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.     

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.     

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.     

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.     

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.     

Optic neuropathy in thyroid eye disease: results of the balanced decompression technique

Objective

To determine the efficacy of combined endoscopic medial and external lateral orbital decompression for the treatment of compressive optic neuropathy (CON) in thyroid eye disease (TED).

Design

A retrospective review of all patients undergoing combined surgical orbital decompression for CON between 2000 and 2010 was conducted.

Participants

Fifty-nine eyes of 34 patients undergoing combined surgical orbital decompression for CON.

Methods

Clinical outcome measures included visual acuity, Hardy-Rand–Rittler (HRR) colour plate testing, relative afferent pupillary defect, intraocular pressure measurement, and Hertel exophthalmometry. A CON score was calculated preoperatively and postoperatively based on the visual acuity and the missed HRR plates. A higher CON score correlates with more severe visual dysfunction.

Results

All patients had improvement of their optic neuropathy after surgical decompression. CON score was calculated for 54 eyes and decreased significantly from a mean of 13.2 ± 10.35 preoperatively to a mean of 8.51 ± 10.24 postoperatively (p < 0.0001). Optic neuropathy was completely resolved in 93.22% (55/59 eyes). Eighteen of 34 patients (52.94%) experienced development of new-onset postoperative strabismus that required subsequent surgical intervention.

Conclusions

Endoscopic medial combined with external lateral orbital decompression is an effective technique for the treatment of TED-associated CON.     

深外侧壁联合内侧壁眼眶减压术治疗甲状腺相关性眼病

目的：探究深外侧壁联合内侧壁眼眶减压术治疗甲状腺相关性眼病的临床治疗效果及安全性。

方法：分析我科既往住院患者病历,纳入2019-01/2020-05在我科住院的符合纳入标准的甲状腺相关性眼病患者17例。所有患者均在全身麻醉下行深外侧壁联合内侧壁眼眶减压术,比较患者术前术后的视力、暴露性角膜炎恢复情况、突眼度、眼压以及并发症情况。

结果：所纳入研究的对象中,有甲状腺相关眼病视神经病变(DON)8例9眼,术前的最佳矫正视力0.78±0.15,术后1mo 0.36±0.12,与术前视力相比有差异(P<0.01),术后6mo 0.38±0.12,与术后1mo无差异(P=0.594)。术前眼球突出度23.75±2.55mm,术后1mo为14.85±1.53mm,与术前突眼度相比有差异(P<0.01),术后6mo为14.60±1.64mm,与术后1mo基本保持稳定(P=0.658)。术前眼压25.56±3.23mmHg,术后1mo为18.42±2.35mmHg,与术前相比有差异(P<0.01),术后6mo眼压降至15.82±2.57mmHg,与术后1mo眼压相比有差异(P<0.01)。术前有暴露性角膜炎6例6眼,术后1mo有4眼好转,2眼治愈,术后6mo 6眼全部治愈。术后患者复视情况均有不同程度减轻,并有部分患者复视症状在此后6mo持续好转,未出现其他严重并发症。

结论：深外侧壁联合内侧壁眼眶减压术可以有效地改善眼突,对DON及暴露性角膜炎等严重并发症也有良好的疗效,并发症少,是治疗严重甲状腺相关性眼病的有效手术方案。     

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.     

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.     

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).     

Repair of medial orbital wall fracture: transcaruncular approach

The aim of this paper is to demonstrate the safety and the use of the transcaruncular approach as a surgical technique for managing a medial wall fracture. This approach was used in 40 patients with a isolated medial or a combined medial and inferior orbital wall fracture between September 1998 and September 2002. A computed tomographic scan was taken before and after surgery. The ocular motility and enophthalmos were checked before and after surgery. The transcaruncular approach provided the appropriate surgical exposure in all cases. Patients were followed up for a mean of 9.4 months (range, 524 months) after repairing the orbital wall fracture. Hertel exophthalmometry showed that among the 40 patients; 24 patients showed no enophthalmos. The enophthalmos ranged from 0.51 mm in 14 patients and 1.5 mm enphthalmos was noted in 2 patients. A clinically significant enophthalmos =2 mm was not found postoperatively. Preoperatively, 12 patients (30%) had a diplopia in the primary position of the gaze and 26 patients (65%) had a diplopia within 30 degrees of the gaze. Postoperatively, all patients had an orthotropia in the primary position but 4 patients (10%) had a residual diplopia either on the lateral gaze (2 patients) or the upgaze (2 patients). There were 2 cases of an implant misplacement. The transcaruncular approach provides a safe, rapid, and cosmetically pleasing surgical approach for managing a isolated medial wall fracture. When combined with the inferior transconjunctival approach, a combined medial and inferior orbital wall fracture can be successfully repaired.     

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.     

Beveled osteotomy with lateral wall advancement and interpositional bone grafting for severe thyroid orbitopathy

PURPOSE: To present a new technique for orbital decompressions for patients with severe thyroid orbitopathy that minimizes complications while maximizing the amount of decompression. This method involves advancing the lateral orbital wall in such a way as to promote osseous union and minimize cosmetic deformities. METHODS: This paper represents a case series (42 eyes from 26 patients) of orbital decompressions for severe thyroid related orbitopathy. All patients were treated via a graded balanced orbital decompression with advancement of the lateral orbital wall with interpositional bone grafts. Preoperative and postoperative measurements were tabulated and statistically analyzed. RESULTS: All patients demonstrated significant improvement in proptosis with an average Hertel exophthalmometry reduction of 8 mm. In addition, 22 patient orbits with preoperative elevation of intraocular pressure demonstrated an average 7 mm Hg improvement in postoperative intraocular pressure. Seven patients required strabismus surgery postoperatively and no patient developed new onset strabismus after surgery. Of all patients, 54% demonstrated improvement of visual acuity of greater than 1 line and no patient experienced a decrease in visual acuity. Postoperative computed tomography scan demonstrated osseous union of the lateral wall after advancement with this new technique. No patient complained of a palpable deformity of the lateral orbital wall. CONCLUSIONS: The graded balanced orbital decompression with interpositional bone grafts effectively decompressed the orbit with significant improvement in final visual acuity, exophthalmometry measurements, and final intraocular pressure. In addition, this technique promotes osseous union with minimal cosmetic deformities.     

Diabetes mellitus: a risk factor in patients with Graves'' orbitopathy

AIMS: To assess the prevalence of dysthyroid optic neuropathy (DON) in patients with diabetes mellitus (DM) and Graves' orbitopathy (GO) and to investigate the complications of surgery for GO in these patients. METHODS: The records of 482 consecutive patients with GO referred in a 5 year period were studied. Those patients who also had DM were selected for further study. The prevalence of insulin dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM) was registered, as well as the prevalence and course of DON. In the patients who underwent surgery for GO the postoperative complications were recorded. RESULTS: Out of 482 patients with GO, 15 (3.1%) also had DM. Eight (1.7%) had IDDM, 7 (1.4%) had NIDDM. Five patients (33.3%) three with IDDM and two with NIDDM developed DON with 50% improvement of visual acuity after treatment, whereas in the whole population of 482 GO patients 19 had DON (3.9%), showing 69.4% improvement of vision after treatment. 10 patients with GO and DM were operated for GO; in one of them an optic atrophy developed as a result of a postoperative haemorrhage directly after a three wall orbital decompression by coronal approach. No other postoperative complications occurred. CONCLUSIONS: The prevalence of IDDM in patients with GO is higher than in the normal population. DON occurs much more frequently in patients with GO and DM than in the total group of GO patients and seems to have a worse visual prognosis.     

Deep lateral orbital decompression for Graves orbitopathy: a systematic review

Purpose

To systematically review the literature on the deep lateral orbital decompression (DLD).

Methods

The authors searched the MEDLINE, Lilac, Scopus, and EMBASE databases for all articles in English, Spanish, and French that used as keywords the terms orbital decompression and lateral wall. Two articles in German were also included. Data retrieved included the number of patients and orbits operated, types of the approach employed, exophthalmometric and horizontal eye position changes, and complications. The 95% confidence intervals (CI) of the mean Hertel changes induced by the surgery were calculated from series with 15 or more data.

Results

Of the 204 publications initially retrieved, 131 were included. Detailed surgical techniques were analyzed from 59 articles representing 4559 procedures of 2705 patients. In 45.8% of the reports, the orbits were decompressed ab-interno. Ab-externo and rim-off techniques were used in 25.4% and 28.8% of the orbits, respectively. Mean and 95% CI intervals of Hertel changes, pooled from 15 articles, indicate that the effect of the surgery is not related to the technique and ranges from 2.5 to 4.5 mm. The rate of new onset of diplopia varied from zero to 8.6%. Several complications have been reported including dry eye, oscillopsia, temporal howling, lateral rectus damage, and bleeding. Unilateral amaurosis and subdural hematoma have been described in only one patients each.

Conclusions

The low rate of new-onset diplopia is the main benefit of DLD. Prospective studies are needed to compare the rate of complications induced by the 3 main surgical techniques used.

     

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.     

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.     

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.