Intracranial Hemorrhage Complicating an Orbital Decompression

We report a case of intracerebral hemorrhage in the left frontal lobe following a left medial wall orbital decompression for thyroid-related optic neuropathy. There was no obvious fracture in the orbital roof bone but the hemorrhage was felt to occur from a disruption in the orbito-frontal branch of the anterior cerebral artery. The patient was asymptomatic and remained so during the follow-up period.     

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).     

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.     

Orbital decompression for Graves' orbitopathy in England

Aims

The purpose of this study was to obtain data on orbital decompression procedures performed in England, classed by hospital and locality, to evaluate regional variation in care.

Methods

Data on orbital decompression taking place in England over a 2-year period between 2007 and 2009 were derived from CHKS Ltd and analysed by the hospital and primary care trust.

Results and conclusions

In all, 44% of these operations took place in hospitals with an annual workload of 10 or fewer procedures. Analysis of the same data by primary care trust suggests an almost 30-fold variance in the rates of decompression performed per unit population. Expertise available to patients with Graves'' orbitopathy and rates of referral for specialist care in England appears to vary significantly by geographic location. These data, along with other outcome measures, will provide a baseline by which progress can be judged.     

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

PurposeTo evaluate the clinical outcomes of balanced deep lateral and medial orbital wall decompression and to estimate surgical effects using computed tomography (CT) images in Korean patients with thyroid-associated ophthalmopathy (TAO).MethodsRetrospective chart review was conducted in TAO patients with exophthalmos who underwent balanced deep lateral and medial orbital wall decompression. Exophthalmos was measured preoperatively and postoperatively at 1 and 3 months. Postoperative complications were evaluated in all study periods. In addition, decompressed bone volume was estimated using CT images. Thereafter, decompression volume in each decompressed orbital wall was analyzed to evaluate the surgical effect and predictability.ResultsTwenty-four patients (48 orbits) with an average age of 34.08 ± 7.03 years were evaluated. The mean preoperative and postoperative exophthalmos at 1 and 3 months was 18.91 ± 1.43, 15.10 ± 1.53, and 14.91 ± 1.49 mm, respectively. Bony decompression volume was 0.80 ± 0.29 cm³ at the medial wall and 0.68 ± 0.23 cm³ at the deep lateral wall. Postoperative complications included strabismus (one patient, 2.08%), upper eyelid fold change (four patients, 8.33%), and dysesthesia (four patients, 8.33%). Postsurgical exophthalmos reduction was more highly correlated with the deep lateral wall than the medial wall.ConclusionsIn TAO patients with exophthalmos, balanced deep lateral and medial orbital wall decompression is a good surgical method with a low-risk of complications. In addition, deep lateral wall decompression has higher surgical predictability than medial wall decompression, as seen with CT analysis.     

Isolated Caruncular Approach for Orbital Decompression

Purpose To evaluate the effectiveness of the isolated caruncular approach to orbital decompression of thyroid ophthalmopathy.Methods In a retrospective, noncomparative, interventional case series, we reviewed the records of 29 patients (48 orbits) who had thyroid ophthalmopathy and had undergone orbital decompression using the caruncular approach. The medial wall was decompressed in two patients (three orbits), and the medial and inferior walls were decompressed in 27 patients (45 orbits).Results The mean retrodisplacement achieved was 2.7mm of decompression of the medial wall, and 4.2mm of decompression of the medial and inferior walls. Diplopia arose in the primary position in 4 of 17 previously asymptomatic patients. Persistent postdecompression strabismus was managed successfully with adjustable strabismus surgery. Other complications were minimal, including a hypertrophic scar in one eye and a pyogenic granuloma in another.Conclusions Orbital decompression using the isolated caruncular approach offers rapid access to the medial and inferior orbital walls and makes graded decompression possible in each case. It is a useful approach for patients wishing surgery for cosmetic purposes and for those with compressive optic neuropathy as well. Jpn J Ophthalmol 2004;48:397–403 © Japanese Ophthalmological Society 2004     

Small Versus Coronal Incision Orbital Decompression In Graves’ Orbitopathy

Ideally the planning of decompression surgery should be adequate to the severity of the orbitopathy, its possible “lipogenic” or “myopathic” variants, the patient’s specific orbital osteology and possible previous surgeries. Due to surgeon’s experience and local traditions, however, a standardized rather than a tailored approach is often offered to the patient. An inferior fornix incision can be used for infero medial bony decompression and/or for removing fat from the medial and lateral inferior orbital quadrants. Through the same route a lateral osteotomy can also be performed although an upper skin crease incision offers a wider access to the lateral orbital wall. As an alternative the swinging eyelid technique, offering an adequate access to the bony orbit and to the orbital fat compartments is a versatile technique that can virtually be used as a standard approach for the greatest majority of patients needing decompression surgery. Orbital decompression by coronal incision is an invasive technique and for this not to be used as a standard approach to orbital decompression. Nevertheless, it is not to be abandoned as it can be an additional tool in surgeons’ hands when dealing with patients who can better benefit out of a particular, tailored rather than a standardised approach. Many are the circumstances in which this may happen. Major complications associated with the coronal approach have been mainly described in small series, where only a few patients per year were operated. In this respect it is therefore unavoidable to emphasize that each technique has its own learning curve and it may be difficult to differentiate the effects of each technique from the experience of the surgeon.     

A Combined Orbital and Antral Approach to Surgical Decompression of the Orbit

A combined orbital decompression procedure has been found effective in treating proptosis. The procedure includes a lower eyelid incision by an ophthalmologist to expose the floor of the orbit, while a Caldwell-Luc antrotomy is performed simultaneously by an otolaryngologist. The ophthalmologist has a better view of the contents of the orbit and the anterior orbital floor. The otolaryngologist has better access to the posterior orbital floor and ethmoid sinus. Together, isolation and preservation of the second division of the fifth cranial nerve are facilitated. The headlight worn by each surgeon helps illuminate the other's field of dissection. This combined approach offers advantages over separate operations.     

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.     

Anatomy of Deep Lateral and Medial Orbital Walls: Implications in Orbital Decompression Surgery

Abstract

Background: Isolated deep lateral and combined medial orbital wall decompressions (balanced decompression) are well accepted for treatment of disfiguring proptosis and compressive optic neuropathy in patients with Graves’ orbitopathy. However, cerebrospinal fluid leakage and/or optic nerve injury occasionally occur during these operations.

Purpose: To describe the anatomy of the deep lateral and medial orbital walls and its surgical implications in orbital decompression.

Methods: We reviewed literature on the anatomy of the deep lateral and medical orbital walls. In addition, we performed cadaver dissection and computed tomographics studies to illustrate the anatomy.

Results: We provided an anatomical overview and elucidated the detailed surgical anatomy of the posterior and superior borders of the deep lateral orbital wall, the posterior and accessory ethmoidal foramina, and the frontoethmoidal suture.

Conclusions: The anatomy of the deep lateral and medical orbital walls presented here will warrant safe and confident performance of orbital decompression surgery.     

Orbital Decompression for Compressive Optic Neuropathy in Patients with a Metastatic Orbital Tumor from Breast Carcinoma

We report two patients who underwent orbital decompression for compressive optic neuropathy due to a metastatic orbital tumor from breast cancer. One patient was a 47-year-old woman with right compressive optic neuropathy. Balanced orbital decompression was performed 11 days after her first visit. At postoperative week 1, her right visual acuity and critical flicker frequency value had improved from 0.1 and 20?Hz to 1.0 and 35?Hz, respectively, and good vision was maintained at 6 months postoperatively. The other patient was a 61-year-old woman with right compressive optic neuropathy. Medial orbital wall decompression was performed 5 days after her first visit. Her right visual acuity and critical flicker frequency values improved until 38 days after the surgery, from 0.5 and 19?Hz to 1.2 and 31?Hz, respectively, with stable good vision for the following 6 months.     

An Orbital Decompression for Severe Dysthyroid Exophthalmos

A procedure has been developed for maximizing decompression in patients with nonspecific orbital inflammatory disease or dysthyroid orbitopathy that involves removal of parts of all four orbital walls through a lateral orbitotomy using a 30-mm incision combined with a canthotomy and an inferior cul-de-sac incision. The procedure has been performed on seven orbits of four patients who had greater than 30 mm of forward placement of the eyes as measured by Hertel exophthalmometry and/or a 10-mm difference in the forward placement of the two eyes, indications considered for this procedure. The procedure has resulted in 10-17 mm of reduction in proptosis in these patients, which is consistently greater than that obtained by any other procedure. A complication of spinal fluid leak resulted in the recommendation that the procedure not be performed in patients over 65 whose dura is considered too thin to prevent spontaneous leakage and minimal surgical trauma. In all circumstances, this procedure must be performed by an experienced neuro-ophthalmic orbital surgical team.     

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

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

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

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

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

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.     

Outcome of Deep Lateral Wall Rim-Sparing Orbital Decompression in Thyroid-associated Orbitopathy: A New Technique and Results of a Case Series

Purpose: To describe a new technique for deep lateral (single) wall orbital decompression surgery, developed by Mr. Geoffrey Rose, for proptosis in patients with thyroid-associated orbitopathy and to analyse the results achieved in our series.

Methods: The study is an interventional, retrospective, non-comparative case series. Twenty-one eyes of seventeen patients underwent the described technique of deep lateral wall orbital decompression for thyroid-associated orbitopathy. All patients had controlled thyroid functions and underwent surgery for cosmetic rehabilitation, with analysis of the reduction in proptosis, changes in visual acuity and post-operative complications. The surgery involved removing the lateral orbital wall whilst preserving the lateral rim, the lateral wall being approached through a horizontal skin incision placed lateral to the lateral canthus. After reflecting the periosteum, most of the bone (deep lateral wall) between the skull base and inferior orbital fissure is removed.

Results: A mean reduction in proptosis of 4.81?mm ±1.23 (SD) (p?<?0.0001) with a median of 5.0?mm (range 3–7?mm) was achieved and the best-corrected visual acuity was maintained in all patients. There were no complications during surgery, and post-operative complications included worsening of pre-existing diplopia in one patient (6%) and transient cheek/temple numbness seen in three patients (18%).

Conclusions: This technique of deep lateral wall orbital decompression developed by Mr. Rose is a safe and effective procedure for patients with mild to moderate proptosis. It carries a low risk of morbidity and avoids complications associated with decompressing the floor and medial wall, including new onset of motility disorders.     

Role of Botulinum Toxin A in Diplopia following Orbital Decompression

Diplopia following orbital decompression is a common complication in Graves' ophthalmopathy. Strabismus surgery is often required to treat the persistent diplopia. The author presents a successful treatment with botulinum toxin A injection in a case of diplopia following orbital decompression. Treatment with botulinum toxin A in the management of new-onset diplopia following orbital decompression has been suggested in a case that is not amenable to prism treatment and may eliminate strabismus surgery in some cases.     

The Management of Patients with Thyroid Eye Disease After Bilateral Orbital 3 Wall Decompression

Introduction: Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. Orbital decompression surgery may cause and/or worsen a pre-existing ocular motility disorder.

Methods: A retrospective review was carried out of all bilateral 3 wall orbital decompressions for severe thyroid eye disease performed between January 2002 and December 2004 by one surgeon. Subsequent surgeries were recorded.

Results: Seventy-four patients were identified, 59 (80%) females and 15 (20%) males. Mean age at the time of decompression was 46 years. Fifteen (20%) patients complained of diplopia due to strabismus prior to decompression surgery and 20 (27%) developed new diplopia postsurgery. Twenty patients (27%) required no further intervention following decompression surgery; the remainder underwent an average of 2.5 procedures. Strabismus surgery was performed in 32 (43%) patients. The mean time from the decompression to first strabismus surgery was 12 months. Forty-three (58%) patients underwent lid surgery. The mean time from decompression to first lid surgery was 16 months.

Conclusion: This study demonstrates how this group of complex patients required multiple surgical procedures within an extended timescale, therefore requiring several in- and outpatient visits.     

The Transantral Orbital Decompression (Ogura Technique) as Performed by the Ophthalmologist: A Series of 24 Patients

Previous reports of transantral-ethmoidal orbital decompression (Ogura technique) have been published by head; and neck surgeons. This is a series of patients who have been operated on and followed by the author, an ophthalmologist. The results, complications, and techniques involved in this surgery are discussed. The feasibility and desirability of the ophthalmologist performing this procedure are considered, as it is the ophthalmologist, who is best able to evaluate the indications, results, and complications of this operation. Finally this paper shows that the cosmetic disfigurement alone, associated with exophthalmos, is a valid indication for the performance of the transantral-ethmoidal decompression.     

Minimally invasive surgery for thyroid eye disease

Thyroid eye disease (TED) can affect the eye in myriad ways: proptosis, strabismus, eyelid retraction, optic neuropathy, soft tissue changes around the eye and an unstable ocular surface. TED consists of two phases: active, and inactive. The active phase of TED is limited to a period of 12–18 months and is mainly managed medically with immunosuppression. The residual structural changes due to the resultant fibrosis are usually addressed with surgery, the mainstay of which is orbital decompression. These surgeries are performed during the inactive phase. The surgical rehabilitation of TED has evolved over the years: not only the surgical techniques, but also the concepts, and the surgical tools available. The indications for decompression surgery have also expanded in the recent past. This article discusses the technological and conceptual advances of minimally invasive surgery for TED that decrease complications and speed up recovery. Current surgical techniques offer predictable, consistent results with better esthetics.