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.     

Effect of prior orbital decompression on outcome of strabismus surgery in patients with thyroid ophthalmopathy.

PURPOSE: To compare strabismus surgery outcomes of patients who have had prior orbital decompression for thyroid ophthalmopathy with those of patients who have not had decompression. METHODS: The records of all patients operated on by the author for strabismus related to thyroid ophthalmopathy were retrospectively reviewed. RESULTS: Fifty patients were included in this study. Seventeen patients had previously undergone orbital decompression, and 33 patients had not. Seventy-six percent of patients who had had orbital decompression had a good or excellent outcome compared with 91% of those who had not had orbital decompression. Patients in the orbital decompression group had an average of 1.4 operations compared with 1.2 in the no-decompression group. The average numbers of muscles operated on were 3.1 in the decompression group and 1.9 in the no-decompression group. Patients who had been decompressed were more than 4 times as likely to require surgery for both a horizontal and vertical deviation than patients who had not been decompressed. CONCLUSIONS: Patients with thyroid ophthalmopathy who have had orbital decompression have a lower success rate of surgery for strabismus, more frequently need correction for both horizontal and vertical deviations, and have more muscles operated on than patients who have not had orbital decompression. The need for orbital decompression in patients with Graves' disease is reflective of a worse degree of orbitopathy. In addition, ocular changes from decompression surgery may interfere with a successful result from strabismus surgery.     

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.     

Ocular motility problems after orbital decompression for dysthyroid ophthalmopathy

Ocular motility problems of 50 consecutive patients following orbital decompression for dysthyroid (Graves') ophthalmopathy were analyzed retrospectively. No significant relationship to the development of postoperative diplopia was seen in the amount of retrodisplacement of the globe, the anatomical approach for orbital decompression, or the indication for decompression. Several clinical observations were made. Patients whose indication for orbital decompression was a vision-threatening ophthalmopathy were more likely (although not statistically significantly) to develop postoperative strabismus. Patients who developed changes in preoperative strabismus were more likely to develop increased esotropia and/or restrictive hypertropia. Of 32 patients who were orthotropic in the primary position before operation, 11 developed postoperative strabismus in the primary position. Only five patients had normal versions and ductions before operation. All five of these patients had normal versions and ductions after operation.     

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.     

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。     

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     

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.     

Retrobulbar pressures measured during surgical decompression of the orbit.

AIMS/BACKGROUND: In Graves' ophthalmopathy the increase in volume of intraocular muscles and fat will cause elevated intraorbital pressure. In order to investigate the pressure levels involved, intraorbital pressure, or retrobulbar pressure (RBP) was measured continuously in orbits of patients with Graves' ophthalmopathy during surgical decompression. METHODS: Retrobulbar pressure was measured before and during surgical decompression using an intraorbitally applied pressure transducer. RESULTS: In eight patients with dysthyroid optic neuropathy (DON) RBPs between 17 and 40 mm Hg were recorded. At the end of the surgical procedure the mean RBP was reduced from 28.7 mm Hg to 18.7 mm Hg, the decrease ranging from 8 to 12 mm Hg, which showed a high correlation with the starting pressures (p < 0.001). In two cases without DON, pressures were 11 and 9 mm Hg. Forces exerted by spatula manipulation usually resulted in a RBP level of more than 70 mm Hg. CONCLUSIONS: This study shows that RBPs are markedly elevated in Graves' ophthalmopathy and that surgical decompression can result in a significant reduction in the intraorbital pressure. Optic nerve dysfunction in Graves' ophthalmopathy may not be caused exclusively by the direct pressure of swollen extraocular muscles upon the optic nerve, but also by a raised RBP. It is hypothesised that the damage inflicted upon the optic nerve can be caused in consequence by RBP induced incarceration of the nerve, compressed by surrounding periosteal lined orbital fat bulging posteriorly into the entrance of the optic canal.     

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.     

Infections, inflammations, and immune-mediated orbital disease

In recent months, many authors have described distinct surgical approaches to orbital decompression in thyroid ophthalmopathy. Comparison of outcomes data should allow the surgeon to decide on the best approach to orbital decompression in an individual patient. Patients with thyroid-associated lid retraction may also benefit from approaches that allow for postoperative suture adjustment, because alignment of the lids can be particularly challenging in these patients. The clinical evaluation of patients with thyroid disease has evolved with the recognition that magnetic resonance T2 relaxation time prolongation may correlate with an inflammatory disease phase and, perhaps, with improved response to medical management. Medical management of orbital inflammation and infection should be tailored to the specific disease process and, in many cases of infection, to the age of the patient.     

The aftermath of orbital radiotherapy for graves' ophthalmopathy

OBJECTIVE: To determine whether long-term improvement could be observed after orbital radiotherapy for Graves' disease; in addition, to evaluate ancillary treatments needed for those who have received radiotherapy, to search for late-emerging adverse consequences of radiotherapy, and to relate orbital changes to serum levels of thyroid-stimulating immunoglobulin (TSI). DESIGN: Three-year follow-up of noncomparative interventional case series. PARTICIPANTS: Forty-two patients. INTERVENTION: All patients had received orbital radiotherapy within 6 months of study entry. Twelve months after study entry, patients were free to select any additional treatment for their ophthalmopathy. MAIN OUTCOME MEASURES: Need for surgery, steroid therapy, volume of extraocular muscles and fat, proptosis, area of diplopia fields and range of extraocular muscle motion, volume changes after decompression and correlations of eye findings with serum TSI levels, retinal status. RESULTS: Half of the patients elected to have a surgical procedure on their eyes or orbits. Among patients who were not decompressed, we found only slight improvement in some of the main outcome measures. TSI did not positively correlate with baseline status or with any observed change in major outcome measures. After orbital decompression, the volumes of both muscle and fat increase, but bony orbital volume increases more and proptosis diminishes. Retinal microvascular abnormalities consistent with radiation retinopathy developed de novo in five eyes of three patients within 3 years of radiation therapy. CONCLUSIONS: In this 3-year uncontrolled follow-up phase, limited evidence for a clinically significant improvement was observed, which may be the result of treatment or of natural remission. In either case, the changes are of little clinical significance. Because it is neither effective nor innocuous, radiotherapy does not seem to be indicated for treatment of mild to moderate ophthalmopathy.     

Coronal approach for rehabilitative orbital decompression in Graves' ophthalmopathy

AIMS—To determine the effectiveness and safety of three wall orbital decompression by the coronal approach in Graves' ophthalmopathy.
METHODS—The records of 125 patients with Graves' ophthalmopathy, who had undergone three wall orbital decompression by coronal approach between April 1984 and October 1993, were studied retrospectively. Special attention was paid to proptosis reduction, changes in ocular motility, and complications.
RESULTS—The preoperative Hertel values ranged from 15 to 30 mm (mean 22.43 mm). The mean proptosis reduction was 4.34 mm (range 0-10 mm). Proptosis reduction in patients with preoperative Hertel values higher than 27 mm was significantly more than in patients with preoperative values between 25 and 27 mm (p < 0.05). This last group showed significantly more proptosis reduction than patients with preoperative Hertel values of 23 and 24 mm (p < 0.01). Postoperatively, 3.2% of the patients showed new diplopia in primary and/or reading position. In 4% of the patients with normal ocular motility preoperatively, diplopia in the extreme directions of gaze developed. In 4% of the patients, preoperative motility disturbances decreased or disappeared postoperatively.
CONCLUSION—Three wall orbital decompression by coronal approach is a safe and effective technique, to achieve proptosis reduction in patients with Graves' ophthalmopathy, with fewer complications than other techniques thus far described.

     

Transnasal transsphenoid approach: a minimally invasive approach for removal of cavernous haemangiomas located at inferomedial part of orbital apex

Ten patients complaining of visual impairment, proptosis or ocular pain, were selected for transnasal transsphenoid microsurgical approach to address cavernous haemangiomas located at inferomedial part of orbital apex. Via this approach, the contents of orbital apex were clearly illuminated and exposed as large as the surgical removal required. All tumours were identified under frameless image‐guided neuronavigation and removed completely without any complications and recurrence in a mean of 12.2 months follow‐up. It is concluded that a transnasal transsphenoid microsurgical approach is a minimally invasive surgery for cavernous haemangiomas located at inferomedial part of orbital apex.     

Ethmoidectomy decompression for the treatment of Graves' optic neuropathy.

When orbital decompression becomes necessary in Graves' optic neuropathy, medial wall decompression is a necessary component of the decompression procedure. The ethmoidectomy approach allows more direct visualization of the posterior ethmoids and sphenoids to effect maximum decompression. This is particularly important in cases in which computed tomography shows the medial rectus muscle to be enlarged posteriorly in the orbit. The procedure provides excellent visualization of the medial rectus. As with any medial wall decompression procedure, postoperative restriction of horizontal motility is a frequent complication, often necessitating more than one subsequent operation. The authors describe their experience with the procedure in 25 patients with Graves' optic neuropathy.     

The inferomedial orbital strut: an anatomic and radiographic study

PURPOSE: To study the anatomic and radiographic features of the inferomedial orbital strut (IOS), with particular emphasis on the region of the posterior IOS. METHODS: Cadaver dissection study of the IOS was performed on 20 orbits of 10 fresh-frozen cadaver specimens. Radiographic volumetric analysis was performed on CT scans of 20 orbits to measure the volume available for decompression in the region of the posterior IOS. RESULTS: The anterior IOS provided bony support to the orbit and served as a site of attachment for globe-supporting suspensory ligaments. The midportion of the IOS demonstrated a contiguous anatomic relation to the maxillary sinus ostium. The posterior IOS consisted of two components: the intraorbital process of the palatine bone and ethmoidal air cells that extended inferior and posterior to the IOS. Radiographic volumetric analysis demonstrated that there was an average of 2.1 mL of volume available for decompression in the region of the posterior IOS (range, 1.2 to 3.3 mL). CONCLUSIONS: The findings of this anatomic and radiographic study of the inferomedial orbital strut support the concept of a posterior inferomedial orbital decompression. The region of the posterior IOS appears to offer significant volume for axial globe mobilization while minimizing the risk of globe dystopia and/or impairment of the maxillary sinus drainage.     

Surgical treatment of globe subluxation in the active phase of the myogenic type of Graves orbitopathy: case reports

The purpose of the present article is to present and discuss two cases of globe subluxation in the active phase of myogenic Graves' orbitopathy and to evaluate the prevalence of this phenomenon. Two patients with the myogenic variant of Graves' orbitopathy that had being treated with oral and intravenous steroid pulses developed globe subluxation. Both had to have urgent eyelid and orbital decompression. After these observations, we reviewed the medical records of a sample of 284 patients (482 orbits) who had had orbital decompression at our Institution from 1992 to 2010, with a search for cases presenting severe proptosis or globe subluxation in the active phase of myogenic Graves' orbitopathy. No patient had to have decompression for globe subluxation in the active phase of Graves' orbitopathy. The prevalence of this event as an indication for surgery in the myogenic variant of Graves' orbitopathy was therefore 0.7% (2/284) or even less. The combination of lowering the upper eyelid and orbital decompression had a dramatic therapeutic effect on these patients despite the presence of intense inflammatory signs in the orbits. In conclusion, patients affected with the myogenic variant of Graves' orbitopathy may develop globe subluxation. Urgent surgical treatments should not be postponed despite the presence of active inflammation.     

Graves'' ophthalmopathy: III. Effect of transantral orbital decompression on optic neuropathy.

Twenty-five patients (48 eyes) underwent transantral, surgical decompression of their orbits for treatment of Graves' ophthalmopathy with optic neuropathy. Visual acuity improved in 77%, remained unchanged in 17%, and worsened in 6%. Colour vision improved in 76%, remained unchanged in 20%, and worsened in 4%. Visual fields improved in 67%, remained unchanged in 12%, and worsened in 22%. In general the worse the vision preoperatively the greater the relative improvement postoperatively. Clinical and radiological findings failed to correlate with visual outcome of surgical intervention. The study shows surgery to be highly effective in restoring optic nerve function for patients with severe Graves' ophthalmopathy.     

Prevalence of eye diseases in Basedow disease. Apropos of a prospective study with 85 cases]

The authors report the results of a prospective study, conducted between March 1990 and March 1991, on 85 patients suffering from Graves' disease, who were systematically examined to evaluate the prevalence of ophthalmopathy in Graves' disease. They were graded according to the Nospecs classification: 32 patients had no ophthalmopathy; 21 had only eyelid retraction (grade I in the Nospecs); 32 had a real ophthalmopathy (Grade II) or more in the Nospecs: 27 patients had signs of inflammation (grade II), that were often minor, 14 patients a moderate or intermediate exophtalmos (grade III), 4 patients had corneal injuries (grade V). The authors discuss the problems caused by this classification.     

Disease-specific assessment of quality of life after decompression surgery for Graves' ophthalmopathy

PURPOSE: Graves' ophthalmopathy (GO) is an organ-specific autoimmune disease. Hydrophily of accumulated acidic mucopolysaccharides into bulbar adipose tissue leads to swelling of the eye muscles. Orbital surgical decompression is performed in severe cases of compressive optic neuropathy and severe corneal exposure or failure of steroid therapy. The study was designed to evaluate decompression surgery with respect to the clinical benefit and the patient's satisfaction by means of a disease-specific questionnaire. METHODS: The 90-item study questionnaire was distributed to 105 patients with GO who underwent orbital decompression surgery at the authors' institution. RESULTS: A total of 88% of patients stated that decompression had helped them, 80% of the interviewees would undergo decompression again, 78% were content with their eye symptoms, and 71% were satisfied with the cosmetic result of decompression. Furthermore, analysis showed a clinically relevant increase in quality of life after surgery. The correlation between the clinical endpoint proptosis at last examination and the quality of life score proved to be significant (p=0.05). CONCLUSIONS: The large majority of interviewees were satisfied with the result of the orbital decompression. These results confirmed that disfiguring proptosis is an important indication for decompression surgery.