reduced but perceptible”, and 3 defined as “total loss”.

Results: The average follow-up after surgery was 16 months (range 13–48 months). The average score in the mechanical drilling group at day 1, week 6, week 12 and final follow-up was 1.9, 1.2, 0.7, and 0.6, respectively (p < 0.001). For the Piezo group, the average scores were 0.3, 0.2, 0.1, and 0.1, respectively. No procedure related complications were noted, and the average surgical time for floor decompression was comparable (p > 0.5).

Conclusions: Piezoelectric technology is effective in orbital floor removal by minimizing infraorbital nerve hypoaesthesia.     

Results of diplopia and strabismus in patients with severe thyroid ophthalmopathy after orbital decompression

Purpose:

It has been frequently stated that the orbital decompression, in patients with thyroid ophthalmopathy, does not usually improve extraocular muscles function and that after the operation there is often a deterioration of these functions. The purpose of this article is evaluation of extraocular muscles function after applying personal method of 3 wall orbital decompression.

Materials And Methods:

Retrospective review of case records of 119 patients with severe thyroid ophthalmopathy seen and treated by the author between December 1986 and December 2010. All patents underwent 3 wall orbital decompression combined with removal of the periorbital, intraorbital and retrobulbar fat. Correction of coexistent eyelid retraction and deformities were also performed.

Results:

Comparison of preoperative and postoperative results was conducted in 65 patients three months after 3 wall decompression. All patients showed a significant reduction of exophthalmos [5-11 mm, 7.2 mm on average], reduction of intraocular pressure, marked improvement in ocular muscle function as well as considerable reduction in or disappearance of subjective symptoms. There were no cases of subsequent impairment of ocular motility. Strabismus surgery was performed in 6 patients with residual diplopia. There was an improvement in vision in 68% patients who had impaired vision before the operation. Less evident relapse of exophthalmos was recorded in 3 cases only and only one patient required unilateral reoperation.

Conclusion:

It can be concluded that this method of orbital decompression is logical, based on an understanding of the pathology, has less complication rates, is relatively easy to perform, gives very good functional and aesthetic long term results and allows rapid recovery.     

Thyroid Eye Disease: A Historical Perspective

Within the short period from 1802 to 1840 four physicians from four different countries (Flajani in Italy, Parry in England, Graves in Ireland and Basedow in Germany) independently described a hitherto unknown disease, the hallmark of which were tachycardia and enlargement of the thyroid. Three of the physicians also noted exophthalmos. In sequence, the disease was attributed to primary cardiac disease, then to increased sympathetic nerve discharge, and finally to thyroid hyper-function. The latter concept failed to explain the exophthalmos, which cannot be reproduced by over-dosage of thyroid hormone. Explanations for the exophthalmos went from cardiac failure (causing swelling of the thyroid and retro-orbital tissues), to sympathetic nerve discharge, to over-secretion of TSH, to production within the pituitary of TSH fragments with exophthalmogenic properties, and finally to shared auto-antigens of thyroidal and retroorbital tissue. The latter theory is favoured today, after it had been recognized that thyroid hyperfunction in Graves’ disease was due to auto-antibodies to the thyroidal TSH receptor; such receptors were postulated also to be present in retroorbital tissue. Thus, each generation of scientists explained the pathogenesis of exophthalmos with the methods and concepts available to medical research at any given time. Although big advances have been made, future research may be good for some unexpected surprises.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression

Introduction: Different minimally invasive surgical approaches to the orbit allow individualized bone resection to reduce proptosis and decompress the optic nerve in patients with Graves’ orbitopathy (GO). This study aims to compare piezosurgery to an oscillating saw used to resect bone from the lateral orbital wall.

Methods: In a retrospective study, we analyzed balanced orbital decompressions performed on 174 patients (318 cases) with GO. An oscillating saw was used in 165 cases (saw group) and piezosurgery in 153 cases (piezo group). Peri- and postoperative complications, reduction of proptosis, new onset of diplopia and improvement of visual acuity in cases of pre-operative optic nerve compression were analyzed.

Results: We observed no significant differences in the surgical outcome between the two groups. Proptosis reduction was 4.6 mm in the saw group (p < 0.01) and 5.3 mm in the piezo group (p < 0.01). Intraoperative handling of the piezosurgery device was judged superior to the oscillating saw, due to soft tissue conservation and favourable cutting properties. Duration of the surgery did not differ between the groups. No serious adverse events were recorded in both groups.

Conclusion: The application of piezosurgery in orbital decompression is more suitable than an oscillation saw due to superior cutting properties such as less damage to surrounding soft tissue or a thinner cutting grove.     

高频超声引导下A型肉毒杆菌毒素注射在甲状腺相关眼病限制性斜视中的应用

目的:探讨高频超声引导下注射A型肉毒杆菌毒素(botulinum toxin A,BTXA)治疗甲状腺相关眼病(thyroid associated ophthalmopathy,TAO)限制性斜视的临床效果。方法:选择32例TAO限制性斜视患者,在眼科高频超声引导下注射BTXA。观察注射前后的斜视度及复视的变化情况。结果:患者32例经重复注射2～4次BTXA后,其斜视度及复视情况有不同程度的减轻。总体显效率占47%,有效率占44%,无效率占9%。结论:高频超声引导下注射BTXA治疗TAO限制性斜视,定位准确,是一种有效缓解眼外肌痉挛和减轻复视症状及斜视度的方法。     

Sensitivity and responsiveness of the patient-reported TED-QOL to rehabilitative surgery in thyroid eye disease

We tested the sensitivity and responsiveness of the TED-QOL to rehabilitative surgery in thyroid eye disease (TED). The 3-item TED-QOL and 16-item GO-QOL, which assess quality of life (QoL) in TED, were administered to consecutive patients undergoing rehabilitative surgery. The questionnaires were completed pre-and post-operatively to assess sensitivity (ability to discriminate between different surgical groups) and responsiveness (ability to detect within patient changes over time).56 patients underwent 69 procedures for TED (29 orbital decompressions, 15 strabismus operations, 25 eyelid procedures).

The differences in scores between the three types of surgery (a measure of sensitivity) were statistically significant at the 5% level pre-operatively and post-operatively for all 3 TED-QOL scales and for both GO-QOL scales, but much more so for the TED-QOL scales in each case.

The within-patient changes between the pre- and post-operative scores for the same subjects (a measure of responsiveness) were statistically very highly significant for the TED-QOL overall and appearance scales for each of the surgeries. The pre- and post-operative difference for the TED-QOL functioning scale was highly statistically significant for strabismus surgery but not for decompression or lid surgery. The change between the pre- and post-operative scores for the GO-QOL was significant for the functioning scale with strabismus and lid surgery, and was highly significant for the appearance scale with lid surgery but not for strabismus surgery or decompression.

The 3-item TED-QOL is sensitive and responsive to rehabilitative surgery in TED and compares favorably with the lengthier GO-QOL for these parameters.     

Adult hypertropia: a guide to diagnostic evaluation based on review of 300 patients

Purpose

To highlight the key clinical features of various aetiologies of adult hypertropia and to discuss the diagnostic approach towards evaluation of vertical double vision.

Methods

This is a retrospective cross-sectional study. A total of 300 consecutive patients with vertical diplopia were evaluated by a single neuro-ophthalmologist and strabismologist in a tertiary care setting from 2005–2008. The medical records of all patients with vertical diplopia coded with one of the following diagnoses; hypertropia, diplopia, thyroid eye disease, fourth nerve palsy, ocular myasthenia, congenital strabismus, and third nerve palsy were reviewed. The main outcome measures were determination of aetiologies of hypertropia.

Results

Fourth nerve palsy and thyroid eye disease were the most common causes of vertical diplopia in our series and comprised more than 50% of patients. The other causes of vertical diplopia were ocular surgery, orbital fracture, neurosurgery, childhood strabismus, skew deviation, third nerve palsy, myasthenia gravis, and decompensated hyperphorias. Ocular motility deficits were seen in 33% of the cohort of whom thyroid eye disease comprised the largest group. Orbital ultrasonography was sensitive in detecting thyroid orbitopathy.

Conclusion

In the majority of patients, the aetiologies of hypertropias can be ascertained by history and careful ophthalmic examination alone. Fourth nerve palsy and thyroid eye disease were the most common causes of vertical diplopia in this series.