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).     

Efficacy and side effects of 'swinging eyelid' orbital decompression in Graves' orbitopathy: a proposal for standardized evaluation of diplopia

OBJECTIVES: To evaluate the efficacy and side effects of 'swinging eyelid' orbital decompression in patients with Graves' orbitopathy (GO). To calculate the incidence of postoperative new-onset diplopia (NOD) using a newly proposed scoring system for diplopia. METHODS: We reviewed the clinical data on proptosis, visual acuity, and diplopia in 104 consecutive patients (198 orbits) with GO, who underwent orbital decompression. A combined lateral canthal and inferior fornix incision ('swinging eyelid' approach) was used for removal of the medial wall, the orbital floor and, if indicated, the lateral wall. Indications for surgery were disfiguring/congestive GO (DGO) in 79 patients (149 orbits) and compressive optic neuropathy (CON) in 25 patients (49 orbits). Diplopia was scored according to four grades. In both groups, the incidence of new-onset (continuous) diplopia (NOD), deterioration of diplopia (DOD), and improvement of diplopia (IOD) were calculated, using strictly defined criteria. Our data on NOD were compared to those from other series, after recalculation according to our criteria. RESULTS: The mean proptosis reduction was 4.6 mm (range 0-9.5 mm) after three-wall decompression (95 patients, 180 orbits) vs 3.1 mm (range 0-7 mm) after two-wall decompression (nine patients, 18 orbits). The visual acuity improved in 98% of the patients with CON. In patients with DGO, NOD occurred in 14%. In patients with CON, NOD was not observed, but DOD occurred in 41%. Our data compare favourably to the reported incidence of NOD after either transantral or transnasal decompression. CONCLUSIONS: "Swinging eyelid' orbital decompression is efficacious for proptosis reduction as well as for optic nerve decompression. A scoring system for standardized evaluation of diplopia is proposed.     

Transcaruncular orbital decompression for dysthyroid optic neuropathy

PURPOSE: To determine the efficacy of transcaruncular approach orbital apex decompression for treatment of dysthyroid optic neuropathy. METHODS: In this retrospective noncomparative interventional case series, charts for all patients undergoing orbital decompression surgery for dysthyroid optic neuropathy performed by one author between October 1999 and September 2001 were included in the study. Primary outcome measures included visual acuity, static perimetry, pupillary testing, and color plate testing before and after surgery. Records were also reviewed for changes in extraocular motility and proptosis after surgery and for surgical complications. RESULTS: Sixteen consecutive patients (6 unilateral, 10 bilateral, for a total of 26 cases) underwent orbital apex decompression for dysthyroid optic neuropathy through a transcaruncular approach. In each orbit, the optic neuropathy was refractory to oral corticosteroid therapy. Preoperative visual acuity remained stable or improved in each case. Preoperative Humphrey visual field testing revealed an average mean deviation of -10.3 +/- 6.5 (range, +0.76 to -25.45). Average postoperative mean deviation was -2.79 +/- 2.4 (range, +0.94 to -9.82). Before surgery, 7 of 23 eyes (30%) had full color plates. After surgery, 22 of 23 eyes (96%) had full color plates. Follow-up ranged from 2 to 26 months (mean, 10 months). New-onset diplopia developed in 2 of 10 (20%) patients without preexisting diplopia. CONCLUSIONS: Transcaruncular approach orbital apex decompression effectively treats dysthyroid optic neuropathy.     

Development of ocular motility following modified 3-wall decompression of the orbita in endocrine orbitopathy for functional and rehabilitative indication

INTRODUCTION: Permanent visual damage due to an increase in volume of the orbital contents may be the result of the failure of conservative therapeutic concepts in the treatment of endocrine orbitopathy. Considerable progress has been achieved in developing successful orbital decompression techniques with regard to functional and cosmetic outcome. Decompression techniques with resection of the bony orbital walls are adequate tools in restoring visual acuity and reducing exophthalmus. A considerable degree of deterioration of motility disorders has been described in the literature depending on the techniques being used. PURPOSE: The purpose of this study was to investigate whether a modified technique of 3-wall orbital decompression with preservation of a medial part of the periorbital tissue to support the medial rectus muscle, is able to reduce the postoperative risk of diplopia. MATERIAL AND METHODS: A modified technique of orbital 3-wall decompression with resection of the medial orbital wall, the medial orbital floor and the floor of the frontal sinus has been used in patients with compressive optic neuropathy (n = 20) and for cosmetic reasons (n = 7) in cases of uni- or bilateral proptosis. Analysis of the results was performed concerning visual outcome, exophthalmus reduction and development of horizontal and vertical motility changes. RESULTS: In all cases of optic neuropathy improvement of visual function at an average of 4.63 +/- 4.5 lines could be achieved. Exophthalmus reduction was 3.2 +/- 2.4 mm in the functional group and 3.9 +/- 1.7 mm in the rehabilitative group. In this group motility of the medial rectus muscle remained unaffected except in one eye. In the functional group motility deterioration was observed in 62 %. CONCLUSION: The modified 3-wall decompression technique with preservation of a medial periorbital tissue strip is an adequate alternative technique in the therapy of optic neuropathy and exophthalmus reduction in endocrine orbitopathy with a low risk of postoperative motility disorders.     

Graded orbital decompression based on severity of proptosis

OBJECTIVE: To study the results of orbital decompression based on the severity of preoperative proptosis. DESIGN: A retrospective noncomparative interventional case series. PARTICIPANTS: Thirty-nine orbits in 23 patients with thyroid-related orbitopathy at a university-based referral center. INTERVENTION: Graded orbital decompression was performed in all patients based on the severity of preoperative exophthalmometry. MAIN OUTCOME MEASURES: Exophthalmometry, visual acuity, margin-to-reflex distance, prism cover testing, and intraocular pressure. RESULTS: Mean proptosis reduction in all orbits was 6.4 +/- 2.7 mm (P < 0.01). In group 1 (preoperative exophthalmometry <22 mm), proptosis decreased with a mean of 4.8 +/- 1.3 mm (P < 0.01); mean proptosis reduction was 6.0 +/- 2.3 mm (P < 0.01) and 8.9 +/- 3.4 mm (P < 0.01) in group 2 (exophthalmometry between 22-25 mm) and group 3 (exophthalmometry >25 mm), respectively. In four of five eyes with compressive optic neuropathy there was an improvement of best-corrected visual acuity of 2 lines or more. Margin-to-reflex distance of the upper and lower lids and intraocular pressure were reduced in all groups. New-onset diplopia developed in two patients (8.7%); 13 of 15 patients (86.7%) who had diplopia preoperatively had persistent diplopia postoperatively. Two patients (13.3%) had relief of diplopia postoperatively. CONCLUSIONS: Graded orbital decompression based on the severity of preoperative exophthalmometry is useful to determine the type and amount of orbital surgery to be performed.     

Orbital decompression for thyroid orbitopathy

Background: Severe thyroid orbitopathy may result in optic neuropathy, corneal exposure and disfiguring proptosis, Orbital decompression has most commonly been performed for optic neuropathy, but with improved techniques, more patients are undergoing decompression for other indications. Purpose: This report evaluates the results and morbidity of orbital decompression for thyroid orbitopathy performed by one surgeon. Methods: The records of 33 patients (53 orbits) undergoing orbital decompression for thyroid orbitopathy were analysed for changes in visual acuity and colour vision (where the indication was optic neuropathy) and reduction in proptosis. Complications were also analysed. Results: Visual acuity and colour vision improved in all 33 eyes with optic neuropathy in the short term postoperative period (4 weeks), but later deteriorated in five eyes (6.6%) of 4 patients (19%). Proptosis decreased by a mean 5.3 mm (range, 1–10). Diplopia developed or worsened overall in 10 of 33 patients (30%), but only in one of 12 (8%) where the indication was cosmesis or corneal exposure. Diplopia improved in 2 of 33 (6%). All patients with symptomatic diplopia achieved binocular single vision in a useful range after one and sometimes two squint procedures. No patient lost vision as a result of surgery. Conclusions: Orbital decompression is effective in improving vision in most patients with thyroid optic neuropathy, but induces or worsens diplopia in a high proportion of these patients. Proptosis can be effectively and dramatically improved.     

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.     

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.     

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.     

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.     

Transcaruncular orbital decompression: an alternate procedure for Graves ophthalmopathy with compressive optic neuropathy

PURPOSE: To study the efficacy of transcaruncular orbital apex decompression for Graves ophthalmopathy with compressive optic neuropathy nonresponsive to pulse corticosteroids. DESIGN: Retrospective, interventional case series study. METHODS: From August 1999 to November 2003, transcaruncular orbital decompression was performed in 22 consecutive Graves ophthalmopathy patients with compressive optic neuropathy refractory to pulse corticosteroids. The average period of corticosteroid treatment was 16.1 +/- 5.2 days. Main outcome measures were preoperative and postoperative best-corrected vision, Hertel exophthalmometry, 100-hue color sensation test, visual evoked potential, visual field, and new-onset diplopia. RESULTS: Visual acuity improved significantly from 1.08 +/- 0.24 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.29 +/- 0.18 logMAR postoperatively (P < .0001). Average improvement in retinal sensitivity was 9.4 +/- 8.2 dB, in P(100) value of visual evoked potential was 27.5 +/- 20.1, and in "total errors" of the 100-hue test was 309.9 +/- 214.3 after surgery. Average retroplacement effect was 3.7 +/- 1.6 mm. Statistical analysis showed significant differences between preoperative and postoperative measurements for all above parameters (P < .0001). New-onset diplopia occurred in 38% of patients. There were no complications specifically attributable to the transcaruncular technique. CONCLUSIONS: The transcaruncular approach offers access to the medial and inferior wall for orbital apex decompression in Graves ophthalmopathy patients with compressive optic neuropathy refractory to pulse corticosteroids. Advantages over other approaches included no external scar, less damage to adjacent tissue, and wide exposure to the entire medial wall.     

Orbital Decompression for Graves' Disease: Exposure Through lateral Canthal and Inferior Fornix Incision

A surgical procedure is described to perform orbital decompression in patients suffering from orbitopathy in Graves' Disease. The decompression technique employs exposure of the orbit through a lateral incision and an inferior fornix incision. These combined incisions with exposure can be used to perform an antral-ethmoidal decompression (two-wall decompression) or an antral-ethmoidal-lateral wall decompression (three-wall decompression). This present series contains 34 patients who underwent decompression through a 2 1/2-year period ending October 1980. The results of decompression were quantitated by measuring the retroplacement of the globe and in patients with compressive optic neuropathy by improvement in vision. The retroplacement of the globe with the antral-ethmoidal (two-wall decompression) was 4 to 7 mm (average 6 mm), and the retroplacement was 6 to 8 mm in four patients who underwent antral-ethmoidal-lateral decompression (three-wall decompression). All patients with compressive optic neuropathy improved to a final visual acuity of 20/40 or better. Five of 11 patients, with compressive optic neuropathy required postoperative super-voltage irradiation to reach this acuity. Fifty percent of the patients undergoing antral-ethmoidal decompression for proptosis required additional eyelid surgery with recession of upper lid retractors.     

Zwei-Wand-Dekompression ohne Resektion der medialen Wand

Background

Postoperative new onset diplopia can be a disadvantage for surgical orbital decompression in patients with exophthalmos in thyroid eye disease. The various modifications of decompression (number and combination of walls) differ in their influence on the postoperative squint angle. We report on postoperative diplopia in a modified 2 wall decompression strategy (lateral wall and floor).

Methods

This study was a retrospective analysis of 36 consecutive 2-wall decompressions performed between 2006?C2010 in 24 patients with 6 months of stable exophthalmos in thyroid eye disease after medical therapy and radiotherapy. The preoperative and postoperative squint angle in prism cover test (PCT), motility, induction of diplopia, reduction of exophthalmos, visual acuity and complications were evaluated.

Results

In all 36 decompressions the postoperative squint angle was equal to or less than before surgery. In 8 eyes additional squint surgery was performed. The mean reduction in exopthalmos was 4.3?mm.

Conclusions

An adverse effect of decompression on the postoperative squint angle was not evident in this study. New induction of diplopia was not observed at all. One possible explanation is the preservation of the medial wall.     

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.     

Preliminary report: long-term results of transnasal orbital decompression in malignant Graves' ophthalmopathy

In order to demonstrate the safety and efficacy of transnasal orbital decompression for malignant Graves' ophthalmopathy, we carried out a retrospective chart review and clinical follow-up examination of 78 consecutive patients who were operated on for compressive optic neuropathy (CON) with loss of visual acuity or visual field defects. The intervention - strictly transnasal, endoscopically controlled, bilateral decompression of the medial and inferomedial wall of the orbit - was performed when medical and radiation therapy had failed. A total of 145 endonasal decompressions were performed on 78 patients (63 female, 15 male, 52. 2 +/- 10.5 yrs.) over 9 years. Of these, 65 were operated bilaterally, 15 required only unilateral decompression; 4 had repeated surgery. Visual acuity increased from an average of 0.50 +/- 0.27 (range, 0.01 - 1.25) to 0.75 +/- 0.21 (range, 0.01 - 1.25). Proptosis decreased by an average of 3.94 +/- 2.73 mm (range, -1.0 - 11.0 mm), from a mean preoperative Hertel measurement of 22.19 +/- 3. 13 mm (range, 15 - 34 mm) to a mean postoperative Hertel measurement of 18.3 +/- 2.65 mm (range, 10 - 26 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 cases, in 26 cases immediately after decompression in the same surgical session. The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques and had favorable cosmetic results without additional disfiguring by scars. Post-decompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.     

Preliminary report: Long-term results of transnasal orbital decompression in malignant Graves' ophthalmopathy

In order to demonstrate the safety and efficacy of transnasal orbital decompression for malignant Graves' ophthalmopathy, we carried out a retrospective chart review and clinical follow-up examination of 78 consecutive patients who were operated on for compressive optic neuropathy (CON) with loss of visual acuity or visual field defects. The intervention – strictly transnasal, endoscopically controlled, bilateral decompression of the medial and inferomedial wall of the orbit – was performed when medical and radiation therapy had failed. A total of 145 endonasal decompressions were performed on 78 patients (63 female, 15 male, 52.2 ± 10.5 yrs.) over 9 years. Of these, 65 were operated bilaterally, 15 required only unilateral decompression; 4 had repeated surgery. Visual acuity increased from an average of 0.50 ± 0.27 (range, 0.01 – 1.25) to 0.75 ± 0.21 (range, 0.01 – 1.25). Proptosis decreased by an average of 3.94 ± 2.73 mm (range, –1.0 – 11.0 mm), from a mean preoperative Hertel measurement of 22.19 ± 3.13 mm (range, 15 – 34 mm) to a mean postoperative Hertel measurement of 18.3 ± 2.65 mm (range, 10 – 26 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 cases, in 26 cases immediately after decompression in the same surgical session. The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques and had favorable cosmetic results without additional disfiguring by scars. Post-decompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.     

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.     

Selected papers from the 17th meeting of the European Society of Ophthalmic Plastic and Reconstructive Surgery

There are numerous reports of the short-term efficacy of orbital decompression for thyroid orbitopathy, but few studies have documented the long-term results of surgery. The authors retrospectively reviewed their long-term (mean time, 43.34 months) follow-up of 44 eyes in 23 patients who underwent orbital decompression for reduction of proptosis (Group 1: 36 eyes) or compressive optic neuropathy (Group 2: 8 eyes) at the Johns Hopkins Medical Institutions. No patient in this series experienced worsening of visual sensory function from surgery. Five of seven (71%) eyes in group 2 improved after decompression and a sixth eye recovered acuity after orbital irradiation. Postoperative worsening of ocular alignment occurred in 52% of patients and may be more likely to occur in patients who have preoperative generalized limitation of extraocular movement with or without preoperative misalignment in the primary position. Postoperative results at final examination 12 months or longer after surgery, both with respect to reduction of proptosis and improvement in visual sensory function, were either unchanged or further improved compared with findings three to six months after surgery.     

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.     

Modified orbital decompression for dysthyroid orbitopathy

PURPOSE: The transantral approach to orbital decompression remains useful for the management of exophthalmos associated with dysthyroid orbitopathy. However, the risk of postoperative diplopia is a concern. Preservation of the anterior periorbita may help support the orbital contents and decrease the incidence of diplopia. METHODS: The medical records were reviewed of 15 consecutive patients who underwent 30 transantral orbital decompressions for proptosis associated with dysthyroid orbitopathy. The procedures were completed in standard fashion, including removal of the inferomedial bony strut between the medial orbital wall and the floor. However, stripping of the periorbita was only done posteriorly; the anterior 10 to 15 mm of periorbita were left intact. RESULTS: Six patients had preoperative diplopia that persisted after decompression. Of the nine patients without diplopia preoperatively, none developed diplopia. Proptosis was reduced a mean of 3.5 +/- 2.6 mm. CONCLUSIONS: Preservation of the anterior periorbita during transantral orbital decompression reduces the risk of postoperative diplopia. An adequate reduction in proptosis is also achieved.