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.     

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.     

Results and predictability of fat-removal orbital decompression for disfiguring graves exophthalmos in an Asian patient population

PURPOSE: To evaluate proptosis reduction by fat-removal orbital decompression (FROD), to determine the incidence of postoperative diplopia, and to assess predictability of proptosis reduction per volume of resected orbital fat. DESIGN: Cross-sectional study. METHODS: One hundred and twenty patients (31 men; 89 women) with Graves ophthalmopathy were treated with FROD via the transforniceal approach on 222 orbits between April 2003 and April 2006. Fifteen (12.5%) patients exhibited preoperative diplopia; 105 (87.5%) were without diplopia; mean follow-up +/- standard deviation (SD) was 10.9 +/- 5.1 months (range, six to 37 months). Univariate and multivariate analyses were used to evaluate Hertel change with FROD by linear regression. The setting was thyroid eye disease special clinics at National Taiwan University Hospital. RESULTS: Mean Hertel values +/- SD decreased from 20.3 +/- 1.8 mm (range, 16.5 to 26.0 mm) to 16.8 +/- 1.4 mm (range, 13.5 to 21.0). Mean proptosis reduction +/- SD was 3.6 +/- 1.0 mm (range, 1.5 to 7.5 mm). Mean volume of resected orbital fat +/- SD was 3.6 +/- 1.0 ml (range, 1.2 to 6.5 ml). New-onset diplopia was noted for 2.8% of patients after FROD. The final predictive equation for Hertel change is shown as: 0.72 x removal of intraconal fat (ml) - 0.001 x age (yrs) - 0.22 x gender (male, 1; female, 0) - 0.19 x preoperative diplopia (yes, 1; no, 0) + 1.02. CONCLUSIONS: FROD can achieve reasonable proptosis reduction and can reduce incidence of new-onset diplopia for patients with disfiguring Graves exophthalmos. The volume of resected orbital fat correlates with mean Hertel value change. The amount of resected orbital fat may predict proptosis reduction.     

Follow-up of transnasal orbital decompression in severe Graves' ophthalmopathy

OBJECTIVE: To evaluate the safety and efficacy of transnasal orbital decompression for severe Graves' ophthalmopathy. DESIGN: Retrospective noncomparative case series with extended clinical follow-up. PARTICIPANTS: Seventy-eight consecutive subjects who were operated on for compressive optic neuropathy with loss of visual acuity or visual field defects after failure of medical and radiation therapy. INTERVENTION: Strictly transnasal, endoscopic-controlled bilateral decompression of the medial and inferomedial wall of the orbit. MAIN OUTCOME MEASUREMENTS: Preoperative and postoperative examination, including vision, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and notification of complications, intranasal signs of inflammation, and subjects' assessment of the procedure. RESULTS: One hundred forty-five endonasal decompressions were performed on 78 subjects (63 women, 15 men, 52.2 +/- 10.3 years) during a 10-year period. Sixty five patients were bilaterally operated on; 15 required only unilateral decompression. Four of 78 needed repeat surgery. Visual acuity increased from a preoperative average of 0.50 +/- 0.27 (range, 0.01-1.25) to 0.75 +/- 0.21 (range, 0.01-1.25) postoperatively. An average reduction of proptosis of 3.94 +/- 2.73 mm (range, -1.0-11.0 mm) was achieved with a mean preoperative Hertel measurement of 22.19 +/- 3.13 mm (range, 15-34 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 of 78 cases. Twenty-six of these 58 cases were simultaneously operated on in the same surgical session immediately after the transnasal decompression, and the others after a period of 2 to 3 months. CONCLUSIONS: The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques, and had favorable cosmetic results without additional disfiguration by scars. Morbidity was far less than with other approaches. Postdecompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.     

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.     

Results of transantral orbital decompression in patients with thyroid-associated ophthalmopathy

PURPOSE: To present the results of orbital decompression in patients with thyroid-associated ophthalmopathy (TAO). METHODS: Transantral orbital decompression was performed in 63 patients with TAO. In 40 patients (63%) the operation was made because of progressive ophthalmopathy not responding to medical therapy, and in 23 patients (37%) the operation was made for rehabilitative reasons. The long-term hypesthesia engaging the infraorbital nerve was assessed with a questionnaire using a Visual Analogue Scale (VAS). RESULTS: The mean proptosis reduction was 3.2 mm (range 0-8 mm). Twenty-one patients had impaired visual acuity preoperatively, and 20 improved. Altogether 30 patients (40%) had worsened ocular motility postoperatively. Forty-three patients did not have diplopia in the primary position preoperatively, and new diplopia developed in 22 of these (51%). Hypesthesia in the infraorbital nerve area was reported for half of the operated sides, but was a major cause of distress (VAS-scoring >5) to eleven patients. CONCLUSIONS: Transantral orbital decompression is indicated in patients with progressive TAO or in patients with prominent exophthalmos, and results in a good proptosis reduction, but the risk of postoperative diplopia is significant. Postoperative hypesthesia is common but often not a major problem.     

Prevalence and management of elevated intraocular pressure in patients with Graves' orbitopathy

AIMS—To investigate the prevalence and to discuss the necessity of treating elevated intraocular pressures (IOP) in patients with Graves' orbitopathy (GO). In addition, to study the effects of orbital decompression and extraocular muscle surgery on IOP.
METHODS—The records of consecutive patients with GO referred in a 5 year period were studied and those selected, in which glaucoma medication had been prescribed, or a diagnosis of primary open angle glaucoma (POAG) or of ocular hypertension (22 mm Hg) (OH) had been made. The necessity of treating these patients with glaucoma medication was questioned and the effects of corticosteroids, orbital decompression, and extraocular muscle surgery on the IOP were evaluated.
RESULTS—Of 482 patients with GO, 23 (4.8%) met the inclusion criteria. Four patients (0.8%) had POAG, four had elevated IOPs and visual field defects consistent with dysthyroid optic neuropathy, and 15 (3.1%) had only elevated IOPs. Five patients with OH showed a permanent drop of IOP after orbital decompression, two had a marked decrease of their IOP after recession of the inferior rectus muscle.
CONCLUSIONS—POAG has the same prevalence in the general Dutch population as in the GO subgroup. The combination of elevated IOPs and visual field defects in GO patients may be attributed to other mechanisms than obstructed aqueous outflow in the trabecular meshwork and should be treated accordingly. Orbital decompression and extraocular muscle surgery may lower the IOP in patients with GO.

Keywords: Graves' orbitopathy; primary open angle glaucoma; intraocular pressure     

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.     

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.     

The removal of the deep lateral wall in orbital decompression: its contribution to exophthalmos reduction and influence on consecutive diplopia

PURPOSE: To evaluate the contribution of maximal removal of the deep lateral wall of the orbit to exophthalmos reduction in Graves' orbitopathy and its influence on the onset of consecutive diplopia. DESIGN: Case-control study. METHODS: The medical records of two cohorts of patients affected by Graves' orbitopathy with exophthalmos > or = 23 mm, without preoperative diplopia, were retrieved at random from the pool of patients decompressed for rehabilitative reasons at our institution (01/1990 to 12/2003), and retrospectively reviewed. They had been treated with an extended (cases, group 1, n = 15) or conservative (controls, group 2, n = 15) 3-wall orbital decompression performed through a coronal approach. The deep portion of the lateral wall had been removed in the extended decompression group while preserved in the conservative decompression group. Demographics, preoperative characteristics, and surgical outcome were compared. The difference in mean exophthalmos reduction between groups 1 and 2 was considered to be the contribution of the deep lateral wall to reduction of exophthalmos. RESULTS: Groups 1 and 2 were drawn from a pool of 37 and 335 patients, respectively. Demographics and preoperative characteristics of the two groups were not significantly different. The mean contribution of the deep lateral wall to exophthalmos reduction was 2.3 mm. The onset of consecutive diplopia was not significantly different between the two groups (case n = 2/15, controls n = 5/15; P = .203). Diplopia resolved spontaneously in all the patients of group 1, while all the patients of group 2 required surgery. CONCLUSIONS: Removal of the deep lateral orbital wall as part of a coronal-approach, 3-wall decompression, enhances the degree of exophthalmos reduction without increasing the risk of consecutive diplopia.     

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.     

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.     

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.     

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.     

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, single-incision, three-wall orbital decompression

PURPOSE: To present the clinical outcome in 55 consecutive patients by using a customized, single-incision, 3-wall orbital decompression. METHODS: A retrospective chart review was performed of 97 customized, single-incision, 3-wall decompressions in 55 consecutive patients within one surgeon's practice. A standardized surgical technique featuring lateral small-incision, 3-wall decompression with specific "strut" preservation was used in all patients. Success of the procedure was assessed on the basis of the amount of proptosis reduction achieved, as measured by the difference in Hertel exophthalmometry measurements, and by improvement in or preservation of preoperative visual acuity and color vision in the setting of compressive optic neuropathy. Subjective diplopia was recorded before and after surgery, as was the presence of extraocular muscle restriction. RESULTS: A total of 97 orbital decompressions in 55 consecutive patients were reviewed. The majority of surgeries were performed for disfiguring proptosis with some degree of exposure-related symptoms (81%), with other indications including compressive optic neuropathy (17%), and pain (2%). The average amount of proptosis reduction achieved at 3 months was 5 mm (range, 1 to 11 mm). Visual acuity in patients with compressive optic neuropathy improved an average of 2 lines on the standard Snellen chart testing (range, 1 to 5). Color vision improved an average of 5 Ishihara plates (range, 0 to 13). Seventy-one percent of patients had subjective diplopia before surgery; 21% of these patients reported improvement or complete resolution of diplopia after surgery. Of the 29% of patients without preoperative subjective diplopia, all but one (1.8 of total patients) remained symptom free. CONCLUSIONS: We find that a customized, single-incision, 3-wall orbital decompression provides adequate decompression and proptosis reduction while minimizing postoperative strabismus and providing an aesthetically desirable result.     

Results of a neurosurgical two-wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy

PURPOSE: Follow-up of patients with severe thyroid associated ophthalmopathy treated with a transcranial two-wall orbital decompression and reconstruction. METHODS: A two-wall transcranial orbital decompression was performed in 30 such patients (50 eyes). The patients were evaluated one month postoperatively, and long-term evaluation (median 14 months, range 2-54 months) was carried out. The main outcome measures were visual acuity, proptosis measured by Hertel ophthalmometry, soft tissue involvement, and restriction of eye motility. RESULT: Visual acuity improved rapidly in 28 of 32 affected eyes with normalization in 19 eyes (p<0.001). Worsening was not seen. Median proptosis was reduced by 4.0 mm, range 0-10.0 (p<0.001). Double vision was present in 24 patients before operation 14 of whom achieved binocular vision (p<0.001). Three patients had unchanged complaints and the double vision worsened in one patient. Seventeen of 20 patients on preoperative corticosteroid treatment discontinued this medication in relation to surgery. Complications included one case of perioperative minor stroke and two cases of facial nerve frontal branch palsy. CONCLUSION: The transcranial two-wall decompression is a simple, an efficient and a low-risk procedure for treatment of patients with severe thyroid associated ophthalmopathy.     

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.     

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.     

Development of a disease specific quality of life questionnaire for patients with Graves' ophthalmopathy: the GO-QOL

AIM—To develop a reliable and valid disease specific quality of life questionnaire (the GO-QOL) for patients with Graves' ophthalmopathy (GO), that can be used to describe the health related quality of life and changes in health related quality of life over time as a consequence of disease and treatment.
METHODS—70 consecutive GO patients (age >18 years) who were referred for the first time to the combined outpatient clinic of the orbital centre and the department of endocrinology completed the 16 questions of the GO-QOL. Additional information on general quality of life and disease characteristics was obtained. Construct validity and internal consistency of the disease specific questionnaire was determined, based on principal component analysis, Cronbach alphas and correlations with MOS-24, three subscales of the SIP, demographic, and clinical measures.
RESULTS—The a priori expected subdivision of the questionnaire in two subscales, one measuring the consequences of double vision and decreased visual acuity on visual functioning, and one measuring the psychosocial consequences of a changed appearance, was confirmed in the principal component analysis. Both scales had a good reliability and high face validity. Correlations with other measures supported construct validity. Mean scores (range 0-100) were 54.7 (SD 22.8) for visual functioning and 60.1 (24.8) for appearance (higher score = better health).
CONCLUSION—The GO-QOL is a promising tool to measure disease specific aspects of quality of life in patients with GO and provides additional information to traditional physiological or biological measures of health status.

Keywords: Graves' ophthalmopathy; health related quality of life; questionnaire