THE SURGICAL TREATMENT OF GRAVES' ORBITOPATHY: A Decade of Progress

Abstract

The total rehabilitation of the patients with Graves' ophthalmopathy is sometimes possible only with sequential surgical procedures. Elective surgical treatment is normally delayed until the inflammatory phase subsides and stability is established, usually 1 to 3 years after onset. Additionally, the metabolic status should be well controlled before elective surgical treatment. Generally, eyelid and motility measurements should remain stable for a period of 6 months before any surgical intervention. 44 Exceptions to delaying surgical repair until stability are severe exposure keratopathy requiring eyelid surgery or progressive optic neuropathy unresponsive to corticosteroid or radiation therapy, which prompts orbital decompression. The overall risk of the need for surgery was estimated as 2.5 times greater in patients older than 50 years than in younger patients. 3 This may be related to the presence of more severe ophthalmopathy in older patients. 33 A systematic surgical approach was introduced in 1986. 75 The usual sequence of reconstruction of the Graves' patient with severe orbitopathy is orbital decompression and strabismus surgery followed by eyelid retraction surgery and other eyelid surgery. Orbital decompression may influence the muscle function and eyelid position. In addition, muscle surgery especially if it involves the vertical rectus muscles; may change eyelid retraction. Despite the usefulness of a systematic conceptual approach, the treatment must be individualized to each patient, as the disease does not follow a uniform course, and the manifestations differ in severity. The first stage of surgical rehabilitation, when necessary, is the orbital decompression. It is indicated to reduce excessive proptosis, to relieve orbital congestion, and to treat compressive optic neuropathy. 6,31,53,74 The goal of strabismus surgery in Graves' orbitopathy is usually to achieve single binocular vision in the primary and reading positions. Stable motility measurements should be achieved muscle surgery. Many patients have restriction of the inferior rectus muscles and benefit from some degree of bilateral inferior rectus recessions. Adjustable sutures frequently are used. Surgery for eyelid retraction and other abnormalities follows strabismus surgery. There are numerous eyelid abnormalities described in dysthyroid ophthalmopathy. The most frequent are upper and lower eyelid retraction, lagophthalmos, ptosis, dermatochalasis, lacrimal gland prolapse and mechanical medial lower eyelid entropion. The eyebrow fat pad may also be enlarged in patients with Graves' orbitopathy. In selected cases, the brow fat may need to be debulked when performing a blepharoplasty to achieve the desired aesthetic result. 21 Cosmetic reduction of herniated fat pads and eyebrow fat pads is generally performed last.