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).     

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.     

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。     

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

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

Orbital decompression in Graves-Basedow disease--preliminary report

The aim of the paper is to present our initial experience in surgical treatment of patients with malignant exophthalmos. MATERIAL AND METHOD: from 2001 to 2004, 11 patients with malignant exophthalmos were treated in our Department. Preoperative exophthalmos ranged from 22 to 40mm, asymmetric exophthalmos was diagnosed in 5 cases. Orbital decompression was indicated in patients with ophthalmopathy (11), decreased visual acuity (4), lagophthalmos (3). Decompression included orbital floor, medial and lateral wall in 8 patients, orbital floor and medial wall in 3. RESULTS: in 5 patients exophthalmos decreased 5-8 mm, in 5 cases 2-3 mm, 1 patient remained without improvement. CONCLUSIONS: 1. The treatment of malignant exophthalmos requires multidisciplinary approach. 2 Orbital decompression should be followed by surgical correction of eyelids and eyeball muscles.     

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     

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.     

Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy

PURPOSE: This study aimed to determine the relative incidence and time course of new-onset strabismus after balanced medial plus lateral wall orbital decompression versus decompression of the lateral wall alone for dysthyroid orbitopathy. METHODS: The study design was a retrospective nonrandomized comparative case series. Thirty-two consecutive patients underwent balanced medial plus lateral wall orbital decompression or lateral wall orbital decompression for dysthyroid orbitopathy. The incidence, duration, and treatment of postoperative strabismus was recorded for each patient. RESULTS: Significant preoperative strabismus was present in 31% (4/13 patients) of the balanced decompression group and in 26% (5/19 patients) of the lateral wall decompression group. Only 25% (1/4) of cases of preexisting strabismus in the balanced decompression group resolved postoperatively without muscle surgery, whereas 60% (3/5) of cases in the lateral wall decompression group resolved postoperatively without surgery. Preoperative strabismus was absent in 69% (9/13) of patients in the balanced decompression group and in 74% (14/19) of patients in the lateral wall decompression group. New-onset, persistent postoperative strabismus developed in 33% (3/9) of patients in the balanced decompression group and in 7% (1/14) of patients in the lateral wall decompression group. CONCLUSION: Lateral wall orbital decompression may produce less new-onset, persistent postoperative strabismus than balanced medial plus lateral wall orbital decompression for dysthyroid orbitopathy.     

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.     

Outcomes of Various Surgical Procedures on Acquired Lower Eyelid Epiblepharon in Thyroid Associated Ophthalmopathy

Purpose

To report the outcomes of acquired lower eyelid epiblepharon after various surgeries in thyroid associated ophthalmopathy (TAO) patients.

Methods

A retrospective review of the medical records of 53 TAO patients with acquired lower eyelid epiblepharon between October 1999 and June 2011 was performed. Data were collected on demographics, type of lower eyelid epiblepharon, the detailed surgical history such as orbital decompression, retraction repair, or epiblepharon repair and surgical outcomes including follow-up period, recurrence of epiblepharon, and post-operative complications.

Results

Among the 53 TAO patients with acquired lower eyelid epiblepharon, 25 eyes of 17 patients underwent surgical management; 6 eyes of orbital decompression, 1 eye of orbital decompression followed by retraction repair, 2 eyes of orbital decompression followed by epiblepharon repair, 6 eyes of lower eyelid retraction repair, and 10 eyes of epiblepharon repair. Twenty two lower eyelid epiblepharons (88%) were resolved after final surgical treatment without complication during mean 16.2 months (SD, ±29.9 months) of follow up period; three of 6 epiblepharons that remained after orbital decompression underwent subsequent surgical management of retraction repair or epiblepharon repair, and epiblepharons were well-corrected. Mean amount of lower eyelid retraction was decreased from 1.68 mm (SD, ±1.17 mm) to 0.29 mm (SD, ±0.44 mm) after surgery, regardless of the type of surgery (n = 25, p < 0.000, Wilcoxon signed rank test).

Conclusions

Acquired lower eyelid epiblepharon of TAO should be managed sequentially according to the general serial order of surgical managements in TAO; orbital decompression, correction of lower eyelid retraction and epiblepharon repair. Acquired lower eyelid epiblepharon was well resolved after surgical management in consecutive order, especially after repair of the lower eyelid retraction with a graft, or lower eyelid epiblepharon repair. Decreased lower eyelid retraction with a resolution of epiblepharon after surgery implied that lower eyelid retraction was associated with lower eyelid epiblepharon.     

Normative magnetic resonance imaging measurements of orbital structures in pediatric population of North-Eastern India: A retrospective cross-sectional study

Purpose:The people of Northeast India comprise mostly of Mongoloid descent with characteristic craniofacial features. The purpose of this study was to evaluate the normal orbital structures with MRI and determine normative data in the Northeast Indian pediatric population.Methods:MRI images of the 302 orbits of 151 pediatric patients below 16 years of age were retrospectively evaluated to measure the various orbital structures. Both axial and coronal MRI images were utilized for various orbital measurements. An independent sample t-test was done to compare various orbital data according to the sex and side. Linear regression was also done.Results:The mean age of the pediatric population was 9.64 ± 1.47 years with a male: Female ratio of 1.13:1. The mean interzygomatic line was 88.4 ± 9.09 mm and the interorbital line was 22.18 ± 3.62 mm. The mean thicknesses of medial, lateral, superior, and inferior recti muscles were 2.58 ± 0.46, 2.34 ± 0.42, 2.16 ± 0.40, and 2.53 ± 0.49 mm in males and 2.41 ± 0.41, 2.08 ± 0.34, 2.08 ± 0.46, and 2.46 ± 0.49 mm in females. The mean horizontal orbital, vertical orbital diameters, orbital index, mean volume of eyeball, and orbital cavity were 30.27 ± 2.97,3 7.06 ± 3.57, 122.58 ± 7.39, 4.63 ± 0.84, and 15.29 ± 3.52 in males, while 29.16 ± 3.23, 34.96 ± 3.99,119.96 ± 7.31, 4.49 ± 0.87, and 14.65 ± 3.47 in females, respectively. With an increase in age, the interzygomatic line (r = 0.883, r² = 0.780; P < 0.0005), anterior medial interorbital line (r = 0.808, r² = 0.652; P < 0.0005), mean volume of eyeball (r = 0.915, r² = 0.838; P < 0.0005), orbital cavity (r = 0.924, r² = 0.854; P < 0.0005), and distance between the optic nerve entry site (r = 0.829, r² = 0.687; P < 0.0005) were increased.Conclusion:This study provides normative data of various orbital structures in a pediatric population and these data likely to be useful for diagnosing various pediatric orbital disorders and helps in the planning of various surgical procedures of orbits.     

甲状腺相关性眼病内镜微创减压术的历史与展望

甲状腺相关性眼病是成人最常见的眼眶疾病,眶减压手术是其重要的治疗手段。随着内窥镜技术的发展,内窥镜下眶减压手术逐渐成为其首选的手术方案。现将重点介绍内窥镜技术在眼眶内侧壁、外侧壁以及下壁减压中的应用进展,并介绍其手术效果以及并发症的预防与处理。同时介绍内窥镜下经筛径路眶减压手术在甲状腺相关性眼病视神经病变中的手术进展。     

CT features of exophthalmos in Chinese subjects with thyroid-associated ophthalmopathy

AIM:To investigate computed tomography (CT) features of exophthalmos in Chinese subjects with thyroid-associated ophthalmopathy (TAO).METHODS:A total of605 eyes of 325 patients with exophthalmos due to TAO were classified as grade I (mild exophthalmos) or II (severe exophthalmos) based on orbital CT imaging. The increased orbital volume features, such as changes from extraocular muscles, orbital fat, or both, were analyzed.RESULTS: A total of 605 eyes were analyzed, among them 62.98% presented grade I exophthalmos, while 36.02% showed grade II exophthalmos.#$TAB In grade I, 56.69% showed orbital fat change, and in grade II, 89.29% exhibited extraocular muscle enlargement.CONCLUSION: Orbital fat and extraocular muscle enlargement are likely to be observed on CTs of subjects with mild and severe exophthalmos, respectively. Our results suggest that CT findings may guide TAO clinical therapy recommendations and prognosis.     

Balanced orbital decompression in Graves' orbitopathy: Upper eyelid crease incision for extended lateral wall decompression

INTRODUCTION . This study reports on the results and complications detected in patients with Graves' orbitopathy who underwent balanced medial and lateral wall orbital decompression through concealed incisions. MATERIALS AND METHODS . The medial and lateral orbital walls of nine consecutive patients (14 eyes) were removed. A transnasal endoscopic spheno-ethmoidectomy was performed for the medial wall decompression. A lateral wall decompression was performed via an upper eyelid crease incision which was extended laterally in a relaxed skin tension line. The lateral aspect of the orbit was sculpted with a high-speed surgical drill from the inferior orbital fissure inferiorly and frontal bone of the lacrimal fossa superiorly to the orbital apex posteriorly, including the thick bone of the greater wing of the sphenoid. RESULTS . The decompression was performed for cosmetic purposes in seven patients (10 orbits) and for exposure keratopathy and restrictive myopathy in the remaining two patients (4 orbits). The average follow-up period was 13.6 months. The mean reduction of proptosis was 4.8 mm. The preoperative diplopia in two cases demonstrating restrictive myopathy worsened during the postoperative period. New onset diplopia was not detected in seven cases operated on for cosmetic purposes. All patients were satisfied with their eye status, visual rehabilitation and cosmetic appearance. CONCLUSIONS . The transnasal endoscopic approach for medial wall and extended lateral wall decompression with hidden eyelid crease incision provides a favorable cosmetic and physiologic outcome with proper retroplacement of the globe.     

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.     

改良结膜入路眼眶内下壁减压术治疗轻中度甲状腺相关眼病的临床效果

目的　评价改良结膜入路眼眶内下壁减压术治疗轻中度甲状腺相关眼病的疗效。方法　回顾性分析2017年1月至2018年8月在云南省第二人民医院行改良结膜入路眼眶内下壁减压术治疗的10例（11眼）轻中度甲状腺相关眼病患者。所有患者在术前均给予眼眶水平位、冠状位和矢状位CT检查，测量视力、眼球突出度、复视情况，检查眼外观进行眼前段照相等。将手术前、后眼球突出度，视力以及复视的改善情况作为效果评价指标，对相关数据进行统计和分析。结果　本组11眼术前眼球突出度为（18.94±1.40）mm，术后（15.22±1.46）mm；术后与术前比较，眼球突出度降低（3.72±0.64）mm，差异有统计学意义（t=18.379，P＜0.001）。术前视力为 0.53±0.29，术后为0.62±0.32；术后与术前比较，视力提高0.08±0.10，差异有统计学意义（t=-2.733，P=0.021）。术前复视2例；术后新发生复视2例，均为轻度复视。术前已存在复视的患者，术后复视程度无加重。结论　改良结膜入路眼眶内下壁减压术能有效改善甲状腺相关眼病患者的眼球突出度与视力，术后复视发生概率低，手术切口隐蔽美观，是一种可靠且有效的眶减压术式。     

Zwei-Wand-Dekompression ohne Resektion der medialen Wand

Background

Postoperative new onset diplopia can be a disadvantage for surgical orbital decompression in patients with exophthalmos in thyroid eye disease. The various modifications of decompression (number and combination of walls) differ in their influence on the postoperative squint angle. We report on postoperative diplopia in a modified 2 wall decompression strategy (lateral wall and floor).

Methods

This study was a retrospective analysis of 36 consecutive 2-wall decompressions performed between 2006?C2010 in 24 patients with 6 months of stable exophthalmos in thyroid eye disease after medical therapy and radiotherapy. The preoperative and postoperative squint angle in prism cover test (PCT), motility, induction of diplopia, reduction of exophthalmos, visual acuity and complications were evaluated.

Results

In all 36 decompressions the postoperative squint angle was equal to or less than before surgery. In 8 eyes additional squint surgery was performed. The mean reduction in exopthalmos was 4.3?mm.

Conclusions

An adverse effect of decompression on the postoperative squint angle was not evident in this study. New induction of diplopia was not observed at all. One possible explanation is the preservation of the medial wall.     

Balanced orbital decompression in Graves' orbitopathy: Upper eyelid crease incision for extended lateral wall decompression

INTRODUCTION. This study reports on the results and complications detected in patients with Graves' orbitopathy who underwent balanced medial and lateral wall orbital decompression through concealed incisions. MATERIALS AND METHODS. The medial and lateral orbital walls of nine consecutive patients (14 eyes) were removed. A transnasal endoscopic spheno-ethmoidectomy was performed for the medial wall decompression. A lateral wall decompression was performed via an upper eyelid crease incision which was extended laterally in a relaxed skin tension line. The lateral aspect of the orbit was sculpted with a high-speed surgical drill from the inferior orbital fissure inferiorly and frontal bone of the lacrimal fossa superiorly to the orbital apex posteriorly, including the thick bone of the greater wing of the sphenoid. RESULTS. The decompression was performed for cosmetic purposes in seven patients (10 orbits) and for exposure keratopathy and restrictive myopathy in the remaining two patients (4 orbits). The average follow-up period was 13.6 months. The mean reduction of proptosis was 4.8 mm. The preoperative diplopia in two cases demonstrating restrictive myopathy worsened during the postoperative period. New onset diplopia was not detected in seven cases operated on for cosmetic purposes. All patients were satisfied with their eye status, visual rehabilitation and cosmetic appearance. CONCLUSIONS. The transnasal endoscopic approach for medial wall and extended lateral wall decompression with hidden eyelid crease incision provides a favorable cosmetic and physiologic outcome with proper retroplacement of the globe.     

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.

     

Blood–aqueous barrier integrity in patients with Graves' ophthalmopathy (GO), before and after rehabilitative surgery

Purpose

The study was conducted to analyze aqueous flare and its correlations in patients with Graves'' ophthalmopathy (GO) undergoing orbital decompression, extraocular muscle, and eyelid surgery. Prospective interventional case series.

Patients and Methods

Forty-eight eyes of 27 patients (20 female and 7 male, aged 54.4±5.7) undergoing surgical treatment for GO. Eighteen eyes of nine patients (aged 55.3±3.6) undergoing orbital decompression. Nineteen eyes of 11 patients (aged 54.7±5.6) undergoing extraocular muscle surgery and 13 eyes of 7 patients (aged 53.9±4.9) undergoing eyelid surgery and control group (34 patients aged 53.9±5.1). Laser flare analysis and clinical assessment were performed before surgery and at 1 day, 7 days, and 3 months following surgery.

Results

Aqueous flare was significantly higher in patients with GO (14.03±8.45) before intervention than in the control group (7.89±3.56) (P<0.001), and correlated with Clinical Activity Score and intraocular pressure. In the patients undergoing orbital decompression, flare increased from 17.77±10.63 pc/ms to 38.32±13.56 pc/ms on the first day and 41.31±17.19 pc/ms on the seventh day and returned to 16.01±8.58 pc/ms in 3 months. In patients undergoing extraocular muscle surgery flare increased from 13.05±6.50 to 23.04±11.53 pc/ms (P<0.001) on the first day and returned to 18.02±14.09 pc/ms on the seventh day. Eyelid surgery did not change flare values.

Conclusions

Orbital decompression disrupts blood–aqueous barrier (BAB). The integrity of BAB returns to preoperative status within 3 months. Extraocular muscle surgery mildly affects BAB integrity, and the effect subsides within 7 days. Eyelid surgery does not affect BAB.