Transnasal Orbital Decompression in Severe Graves’ Ophthalmopathy

Abstract

Recently, Michel et al (Ophthalmology 2001;108:400–4) presented the results of 145 endonasal orbital decompression procedures in 78 subjects. They concluded that the proptosis reduction (on average, 3.94 mm) is comparable to that achieved with other decompression techniques, whereas the morbidity of the approach is less, because it leaves no visible scarring. We question the validity of both these conclusions. By use of transconjunctival decompression and a small cutaneous incision in the lateral canthus (the “swinging eyelid” approach), we recently reported an average reduction of exophthalmos of about 5.5 mm.1Paridaens D.A. Verhoeff K. Bouwens D. van den Bosch W.A. Transconjunctival orbital decompression in Graves’ ophthalmopathy lateral wall approach ab interno.Br J Ophthalmol. 2000; 84: 775-781Crossref PubMed Scopus (71) Google Scholar Furthermore, although 53.7% of the patients presented by Michel had oculomotor imbalance before surgery, this increased to 81.2% after decompression surgery. Using these figures, we calculate a 60% incidence of induced diplopia. This percentage is comparable to previously reported results of transantral decompression, but it compares unfavorably with the reported results of translid decompression techniques, even in patients with compressive optic neuropathy.2McCord Jr, C.D. Current trends in orbital decompression.Ophthalmology. 1985; 92: 21-33Abstract Full Text PDF PubMed Scopus (152) Google Scholar, 3Hutchison B.M. Kyle P.M. Long-term visual outcome following orbital decompression for dysthyroid eye disease.Eye. 1995; 9: 578-581Crossref PubMed Scopus (26) Google Scholar We point out that transconjunctival decompression also leaves no visible scar, whereas the scar induced by the “swinging eyelid” approach is hardly, if at all, noticeable. In the latter procedure, an inferior forniceal conjunctival incision is combined with a small cutaneous incision in the frown lines at the lateral canthus. We acknowledge that 78% of the patients presented by Michel et al, had some degree of compressive optic neuropathy and that transnasal decompression seems quite successful in decompressing the optic nerve. This does, however, not validate their conclusions as stated earlier, which in our opinion, could only be based on a comparative series. As long as such data are lacking, we conclude that transnasal orbital decompression is associated with relatively little proptosis reduction and a relatively large component of oculomotor imbalance. In our opinion, the abscence of a visible scar does not counterbalance these disadvantages, especially because several other techniques also do not leave visible scarring and yet yield better results. Transnasal Orbital Decompression in Severe Graves’ Ophthalmopathy: author replyOphthalmologyVol. 108Issue 12Preview Full-Text PDF