Endoscopic transnasal orbital decompression

Orbital decompression for dysthyroid orbitopathy has traditionally been performed through either an external or a transantral approach. The advent of intranasal endoscopes allowed for the development of a transnasal approach for medial and inferior orbital wall decompression. Using this approach, orbital decompressions were performed on 13 orbits in eight patients with severe complicated dysthyroid orbitopathy. Simultaneous bilateral lateral orbitotomies were performed on five patients. Walsh-Ogura decompressions and lateral orbitotomies were performed on two orbits. When combined with lateral orbitotomy, Hertel measurements improved an average of 5.7 mm in orbits decompressed transnasally and 4.5 mm in orbits decompressed with a Walsh-Ogura approach. Transnasal decompression alone improved Hertel measurements an average of 4.7 mm. Visual acuity improved in three of four patients with optic neuropathy, and in all patients with exposure keratopathy. We conclude that the endoscopic transnasal approach provides comparable decompression to traditional methods while avoiding the morbidity of an external ethmoidectomy or Caldwell-Luc antrotomy.     

Combined endonasal and orbital approach for annulus of Zinn area decompression in dysthyroid optic neuropathy

BackgroundDysthyroid optic neuropathy (DON) is a serious complication of thyroid-associated ophthalmopathy (TAO) that can cause permanent vision loss from orbital apex syndrome. Urgent management of high-dose corticosteroid pulse therapy is recommended, and salvage orbital apex decompression surgery may require in refractory patients ineffective with corticosteroid pulse therapy.PurposeTo evaluate the short-term efficacy and safety of combined endoscopic endonasal and orbital approach decompression in the annulus of the Zinn (AZ) area in refractory dysthyroid optic neuropathy (DON).MethodsIn this retrospective study, patients who underwent combined endoscopic endonasal and orbital approach decompression around the AZ area for the treatment of refractory DON from May 2021 to March 2022 were enrolled. A total of 15 orbital apex were decompressed across 9 patients. The demographic, imaging, and surgical data, as well as preoperative and postoperative best corrected visual acuity (BCVA), proptosis degree and Modified-Chinese-TAO-QOL scores, were collected and assessed. The t-test was used to identify differences between preoperative and postoperative parameters: visual acuity, proptosis and QOL scores.ResultsThe mean best corrected visual acuity (BCVA) improved from 0.79 ± 0.77 LogMAR preoperatively to 0.21 ± 0.27 LogMAR (P < 0.001) postoperatively. Additionally, proptosis decreased from 22.25 ± 2.01 mm to 18.42 ± 1.85 mm (P < 0.01), with an average decrease of 3.7 mm. The preoperative scores of the visual, psychological, and comprehensive components of QoL were 14.60 ± 9.08, 37.49 ± 6.26 and 26.75 ± 3.70, respectively, which significantly improved postoperatively to 54.18 ± 7.23, 68.78 ± 12.53 and 61.88 ± 9.37, respectively. The postoperative follow-up time ranged from 2 to 11 months, and the median follow-up time was 7 months. There was 1 case of transient postoperative sinusitis and 1 new case of transient diplopia, which was relieved after 3 months.ConclusionCombined endoscopic endonasal and orbital approach adequate decompression for AZ area significantly improves visual acuity and QOL in patients with DON.     

鼻内镜下经鼻眶减压术治疗甲状腺机能障碍性眶病

OBJECTIVE: To evaluate the effect of endoscopic transnasal orbital decompression for patients with dysthyroid orbitopathy. METHODS: Nine cases (15 eyes) of dysthyroid orbitopathy were included in this study. All patients were treated by transnasal endoscopic orbital decompression. RESULTS: The follow-up ranged from 6 months to 2 years. Proptosis measured' by exophthalmoter reduced from (21.93 +/- 1.49) mm to (16.87 +/- 1.25) mm after operation. The visual acuity improved from 0.57 +/- 0.12 to 0.69 +/- 0.12, the palperbral fissures reduced from (11.07 +/- 1.44) mm to (8.20 +/- 1.15) mm. Postoperatively, the orbital pressure was significantly decreased as compared with the preoperative result (P < 0.001). Diplopia was cured in 3 of 7 cases. CONCLUSION: Endoscopic transnasal orbital decompression is an effective method for the treatment of dysthyroid orbitopathy.     

Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves’ orbitopathy

Background: To determine the clinical outcomes and morbidity of endoscopic medial wall combined with transcutaneous lateral orbital wall decompression in Graves’ orbitopathy.

Methodology: A retrospective noncomparative case series of patients who underwent surgical decompression for Graves’ orbitopathy at Hospital Universitario de Fuenlabrada between 2004 and 2014 was performed. We reviewed the patients’ charts and analyzed before and after the decompression, the visual acuity (Snellen chart), optic nerve compression (fundoscopy and optic coherence tomography), exophthalmometry (Hertel measurement), ocular motility, diplopia, eyelid surgery needed after decompression and its possible complications.

Results: A total of 20 patients (36 orbits) were operated. The mean follow-up was 44 months (range 18–84). Vision improved dramatically in all compressive optic neuropathy cases (5 cases). Hertel measurements improved on average 3.5?mm (range 1.5–4.5). Diplopia was cured in eight patients (40%) and nine patients with severe preoperative diplopia required strabismus surgery after decompression. Eyelid surgery was further needed in 13 patients. Hyaluronic acid injection was the most used technique for the treatment of eyelid retraction (6 out of 13 patients). Only two major complications were observed: one case had a major post-operative epistaxis and another a cerebrospinal fluid leak. Both were resolved without further sequelae.

Conclusions: These results suggest that endoscopic medial wall combined with transcutaneous lateral wall orbital decompression is an effective and safe treatment for the symptomatic dysthyroid eye disease with important proptosis or compressive optic neuropathy.     

视神经减压术治疗创伤性视神经病的疗效观察

目的 观察视神经减压术治疗创伤性视神经病的临床疗效.方法 30例创伤性视神经病患者,分别采用鼻外径路或经鼻内镜筛蝶窦径路施行视神经减压术,观察手术治疗的临床效果.结果 总有效率56.67%.术前无光感的16例中,6例术后视力显示一定程度的改善;术前有残余视力的14例中,11例的术后视力均有不同程度的提高.无1例发生严重并发症.结论 视神经减压术对创伤性视神经病导致的视力障碍,无论伤后时间长短和是否具有残余视力,均具有确切疗效.     

Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression

OBJECTIVE: To evaluate the efficacy and safety of a combined endoscopic and transconjunctival orbital decompression in patients with thyroid-related orbitopathy with orbital apex compression. STUDY DESIGN: Retrospective review. METHODS: A sequential series of patients with thyroid-related orbitopathy presenting with orbital apex compressive myopathy with and without optic neuropathy who were undergoing combined endoscopic and transconjunctival decompression by the same surgeons from 1992 to 2001 was reviewed. Patients were regularly evaluated preoperatively and postoperatively over a 3- to 55-month period to record the effects of this approach on visual acuity, Hertel exophthalmometry, and diplopia. Complications and secondary ophthalmological procedures were reviewed. RESULTS: Between 1992 and 2001, 72 combined endoscopic and transconjunctival decompressions were performed on 41 patients with orbital apex compression. Visual acuity improved in 89.3% of the patients with compressive optic neuropathy (P <.0005) and in 34.1% of those without neuropathy. Proptosis was reduced by 3.65 mm, on average. There was one case of transient intraoperative cerebrospinal fluid extravasation at the site of the optic nerve decompression, and one patient developed epistaxis. CONCLUSIONS: The study supports the treatment of thyroid-related orbital apex compression with and without compressive optic neuropathy by a combined transconjunctival and endoscopic approach. This approach offers short hospital stays, excellent visual recovery, and minimal complications in patients with thyroid-related orbital apex compressive myopathy and related compressive optic neuropathy. The beneficial effects observed in the patients with visual loss continued to improve over time and were significant (P <.001).     

Vision improvement in indirect traumatic optic neuropathy treated by endoscopic transnasal optic canal decompression

BackgroundIndirect Traumatic optic neuropathy (ITON) is a severe disease characterized by a sudden decline of visual function after craniofacial injury. However, the best treatment for ITON is unknown. Endoscopic transnasal optic canal decompression (ETOCD) has gradually been used for ITON treatment worldwide in recent years.ObjectiveTo assess the effect of ETOCD on visual acuity in patients with ITON and identify factors that affect prognosis.MethodsIn this study, clinical characteristics of 44 ITON patients who underwent ETOCD in Qilu Hospital of Shandong University were retrospectively analyzed. Factors affecting prognosis were also evaluated.ResultsETOCD treatment improved the vision of 20 (45.5%) patients with no patient suffering from vision deterioration. The mean value of visual acuity (VA) scores improved from 1.57 to 2.39 (P < 0.001). Patients with residual vision had a better VA improvement percent than those without light perception (66.67% versus 34.48%, χ² = 4.13, P = 0.042). Although shorter duration before ETOCD was associated with better improvement score in ITON patients (r = ?0.30, P = 0.044), optic canal fracture (OCF) and optic nerve sheath incision did not affect the prognosis of these patients. Five ITON patients with cerebrospinal fluid rhinorrhea were treated with free nasal mucosal flap during the surgery, and no other severe surgical complication occurred.ConclusionsETOCD can effectively and safely improve the vision of ITON patients, patients with residual vision and those treated earlier may benefit more from this surgery.     

Functional outcomes and complications in refractory dysthyroid optic neuropathy management: Experience with 3 different surgical protocols

IntroductionDysthyroid optic neuropathy (DON) is the most severe complication of Graves' orbitopathy (GO) and its management may require decompression surgery. Clear recommendations do not exist about which surgery should be performed and how extended the decompression should be. In this paper we present our experience regarding the management of DON via 3 different surgical protocols: a modified extended orbital apex decompression, a 2 walls decompression (inferior and lateral) and a 3 walls decompression (inferior, lateral and medial) and evaluate the functional outcomes.MethodsRetrospective evaluation of subjects affected by DON not responding to medical therapy has been performed. All patients were submitted to pre- and post-operative ophthalmologic evaluations and orbital and sinuses CT scan in order to evaluate functional and surgical outcomes.Results27 patients were enrolled in the study. Surgical procedures were performed on 42 orbits. A statistically significant post-operative improvement was recorded in visual acuity, proptosis, color vision and fundus oculi evaluation for all groups. No patient developed major or minor complications after surgery.ConclusionsExtended endonasal approach and 3 walls decompression have been proved effective in the management of DON. The choice between them is done according to degree of proptosis, general status and eye-surface damages.     

外伤性视神经损伤的临床处理

目的 :观察经鼻外筛蝶窦径路行视神经减压术辅助药物治疗对外伤性视神经损伤的疗效。方法 :14例外伤性视神经损伤患者经鼻外筛蝶窦径路行视神经减压术的同时辅以大剂量激素及神经营养药物治疗。结果 :总有效率为 5 7.14% ,术中、术后无任何严重并发症 ;其中 2例伤后 8、11d手术 ,术后 6个月仍无光感。结论 :鼻外筛蝶窦径路行视神经减压术损伤较小 ,术野暴露充分 ,简易安全 ;同时辅以药物治疗 ,更有利于神经功能恢复。综合性治疗对外伤性失明患者是一种较好的措施。     

Endoscopic optic nerve decompression for nontraumatic optic neuropathy

OBJECTIVE: To determine the efficacy of endoscopic optic nerve decompression for the treatment of patients with nontraumatic optic neuropathy. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: Ten optic nerve decompressions were performed on 7 patients with nontraumatic optic neuropathy caused by various pathologic entities, including meningioma, lymphangioma, fibro-osseous lesions (fibrous dysplasia and osteoma), mucopyocele, and Graves orbitopathy. INTERVENTIONS: Endoscopic instrumentation was used in a transnasal fashion to decompress the optic nerve. MAIN OUTCOME MEASURES: Visual acuity and complication rates. RESULTS: Mean visual acuity improved from 20/300 preoperatively to 20/30 after surgery. Visual acuity improved by at least 2 lines on the Snellen chart following 7 of the 10 decompressions. Median operative time was 133 minutes, and median length of stay was less than 24 hours. Complications were limited to postoperative hyponatremia and corneal abrasions, both of which resolved with conservative therapy. Mean follow-up time was 6.1 months. CONCLUSION: Endoscopic optic nerve decompression appears to be an effective treatment for restoring visual acuity in select patients who present with compressive optic neuropathy.     

Orbital decompression in Graves' orbitopathy: a combined endoscopic and external lateral approach

AIMS: First, to assess the outcomes of endoscopic and external lateral orbital decompression in patients with dysthyroid orbitopathy. Second, to establish a correlation between the percentage of postoperative diplopia and the technique used. METHODS: A retrospective review of 40 patients (73 eyes) who underwent endoscopic medial orbital decompression and external lateral orbital decompression between 1997 and 2003 at the H?pital Enfant-Jesus in Quebec City. Some of these patients also had an inferior endoscopic decompression. All patients had exophthalmos. The principal indications for surgery were 42 eyes with compressive optic neuropathy, 13 eyes with other ocular disorders, and 18 eyes with exophthalmos only. All patients with neuropathy underwent endoscopic decompression of the optic canal. RESULTS: All patients had satisfactory improvement of their ocular pathology. Optic neuropathy was completely resolved in 92.85% (39 of 42 eyes). In patients who did not have preoperative diplopia (26), diplopia developed in 70% (14 of 20) of those who underwent medial and inferior decompression compared with 16.6% (1 of 6) of patients who underwent medial decompression only. CONCLUSION: Endoscopic medial orbital decompression is very effective in resolving compressive optic neuropathy. Preservation of the orbital floor, when the degree of exophthalmos allows, reduces the incidence of postoperative diplopia.     

经鼻内镜视神经减压术治疗外伤性视神经病

目的 探讨经鼻内镜视神经减压术治疗外伤性视神经病(TON)的临床疗效及相关预后因素.方法 回顾性分析深圳市龙岗区耳鼻咽喉医院2015-2018年21例TON患者经过大剂量激素冲击治疗无效后经鼻内镜行视神经减压术,术后以提高患者视力级别作为判断临床疗效的标准.结果 术后常规予抗生素及激素、改善循环、营养神经等药物治疗,所...     

鼻内镜视神经减压术治疗外伤性视神经病与VEP的诊断价值

目的探索鼻内镜下视神经减压术的疗效及影响疗效的相关因素。方法外伤性视神经病37例,在外伤后3～30d内行鼻内镜下视神经减压术。13例病人术前和术后行FVEP检查。结果37例病人中21例术后视力获得改善,有效率为56.8%。13例术前和术后行FVEP监测中,能引出P100波的患眼术后疗效好于无P100波者(P<0.005)。结论外伤性视神经病应积极采用视神经减压术,手术后疗效与视神经的损伤程度密切相关,似并不完全取决于伤后时间。术前FVEP检测情况对预测预后有一定的帮助。     

内镜下治疗鼻源性视觉障碍的临床研究

目的 探讨鼻源性视觉障碍性疾病的诊断与治疗模式.方法 回顾性分析23例(25眼)资料完整的鼻眼相关视功能障碍病例,23例均行内镜下鼻腔鼻窦探查+鼻窦开放术,其中9例行视神经管减压术.结果 双侧全组鼻窦炎4例,单侧后组筛窦、蝶窦炎6例,额窦、筛窦炎1例,孤立性蝶窦炎5例,单侧后组筛窦、蝶窦真菌病5例,单侧蝶窦、筛囊肿或脓囊肿2例,均经术后病理证实.术前视功能:2例(2眼)无光感;6例(7眼)眼前手动;7例(7眼)眼前指数(＜ 20 cm);8例(9眼)有不同程度视力下降.1例次(1眼)眼球突出、直接和间接瞳孔对光反射消失;3例次(3眼)复视;2例次(2眼)外展麻痹;3例次(3眼)视野缺损(1眼中央性,2眼颞侧);1例次(1眼)上睑下垂.全部病例术后鼻窦术腔上皮化.术后视功能:2眼无改善;10眼恢复到发病前水平;13眼由术前眼前手动、指数改善到眼前指数(30～60 cm).其他眼部症状消失.结论鼻源性视觉障碍患者出现视力障碍时,若药物保守治疗无效应及早行鼻内镜下鼻腔鼻窦探查术;对严重视力障碍、视力急剧下降患者及早实施视神经减压手术,可以有效改善患者的视功能.     

Traumatische Optikusneuropathie

Background

Traumatic optic nerve neuropathy (TON) is defined as injury to the optic nerve with subsequent vision loss due to head or craniocerebral trauma. The treatment of this disease is the subject of controversial discussions. The purpose of the present study was to investigate pre- and immediate postoperative visual acuity in patients with unilateral TON and to compare the results with the time interval between trauma and surgical intervention.

Patients and Methods

A total of 20 patients with unilateral TON and considerable vision loss were examined. All were treated with high dose corticoids and underwent microsurgical optic nerve decompression. Visual acuity was determined pre- and postoperatively. In long-term follow-up visual acuity was determined 3?months postoperatively.

Results

Postoperatively, nine patients (45%) achieved an improvement in visual acuity of more than 0.4, and another three patients (15%) an improvement of ??0.2. At 3?months postoperatively another four patients achieved a further improvement of their visual acuity of >0.2. A decrease in visual acuity was not observed in any case, nor were major surgical complications.

Conclusions

Factors which predict good prognosis for vision recovery include a short time interval between trauma and intervention, edema, and/or hematoma of the optic nerve sheath. Factors which predict a worse prognosis are a fracture line directly through the nerve canal, a time period between trauma and intervention of more than 24?h, and initial complete amaurosis.     

手术联合药物治疗外伤性视神经病的疗效分析

目的 评价手术联合药物治疗外伤性视神经病(traumatic optic neuropathy,TON)的疗效,分析影响临床疗效的因素.方法 对69例(70眼)确诊为TON并行鼻内镜下视神经管减压术联合药物治疗患者的临床资料作回顾分析.将入院时视力分为无光感、光感、眼前手动、眼前指数和能见标准视力表(0.02以上)5个级别,分别计为Ⅰ～Ⅴ级.入院视力Ⅰ级(无光感)者40眼,18眼因CT证实严重视神经管骨折,急诊行鼻内镜下视神经管减压术;22眼入院后先行糖皮质激素冲击治疗后再行手术治疗.入院视力I级以上者30眼,CT显示视神经管骨折的16眼行急诊手术;14眼行糖皮质激素冲击治疗3 d后行手术治疗.随访3～12个月,观察视力恢复情况.结果 入院视力有光感者疗效显著优于入院视力无光感者(90.0%比27.5%),两组疗效相比差异有统计学意义(χ2=26.98,P<0.001).入院视力Ⅰ级患眼,糖皮质激素冲击治疗后视力提高者手术疗效(80.0%)优于无改变者(5.9%),两组疗效相比差异有统计学意义(χ2=12.09,P<0.001).结论 对于无光感的患者,经药物冲击治疗后视力仍无改善者,手术疗效较差;治疗前视力是影响疗效的主要因素.影像学检查有无视神经管骨折,不应作为是否手术的决定因素.     

Delayed optic nerve decompression for indirect optic nerve injury

OBJECTIVE: To test the efficacy of delayed optic nerve decompression in traumatic optic nerve injury. STUDY DESIGN: Critical analysis of Proforma-based, prospectively accrued data of all cases with injury to surgery interval of greater than 2 weeks. METHODS: Thirty-five cases with a median injury to surgery interval of 56 days (range, 16-374 d). Surgical decompression was undertaken only in cases that continued to have poor vision after treatment with steroids in conventional doses (1 mg/kg prednisolone). Pre- and postoperative visual acuity measurements were converted to the logMAR scale of visual acuity and the percentage of visual improvement was calculated. RESULTS: Surgery was universally unrewarding in all 9 cases with persistent and complete blindness of greater than 2 weeks and no response to steroid therapy. Of the cases with some residual vision, 20 of 26 cases improved (mean percentage improvement, 41.0 +/- 5.7%). Cases were categorized on the basis of the injury to surgery interval into groups of 2 weeks to 2 months, 2 months to 4 months, and greater than 4 months. No significant difference was demonstrated in the probability or quantum of improvement in these groups (P =.97). CONCLUSIONS: Optic nerve decompression remains useful as a salvage procedure for conventional dose steroid failed cases of traumatic optic neuropathy. In cases that are not completely blind, vision can be improved even when surgery is undertaken a few months after the injury.     

鼻内镜下视神经减压术治疗外伤性视神经病72例

目的 探讨视神经减压术治疗外伤性视神经病的疗效。方法 对大剂量糖皮质激素冲击治疗无效的外伤性视神经病患者72例（73眼），采用鼻内镜下视神经减压术治疗。外伤至手术时间1～57d，其中≤3d15例，4—7d37例，8—10d9例，11—15d5例，16～30d5例，〉30d1例。术前视力：光感以上18眼；无光感55眼。结果 术后随访3个月-5年。73眼中46眼视力有不同程度的提高，总有效率63．01％。原无光感的55眼中，31眼视力有提高，有效率56．36％。有光感以上视力的18眼中，15眼视力有提高，有效率83．33％。术后全部患者术腔上皮化，术中无并发症发生。结论 经鼻内镜筛蝶窦入路视神经减压术进路简捷，损伤较小、疗效确切，且不遗留面部瘢痕，容易为患者所接受。对伤后时间较长、大剂量激素治疗无效、视力损伤严重的患者，手术仍有挽救视力的可能。     

Course of proptosis in patients with Graves' disease after endoscopic orbital decompression.

AIM: To evaluate the results of follow-up and postoperative course of proptosis in patients with Graves' disease who underwent combined transconjunctival and transnasal endoscopic orbital decompression. METHODS: Charts of patients with Graves' disease who underwent orbital decompression using combined transconjunctival and transnasal endoscopic technique were reviewed. The surgical technique involved preservation of the strut of bone between the lamina papyracea of the ethmoid and floor of the orbit of the maxilla. Data pertaining to patient demographics, previous treatments for orbital manifestations of Graves' disease, and preoperative and postoperative otolaryngologic and ophthalmologic examination findings were obtained. Postoperative course of reduction in proptosis was evaluated based on Hertel exophthalmometry measurements obtained in four intervals: 1) 0 to 1 month, 2) 1 month to 3 months, 3) 3 to 6 months, 4) 6 to 12 months. RESULTS: Twenty-eight orbital decompressions were performed on 15 patients. All patients were unresponsive to corticosteroids and orbital irradiation. Ten orbits exhibited preoperative and postoperative visual acuity of 20/20. Vision improved in nine orbits and did not change in six orbits. Proptosis was reduced in 25 orbits. Postoperative course of reduction in proptosis varied within year 1, with the smallest proptosis measurements documented between 6 and 12 months. CONCLUSIONS: Combined transconjunctival and transnasal endoscopic orbital decompression with preservation of the strut resulted in regression of proptosis, marked reduction in postoperative diplopia development, and improvement of visual acuity in patients with Graves' disease. Course of reduction in proptosis varied within postoperative 1 year, with the biggest reduction occurring between 6 and 12 months.     

Revision orbital decompression for thyroid eye disease

ObjectiveTo compare the indications, surgical techniques and outcomes for revision orbital decompression surgery for thyroid eye disease in open, endoscopic, and combined open and endoscopic approaches.MethodsA retrospective review of all revision orbital decompression procedures for thyroid eye disease from a single large academic institution over a 17-year period (01/01/2004–01/01/2021) was performed. Patient demographics, as well as indications and types of surgery were reviewed. Outcome measures included changes in proptosis, intraocular pressure, visual acuity and diplopia.ResultsThirty procedures were performed on 21 patients. There was a median of 9.4 months between primary orbital decompression and revision decompression surgery. There were 6 bilateral procedures, and 2 of these patients underwent additional revision surgeries due to decreased visual acuity with concern for persistent orbital apex compression or sight-threatening ocular surface exposure in the setting of proptosis. Twenty-five procedures were performed as open surgeries with 5 endoscopic/combined cases. Combined Ophthalmology/Otolaryngology surgery via combined open/endoscopic approaches was favoured for persistent orbital apex disease. Visual acuity remained preserved in all patients. The overall median reduction in proptosis was 2 mm and intraocular pressure change was 1 mmHg regardless of surgical approach. The overall rate of new onset diplopia after surgery was 15%. These patients had open approaches. All endoscopic/combined approach patients had pre-existing diplopia. There were no statistically significant differences between the open and endoscopic/combined groups in regard to change in visual acuity, reduction in proptosis or intraocular pressure.ConclusionRevision orbital decompression is an uncommon procedure indicated for those patients with progressive symptoms despite previous surgery and intensive medical management. Both endoscopic and non-endoscopic techniques offer favourable outcomes with respect to visual acuity, decrease in intraocular pressure, and improvement in proptosis and overall lead to a low incidence of new onset diplopia.Level of evidenceLevel IV.