Abstract
OBJECTIVES:To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves’ orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.METHODS:Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.RESULTS:Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).CONCLUSIONS:IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.
Highlights
IntroductionGraves’ orbitopathy (GO) covers an array of orbital and periocular changes associated with dysthyroid autoimmune disease, and can lead to muscle and fat expansion, orbital tissue fibrosis, and restriction of extraocular motility, which occur in a self-limited and highly heterogeneous manner [1]
Postoperative reduction on exophthalmometry was significant in both groups, but significantly greater with medial plus lateral wall orbital decompression (ML-Orbital decompression (OD)) than with inferomedial wall orbital decompression (IM-OD) (3.8±3.1 mm vs. 2.4±1.9 mm; p=0.010) (Table 2)
IM-OD is efficient in reducing moderate exophthalmos and is safe for postoperative maintenance of ocular alignment and stereoacuity
Summary
Graves’ orbitopathy (GO) covers an array of orbital and periocular changes associated with dysthyroid autoimmune disease, and can lead to muscle and fat expansion, orbital tissue fibrosis, and restriction of extraocular motility, which occur in a self-limited and highly heterogeneous manner [1]. No potential conflict of interest was reported. Received for publication on November 10, 2020. Accepted for publication on February 24, 2021. The disease significantly affects patients’ quality of life due to disfigurement and functional limitations, including exophthalmos, diplopia, and dysthyroid optic neuropathy [3]
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