Orbital decompression in thyroid eye disease

Jane S Kim,Jason Liss

doi:10.1016/j.otot.2018.10.009

Abstract

Thyroid eye disease is an orbital inflammatory manifestation of autoimmune thyroid disease that results in orbital congestion and can lead to significant cosmetic disfigurement, diplopia, and vision loss. Typically, there is an active, inflammatory phase that transitions into a quiescent, fibrotic state. Management of this condition consists of regulation of the underlying thyroid disease, modulation of risk factors, supportive care for symptoms, and both medical and surgical treatment of ocular sequelae. Orbital decompression is generally indicated in 2 main subsets of cases: in active disease that includes ulcerative keratitis from severe corneal exposure or compressive optic neuropathy that does not resolve with high-dose corticosteroids, and in quiescent cases with persistent congestive or exposure symptoms and/or cosmetic deformity. Decompression may involve the medial wall, the lateral wall, the orbital floor, or any combination thereof, and this decision is dependent on surgeon preference and the overall goal of decompression. The medial wall is commonly selected due to the ease of approach, the potential for orbital volume expansion, and the opportunity for direct decompression of the optic nerve in cases of compressive optic neuropathy. Various surgical approaches to the medial wall have been proposed. The transcaruncular approach offers immediate access to the orbit with direct exposure, excellent visualization of the medial wall and the medial portion of the orbital floor, and the absence of cutaneous scars.

Highlights

Thyroid-associated orbitopathy (TAO) can be functionally disabling and, in severe cases, may result in permanent visual loss
Many authors use the term “cosmetic decompression,” it must be kept in mind that this represents reconstructive surgery because it addresses an abnormality caused by a disease
By comparing preoperative and postoperative computed tomography (CT) scans, motility measurements, and Gorman score, we have demonstrated in our own series a clear displacement of the lateral rectus muscle after deep lateral wall removal [65] but without significant influence on motility though we observed a worsening of motility in 4% (4 out of 100 patients) after lateral wall decompression with orbital fat resection

Summary

Introduction

Thyroid-associated orbitopathy (TAO) can be functionally disabling and, in severe cases, may result in permanent visual loss. Many authors use the term “cosmetic decompression,” it must be kept in mind that this represents reconstructive surgery because it addresses an abnormality caused by a disease. While decompression surgery has the potential to improve facial appearance, patients should be carefully informed that it is often impossible to restore their look to what it has been before the disease began to modify the tissues involved. It is important to note that most TAO patients will not require surgical treatment. The need for surgery was significantly related to age, with a 2.6 times greater overall risk in patients older than 50 years

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