Combined-approach orbital decompresion for thyroid-related orbitopathy

Surgical treatment of thyroid-related orbitopathy can be accomplished by transorbital or endoscopic techniques. Transorbital surgery has advantages in the orbital floor and lateral wall, and endoscopic decompression is best suited to the medial orbital wall. We describe a retrospective review of 16 orbits (10 patients) treated with surgery, combining endoscopic decompression of the medial wall and a transorbital approach to the floor and lateral wall. Follow-up averaged 20.8 months. Vision and field defects improved dramatically in compressive optic neuropathy cases. Hertel measurements improved, on average, 4.9 mm. Two patients with severe preoperative diplopia required strabismus surgery after decompression. Combined-approach decompression is a safe and efficacious operation with conceptual advantages over current surgical techniques.     

Combined-approach orbital decompression for thyroid-related orbitopathy

Surgical treatment of thyroid-related orbitopathy can be accomplished by transorbital or endoscopic techniques. Transorbital surgery has advantages in the orbital floor and lateral wall, and endoscopic decompression is best suited to the medial orbital wall. We describe a retrospective review of 16 orbits (10 patients) treated with surgery, combining endoscopic decompression of the medial wall and a transorbital approach to the floor and lateral wall. Follow-up averaged 20.8 months. Vision and field defects improved dramatically in compressive optic neuropathy cases. Hertel measurements improved, on average, 4.9 mm. Two patients with severe preoperative diplopia required strabismus surgery after decompression. Combined-approach decompression is a safe and efficacious operation with conceptual advantages over current surgical techniques.     

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.     

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.     

Endoscopic orbital and optic nerve decompression

The endoscopic transnasal approach is well suited for decompression of both the orbit and optic canal. High-resolution nasal endoscopes provide excellent visualization for bone removal along the orbital apex and skull base. Endoscopic orbital decompression has proved to be safe and effective for the treatment of patients with Graves' orbitopathy; however, the indications and outcomes for endoscopic decompression of the optic nerve remain controversial.     

Combined Transconjunctival/Intranasal Endoscopic Approach to the Optic Canal in Traumatic Optic Neuropathy

Surgical decompression of the optic canal is indicated in patients with traumatic optic neuropathy who fail to respond to corticosteroids. Traditional surgical approaches to the orbital apex have been effective in achieving optic nerve decompression but require either a craniotomy, provide limited exposure with late identification and protection of the optic nerve, or require external incisions. The combined transconjunctival/intranasal endoscopic approach to the optic canal offers sufficient exposure, allows early identification and protection of the optic nerve, provides space for the use of multiple surgical instruments, obviates a craniotomy and external incisions, and can be performed quickly with minimal morbidity. The technique of combined transconjunctival/intranasal endoscopic optic nerve decompression will be described and the experience with nine cases will be presented.     

The transcaruncular approach to the medial orbital wall

OBJECTIVE: To demonstrate the safety and use of the transcaruncular approach as a surgical technique that provides rapid exposure of the medial orbital wall and apex through a small cosmetic conjunctival incision. METHODS: The transcaruncular anterior orbitotomy incision is made through the conjunctiva, between the plica and caruncle, with dissection to a subperiorbital plane along the medial orbital wall. This technique was used in 49 patients (58 orbits) between July 1995 and December 2000. The patients' ages ranged from 5 to 89 years (mean, 50 y). RESULTS: The transcaruncular anterior orbitotomy approach provided appropriate surgical exposure in all cases of orbital decompression for thyroid-related orbitopathy (in 33 orbits [26 patients]); for biopsy of medial orbital or orbital apex masses in 12 patients; and for drainage of an orbital abscess or marsupialization of a mucocele in 7 orbits (6 patients). Five patients (6 orbits) underwent a transcaruncular approach for release of medial rectus entrapment after fracture. The single complication was 1 patient who required a revision procedure for treatment of medial fornix scarring with resolution of diplopia. CONCLUSIONS: The transcaruncular approach provides a safe, rapid, and cosmetically pleasing surgical approach to the medial orbital wall and orbital apex. This technique can be used for a variety of indications.     

内镜下经筛径路眶内侧壁减压联合脂肪减压术治疗Graves眼病

目的 探讨内镜下经筛径路眶内侧壁减压术联合内镜下经筛径路眶肌锥内脂肪减压术治疗Graves眼病(Graves' ophthalmopathy,GO)的可行性,并分析其疗效.方法 对2006年10月至2011年5月因并发眶尖拥挤视神经病变而接受眶减压手术的29例GO患者进行回顾性分析.所有患者术前确诊为非组织活动期,均因视力下降、视野缺损或色觉障碍,同时合并眼球突出而接受内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术,术后定期随访.根据术后9个月视力、色觉改善程度,以及眼球突出度矫正度、复视等并发症判断疗效.结果 共收集资料齐全的GO患者29例(45眼).术后9个月,44眼(97.8％)视力明显改善,视力从术前((x)±s,下同)的-0.65±0.30提高至-0.24±0.22,视力平均提高达0.55 ±0.17,手术前后比较差异有统计学意义(t=- 13.012,p＜0.001);29眼术前色觉障碍者,23眼(79.3％)术后明显改善;术后双眼眼球对称度达100％,手术前后比较,平均眼球突出矫正度达(7.07±1.59) mm(4～11 mm).术后所有病例双眼眼球突出度相差＜2 mm,除1例术后复视加重外,术后无一例新发复视、视力下降、眶内出血等并发症发生.结论内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术在实现眶尖部减压的同时可以达到有效矫正眼球突出度的效果,且具有微创,无颜面部瘢痕,术后复视、眼球移位等发生率极低的优点,该术式是治疗GO并发眶尖拥挤视神经病变患者的安全有效的手段之一.     

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.     

Orbit and orbital apex

Pathology affecting the orbit and orbital apex is diverse and heterogeneous. Many of the differential pathologies require management in a multidisciplinary team involving both otolaryngology and ophthalmology. This article discusses the differential pathologies. Emphasis has been placed on Graves orbitopathy, traumatic optic neuropathy, and the indications for decompression in each. The differential diagnosis for a lesion within the orbit and orbital apex is diverse. The presentation, investigation, and appropriate management of these conditions is discussed with emphasis on traumatic optic neuropathy and Graves orbitopathy.     

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.     

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.     

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.     

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.     

Visual changes after transnasal endoscopic versus transcaruncular medial orbital wall decompression for dysthyroid optic neuropathy

ObjectiveTo compare postoperative changes in visual acuity between the transnasal endoscopic approach and the transcaruncular approach when comparison of preoperative values used for medial orbital wall decompression in patients with dysthyroid optic neuropathy.MethodsWe included 14 patients (23 sides) and divided them into a transnasal group (11 sides, 8 patients) and a transcaruncular group (12 sides, 6 patients). Visual acuity was examined preoperatively, on postoperative days 1, 3, and 7, and at a final follow-up visit. The differences in postoperative improvement of the logarithm of the minimum angle of resolution (logMAR) visual acuity and critical flicker frequency (CFF) between the two surgical groups at each time point were analyzed using the Mann–Whitney U test.ResultsPostoperative improvement in logMAR visual acuity on postoperative days 1 and 3 and that in CFF on postoperative day 1 were greater in the endonasal group than in the transcaruncular group (P < 0.050). Vision was improved or maintained in all patients in the transnasal group at the final follow-up. One patient in the transcaruncular group had loss of vision on one side and decreased vision on the other side after surgery.ConclusionMedial orbital decompression appears to provide better postoperative vision when performed by the transnasal approach than by the transcaruncular approach in patients with dysthyroid optic neuropathy.     

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.     

Image-guided endoscopic orbital decompression for Graves' orbitopathy

OBJECTIVES: We studied the efficacy and safety of image-guided balanced orbital decompression for Graves' orbitopathy. METHODS: The data of 24 patients (45 orbits) were reviewed for demographics, ophthalmologic outcomes, and complications in regard to image-guided (18 orbits) versus non-image-guided surgery (27 orbits). RESULTS: Overall, all patients had a reduction in proptosis (mean reduction, 6.2 mm in proptosis) as measured by Hertel exophthalmometry. There was improvement in the visual acuity of all 12 orbits with preoperative acuity of 20/40 or worse and either complete resolution (38%) or improvement (62%) in the 16 orbits with optic neuropathy. These measures reached statistical significance. Despite subjective improvement in surgeon confidence, the use of image guidance did not result in a statistically significant difference in postoperative ophthalmologic outcomes. Medical and sinonasal complications were experienced by 11.1% and 18.5% of patients who underwent image-guided and non-image-guided orbital decompression, respectively. CONCLUSIONS: Image guidance may be a useful adjunct to balanced orbital decompression for Graves' orbitopathy, but it was not associated with a statistically significant improvement in outcomes in this study.     

Endoscopic orbital and optic nerve decompression

Endoscopic orbital decompression has become the surgical treatment of choice for many patients with orbital manifestations of Graves' disease, including proptosis and optic neuropathy. The unparalleled visualization provided by endoscopic instrumentation allows for a safe and thorough decompression, particularly when operating along the orbital apex and skull base. Although the benefits of and indications for decompression of the orbit are well established, the role of optic nerve decompression remains controversial.     

Selection of patients and choice of operation for orbital decompression in graves ophthalmopathy

Until the fundamental cause of the orbital problem associated with Graves' disease is better understood and can be prevented or reversed, some patients will need palliative orbital decompression. Of the available methods of orbital enlargement, the transantral ethmoidal decompression and the transfrontal operation seem most useful because of the amount of bone that can be removed by either approach. Transantral decompression is an appropriate operation for those patients with serious bilateral disease who would otherwise be treated systemically with corticosteroids. It also is of value as a preliminary step to extraocular muscle surgery after the orbital process has stabilized in those patients with exophthalmos and extraocular muscle myopathy and diplopia. Cosmetic decompression by this route is practical but total rehabilitation may also require upper lid and rectus muscle surgery. Forty patients with Graves' ophthalmopathy were treated by transantral decompression in the period July, 1969, to July, 1972. Seventeen of these had optic nerve dysfunction and visual field defects, papilledema, or choroidal folding. Fourteen patients had proptosis without optic neuropathy and six of these had corneal ulceration. Five patients had decompression specifically as a preliminary to eye muscle surgery and four patients had decompression for purely cosmetic reasons. The transfrontal decompression is ideal for patients with unilateral exophthalmos and when orbital exploration is needed. The transfrontal operation can salvage vision in the occasional patient with serious disease that is not palliated by transantral decompression. Orbital decompression is a more conservative approach to palliation than is high-dose long-term systemic steroid therapy. Orbital decompression has effectively controlled the optic neuropathy of Graves' disease without serious complications from the operation and without risking the potential side-effects of long-term high-dose steroid therapy.     

Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique

OBJECTIVE: Although endoscopic orbital decompression has become the surgical treatment of choice for patients with proptosis from Graves disease, postoperative diplopia requiring corrective eye muscle surgery can occur in up to 63% of patients. The purpose of the study was to evaluate a new technique intended to reduce the incidence of diplopia following endoscopic orbital decompression. STUDY DESIGN: Case-control. METHODS: Endoscopic orbital decompression was performed on 58 orbits in 37 patients with proptosis from Graves disease. The orbital sling technique, which makes use of a horizontal strip of periorbital fascia to prevent prolapse of the medial rectus muscle, was used on 20 orbits in 13 patients. Conventional endoscopic decompression was performed in 24 control subjects. The mean duration of follow-up was 3.3 +/- 1.3 years (range, 1.7-5.1 y). RESULTS: The incidence of new-onset or worsened diplopia following endoscopic decompression was significantly lower for the orbital sling group compared with control subjects (0% vs. 29.2%, respectively [ =.038]). No patients in the orbital sling group developed new-onset diplopia following surgery. Of the eight patients with pre-existing diplopia from the orbitopathy, double vision improved in four patients (50%) and was unchanged in the remaining four patients (50%). The mean reduction in proptosis was comparable for the orbital sling and control groups (5.1 +/- 1.1 mm vs. 5.0 +/- 1.9 mm, respectively [ P=.98]). CONCLUSIONS The preservation of a fascial sling overlying the medial rectus muscle during endoscopic orbital decompression appears to reduce the incidence of postoperative diplopia, while still allowing for a satisfactory reduction in proptosis. This modification of the standard decompression technique should be considered for the treatment of patients with proptosis.