Average Reduction In Proptosis Research Articles

Long-term outcomes of inferomedial orbital wall decompression in Graves' ophthalmopathy in an Asian population: A 30-year retrospective study.

This study aims to evaluate the long-term outcomes of inferomedial orbital wall decompression (IMOD) in Graves' ophthalmopathy (GO). A retrospective review of 422 eyes of 226 patients with GO-related cosmetically disfiguring proptosis (COS), dysthyroid optic neuropathy (DON), or exposure keratopathy (EXP) who received IMOD from 1989 to 2020 was conducted. Hertel value (HE) and corrected visual acuity (CVA) were evaluated at baseline and regularly thereafter. Proptosis recurrence, diplopia, and adjuvant surgeries were assessed. Complete success was defined as proptosis reduction over 2 mm without recurrence and improved diplopia. Partial success was defined as proptosis reduction without recurrence but with persistent or new-onset diplopia, and failure as proptosis recurrence. After follow-up for 40.1 ± 39.6 months (range, 6-239 months), 236 eyes (55.9%) achieved complete success, 175 eyes (41.5%) achieved partial success, and 11 eyes (2.6%) had failure. Significant CVA improvement was observed in both DON and COS groups (P < 0.001 and P = 0.045, respectively). Average proptosis reduction was 5.2 ± 2.2 mm, with a significant increase of 0.5 mm after long-term follow-up (P < 0.001). Incidence of proptosis recurrence was 2.6%. Surgical success rate of COS group was positively correlated with preoperative HE. IMOD demonstrated excellent success rate in all three subgroups with a low proptosis recurrence rate and improved visual outcome in both DON and COS groups. Delayed proptosis reduction effect of IMOD may result in delayed-onset asymmetry, especially in the unilateral group.

A comparison of proptosis reduction with teprotumumab versus surgical decompression based on fat-to-muscle ratio in thyroid eye disease

ABSTRACT Purpose To explore if orbital fat-to-muscle ratio (FMR) is predictive of whether surgical decompression or teprotumumab leads to greater proptosis reduction in thyroid eye disease (TED). Methods A single-center retrospective cohort study comparing surgical decompression with teprotumumab according to FMR. All TED patients completing an 8-dose course of teprotumumab between January 2020 and September 2022 and all patients undergoing bony orbital decompression from January 2017 to December 2019 were included. Subjects were excluded if they were <18 years, received both surgical decompression and teprotumumab, or lacked orbital imaging. The primary exposure variable was teprotumumab or surgical decompression. The secondary exposure variable was baseline FMR. The primary outcome measure was change in proptosis (mm). Results Thirty-eight patients, mean age 53.5 years (±11.4), were included in the teprotumumab group and 160 patients, mean age 48 years (±11.1), in the surgical group. Average proptosis reduction after teprotumumab and surgical decompression was 3 mm (±1.44) and 5 mm (±1.75), respectively. The FMR was stratified at the median of 1.80. In subjects with FMR < 1.80, teprotumumab showed equivalent proptosis reduction compared to surgical decompression, −0.33 mm (SE 1.32) p = .802. In subjects with FMR ≥ 1.80, surgical decompression led to significantly more proptosis reduction than teprotumumab, 3.01 mm (SE 0.54), p < .001. Conclusions Baseline FMR can be used to counsel patients as to proptosis reduction with teprotumumab versus surgery. Subjects with low FMR obtain comparable proptosis reduction with teprotumumab or surgery, whereas high FMR is associated with more significant proptosis reduction following surgery over teprotumumab.

Factors Predicting the Success of Combined Orbital Decompression and Strabismus Surgery in Thyroid-Associated Orbitopathy.

To evaluate the safety and efficacy of orbital decompression combined with strabismus surgery in thyroid-associated orbitopathy (TAO) and identify factors leading to surgical success. A retrospective comparative case series was conducted on 52 patients who were treated with combined orbital decompression and strabismus surgery. Outcome measurements included perioperative Hertel exophthalmometry and strabismus measurements. Surgical success was defined as binocular single vision (BSV) in the primary and reading positions within 5 prism diopters (PDs). As a result, the average reduction in proptosis was 3.23 mm, with a mean preoperative Hertel measurement of 22.64 mm. Forty-four patients (84.6%) achieved the success criterion and composed the success group. In addition to sex and underlying hyperthyroidism, symmetry of orbitopathy, interocular exophthalmos difference of more than 2 mm, predominant esotropia type, mixed type strabismus, baseline horizontal deviations, baseline vertical deviations, and combination with one-wall decompression surgery were significantly different between the success and failure groups. All complications were mild and temporary. Orbital decompression combined with strabismus surgery produced satisfactory outcomes in selected patients with efficacy and safety. Symmetry between the two eyes with relatively simple strabismus and proptosis ensured surgical success. With experienced surgeons, advanced techniques, and selected patients, this method can serve as an alternative treatment option to minimize the number of surgeries, medical costs and recovery period.

Quantitative Assessment of Orbital Decompression Surgery Using Photogrammetric Stereoimaging.

To evaluate periorbital volume changes, using quantitative photogrammetric stereoimaging, after bony orbital decompression for thyroid eye disease (TED) and compare this to changes in Hertel exophthalmometry. Tissue volumes of the upper and lower eyelids were also assessed independently. Prospective, nonrandomized, nonconsecutive series of patients. Adults with inactive TED who had elected to undergo bony orbital decompression at Moorfields Eye Hospital between 2015 and 2017. With their eyes gently closed, patients with inactive TED underwent imaging using the VECTRA M3 system (Canfields Imaging, Fairfield, NJ), both before and at least 3 months after orbital decompression. Proptosis was assessed by Hertel exophthalmometry. Using the manufacturer's software, changes in periorbital volumes between the preoperative and postoperative images were calculated for the upper and lower eyelids. The Pearson product-moment correlation coefficient was used to assess the linear relationship between changes in periorbital volume and exophthalmometry. Change in stereoimaging volumes of the upper and lower eyelids, and clinical proptosis as measured with Hertel exophthalmometry. Thirty-three patients (11 males; 33%) underwent lateral decompression (39 orbits in 26 patients), lateral decompression with complete ethmoidectomy (3 orbits in 3 patients), combined decompression of lateral wall, medial wall, and medial half of floor (10 orbits in 6 patients), or bilateral lateral, medial, and complete floor decompression (1 patient). The corresponding average volumetric changes were 1.74 ml (median 1.64; range 0.39-3.73 ml), 3.38 ml (median 3.38, range 1.89-4.88 ml), 4.05 ml (median 3.53, range 1.72-6.43 ml), and 4.52 ml (range 4.36-4.68 ml), respectively. Similarly, the average reduction in proptosis was 3.6 mm (median 3; range 1.5-7 mm), 5.3 mm (median 5; range 5-6 mm), 7.4 mm (7.5; range 6-9 mm), and 9 mm (range 8-10 mm). Periorbital volume changes were related to the reduction in exophthalmometry (r = 0.713, p < 0.0001), and reduction of lower eyelid volume did not increase further with more than two-wall decompression. Graded orbital decompression reduces both proptosis and the upper and lower eyelid tissue volumes, the eyelid changes being likely to influence decisions about future restorative eyelid surgery. The significant changes in eyelid profiles underlines the established principle of thyroid periocular rehabilitation, namely decompression, then strabismus surgery, and finally eyelid surgery.

Reply re: "Stereotactic Navigation Improves Outcomes of Orbital Decompression Surgery for Thyroid Associated Orbitopathy".

PURPOSE To test whether intraoperative stereotactic navigation during orbital decompression surgery resulted in quantifiable surgical benefit. METHODS This retrospective cohort study examined all consecutive patients who underwent primary orbital decompression surgery for thyroid associated orbitopathy performed by a single surgeon (A.K.) during the periods of 2012-2014 (non-navigated), and 2017-2018 (navigated). The study was HIPAA-compliant, was approved by the Institutional Review Board, and adhered to the tenets of the Helsinki declaration. Recorded parameters included patient age, sex, race, decompression technique (side of operation and walls decompressed), estimated blood loss (EBL), intraoperative complications, times that patient entered and exited the operating room (OR), times of surgical incision and dressing completion, pre- and postoperative best corrected visual acuity (BCVA), proptosis, diplopia, postoperative change in strabismus deviation, and need for subsequent strabismus surgery. Recorded times were used to calculate operating time (initial incision to dressing) and maintenance time (time between OR entry and initial incision and time between dressings and OR exit). The total maintenance time was averaged over total number of operations. Student t test was used to compare surgical times, maintenance times, EBL, and proptosis reduction. Fisher exact test was used to compare BCVA change, strabismus deviation change, resolution or onset of diplopia, and need for corrective strabismus surgery. RESULTS Twenty-two patients underwent primary orbital decompression surgery without navigation, and 23 patients underwent navigation-guided primary orbital decompression surgery. There were no intraoperative complications in either group. The average operative time was shorter in the navigated group for a unilateral balanced decompression (n = 10 vs. 19; 125.8 ± 13.6 vs. 141.3 ± 19.4 min; p-value = 0.019), and a unilateral lateral wall only decompression (n = 13 vs. 3; 80.5 ± 12.8 vs. 93.0 ± 6.1 min; p-value = 0.041). The average maintenance time per surgery was not significantly different between the non-navigated group (51.3 ± 12.7 min) and the navigated group (50.5 ± 6.4 min). There was no significant difference between the navigated and non-navigated groups in average EBL per surgery. There was no significant difference in BCVA change. Average proptosis reduction was larger in the navigated group, but this was not significant. There was a significantly lower proportion of patients who required corrective strabismus surgery following decompression in the navigated group than in the non-navigated group (39.1% vs. 77.3%, p-value = 0.012). CONCLUSIONS Intraoperative stereotactic navigation during orbital decompression surgery has the potential to provide the surgeon with superior spatial awareness to improve patient outcomes. This study found that use of intraoperative navigation reduced operative time (even without factoring in a resident teaching component) while also reducing the need for subsequent strabismus surgery. This study is limited by its size but illustrates that use of intraoperative navigation guidance has substantive benefits in orbital decompression surgery.

Graded transantral orbital decompression outcomes in stable thyroid eye disease: a series of 47 orbits

ABSTRACT Purpose: To provide outcome data for transantral orbital decompression for functional and aesthetic rehabilitation for exophthalmos in stable thyroid eye disease (TED). Methods: Retrospective, non-comparative chart review of consecutive TED patients who underwent primary-graded transantral orbital decompression for exophthalmos by a single surgeon (MAB) between 2005 and 2018. Additional inclusion criteria included follow-up >90 days and no prior orbital surgery. Outcome data collection included millimeters of proptosis reduction, postoperative complications, and patient satisfaction. Results: A total 30 patients (47 orbits) were included. Average reduction in proptosis: 2.8 mm (range 0–9 mm, median 2.5 mm). Post-operatively, new onset diplopia occurred in four patients, V2 numbness in 15 patients (17 orbits), and sinusitis in 2 patients (2 orbits). Phone surveys reached 9/30 patients (14 orbits): cosmetic improvement was reported in 14/14 orbits, relief of orbital ache reported in 10/10 orbits with pre-operative ache, relief of dry eye in 8/13 orbits with preoperative dry eye, and overall satisfaction score: 8.9/10 (range 4–10, median 10). Conclusions: Graded transantral orbital decompression is a viable option for stable TED patients with orbital ache, exophthalmos, and exposure keratopathy, resulting in a high degree of functional and cosmetic satisfaction in our cohort.

Stereotactic Navigation Improves Outcomes of Orbital Decompression Surgery for Thyroid Associated Orbitopathy.

To test whether intraoperative stereotactic navigation during orbital decompression surgery resulted in quantifiable surgical benefit. This retrospective cohort study examined all consecutive patients who underwent primary orbital decompression surgery for thyroid associated orbitopathy performed by a single surgeon (A.K.) during the periods of 2012-2014 (non-navigated), and 2017-2018 (navigated). The study was HIPAA-compliant, was approved by the Institutional Review Board, and adhered to the tenets of the Helsinki declaration. Recorded parameters included patient age, sex, race, decompression technique (side of operation and walls decompressed), estimated blood loss (EBL), intraoperative complications, times that patient entered and exited the operating room (OR), times of surgical incision and dressing completion, pre- and postoperative best corrected visual acuity (BCVA), proptosis, diplopia, postoperative change in strabismus deviation, and need for subsequent strabismus surgery. Recorded times were used to calculate operating time (initial incision to dressing) and maintenance time (time between OR entry and initial incision and time between dressings and OR exit). The total maintenance time was averaged over total number of operations. Student t test was used to compare surgical times, maintenance times, EBL, and proptosis reduction. Fisher exact test was used to compare BCVA change, strabismus deviation change, resolution or onset of diplopia, and need for corrective strabismus surgery. Twenty-two patients underwent primary orbital decompression surgery without navigation, and 23 patients underwent navigation-guided primary orbital decompression surgery. There were no intraoperative complications in either group. The average operative time was shorter in the navigated group for a unilateral balanced decompression (n = 10 vs. 19; 125.8 ± 13.6 vs. 141.3 ± 19.4 min; p-value = 0.019), and a unilateral lateral wall only decompression (n = 13 vs. 3; 80.5 ± 12.8 vs. 93.0 ± 6.1 min; p-value = 0.041). The average maintenance time per surgery was not significantly different between the non-navigated group (51.3 ± 12.7 min) and the navigated group (50.5 ± 6.4 min). There was no significant difference between the navigated and non-navigated groups in average EBL per surgery. There was no significant difference in BCVA change. Average proptosis reduction was larger in the navigated group, but this was not significant. There was a significantly lower proportion of patients who required corrective strabismus surgery following decompression in the navigated group than in the non-navigated group (39.1% vs. 77.3%, p-value = 0.012). Intraoperative stereotactic navigation during orbital decompression surgery has the potential to provide the surgeon with superior spatial awareness to improve patient outcomes. This study found that use of intraoperative navigation reduced operative time (even without factoring in a resident teaching component) while also reducing the need for subsequent strabismus surgery. This study is limited by its size but illustrates that use of intraoperative navigation guidance has substantive benefits in orbital decompression surgery.

Endoscopic orbital decompression for proptosis in non-thyroid eye disease.

Orbital decompression is an established surgical treatment option for a range of orbital conditions. We report the outcomes of endonasal decompression to recess the globe for conditions and pathologies other than thyroid eye disease. This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to non-thyroid eye disease orbital pathologies. The procedures were carried out by oculoplastic surgeons across two hospital sites between January 2011 and July 2018. Information collected includes patient demographics, diagnosis, surgical details, pre- and postoperative clinical findings (including visual acuity, exophthalmometry readings, intraocular pressure, ocular motility and diplopia), complications and further treatment. There were seven cases of endoscopic decompression, each due to a different pathology. The reasons for decompression were proptosis secondary to optic nerve sheath meningioma (1); sphenoid wing meningioma (1); idiopathic myositis (1); axial myopia (1); chronic third nerve palsy (1); to protuberant keratoprosthesis (1); and Crouzon syndrome with corneal exposure (1). Visual acuity remained stable or improved in all patients postoperatively. There was an average reduction in proptosis of 3.5 ± 1.4mm (standard deviation - SD). Ocular motility remained stable in 100% (7/7). There were no intraoperative or postoperative complications, including no new cases of postoperative diplopia. Endoscopic orbital decompression can be performed for patients with proptosis associated with a large globe, facial dysplasia or medial and infero-medial orbital lesions.

Endoscopic Orbital Decompression by Oculoplastic Surgeons for Proptosis in Thyroid Eye Disease.

Orbital decompression is an established surgical treatment option for a range of orbital conditions. Traditionally, Ear, Nose and Throat surgeons have adopted the endoscopic route while ophthalmologists operate via an external approach. The authors report the outcomes of endonasal decompression performed by oculoplastic surgeons experienced in endonasal techniques. This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to thyroid eye disease across 2 hospital sites between January 2011 and July 2018. Inclusion criteria were patients who had endoscopic decompression for proptosis in inactive thyroid eye disease or active disease without dysthyroid optic neuropathy. Information collected includes patient demographics, diagnosis, surgical details, preoperative and postoperative clinical findings (including, visual acuity, color vision, exophthalmometry readings, palpebral aperture, intraocular pressure, ocular motility, diplopia, and visual field), complications, and further treatment. There were 70 cases of endoscopic decompression. The majority of patients had endoscopic medial and posterior medial wall/floor decompression (44.3%; 31/70 cases). Visual acuity remained stable in 98.6% (69/70). There was an average reduction in proptosis of 3.5 ± 1.2 mm (standard deviation [SD]) in the endoscopic medial wall only group, 3.9 ± 0.9 mm (SD) in endoscopic medial wall and posterior medial portion of the floor group, and 7.6 ± 2.1 mm (SD) in the 3-wall decompression group. Motility improved in 11.4% (8/70) and worsened in 2.9% (2/70). There were no significant intraoperative or postoperative complications associated with endoscopic surgery. Oculoplastic surgeons experienced in endonasal techniques can perform endoscopic orbital decompression with outcomes comparable to the literature.The authors report the outcomes of a series of endonasal orbital decompression carried out by oculoplastic surgeons.

Comparison of rim-sparing versus rim-removal techniques in deep lateral wall orbital decompression for Graves’ orbitopathy

The aim of this study was to compare the surgical outcomes of deep lateral orbital decompression using the rim-sparing technique versus the rim-removal technique in Graves’ orbitopathy (GO). A retrospective cohort study of 75 orbits in 50 patients with GO was performed. Proptosis, best corrected visual acuity (BCVA), intraocular pressure (IOP), upper and lower lid margin to reflex distances (MRD-1 and MRD-2, respectively), diplopia, ocular restriction, and GO quality of life (GO-QOL) questionnaire results were analyzed pre- and postoperatively. The average proptosis reduction ranged from 3.5mm to 6.7mm with the rim-sparing technique and from 3.6mm to 6.7mm with the rim-removal technique (P>0.05). All orbits with dysthyroid optic neuropathy in the rim-sparing group and 87.5% of such orbits in the rim-removal group showed improved BCVA (P=0.321). Reductions in IOP, MRD-1, and MRD-2 were observed with both techniques. Patients in the rim-sparing group had greater improvements in GO-QOL appearance score (P=0.043). In conclusion, rim-sparing orbital decompression provides efficacious outcomes with greater improvements in patient quality of life than the rim-removal technique. The rim-sparing technique should be considered as a preferable option because it preserves the integrity of the lateral vertical maxillary buttress and bony protection for the orbital contents.

Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease

Rim-off lateral wall decompression may be associated with functional and cosmetic deficit. Our objective, therefore, was to describe the functional and cosmetic results of deep lateral orbital decompression with and without anterior rim repositioning for thyroid eye disease. In this retrospective comparative case series all consecutive thyroid eye disease patients who underwent deep lateral wall decompression at the Royal Victorian Eye and Ear Hospital between 1990-2007 and the Goldschleger Eye Institute, Sheba Medical Center between 2008-2011 were included. Patients were divided into two groups: the "rim-on" group in which the anterior lateral orbital rim was repositioned and the "rim-off" group in which it was left off. Main outcome measures were: proptosis reduction, postoperative oscillopsia and diplopia, presence of visible or palpable lateral orbit depression. One hundred and twelve patients who underwent 186 orbital decompressions were included in the final analysis. The average proptosis reduction for two- and three-wall decompressions ranged between 4.6-4.9mm in the rim-on and 4.6-5.7mm in the rim-off group respectively. The prevalence of postoperative oscillopsia was similar in both groups. The preoperative diplopia worsened in 17 patients (32.1%) in the rim-on group and in seven patients (12.3%) in the rim-off group (P = .02, chi-square test). None of the patients developed visible or palpable lateral orbit depression. Deep lateral orbital decompression without anterior rim repositioning may be an effective approach to enhance functional and cosmetic outcomes in thyroid eye disease patients without increasing the risk of lateral wall depression or postoperative oscillopsia.

The importance of rim removal in deep lateral orbital wall decompression

Purpose:To evaluate the surgical outcome of deep lateral orbital decompression with or without rim removal.Design:Retrospective case series.Methods:Thirty-two patients (47 orbits) with Graves’ orbitopathy who underwent simple deep lateral decompression or balanced lateral plus medial decompression. Of the 14 patients (24 orbits) who underwent simple deep lateral decompression, 8 (13 orbits) had temporary rim removal and in 6 (11 orbits) the rim was left intact. Of the 18 patients (23 orbits) who underwent a balanced decompression, 7 (9 orbits) had temporary rim removal and in 11 (14 orbits) the rim was left intact. The amount of postoperative reduction in proptosis was compared among these four groups.Results:The average reduction in proptosis in the simple deep lateral decompression group was 5.73 mm (range: 4.0–8.0 mm) in the rim removal group and 4.09 mm (range: 2.5–6.0 mm) in the intact rim group (P = 0.005). The average reduction in proptosis in the balanced decompression group was 6.39 mm (range: 5.0–8.5 mm) in the rim removal group and 5.07 mm (range: 3.0–8.0 mm) in the intact rim group (P = 0.039). There was no statistically significant difference in proptosis reduction between the simple deep lateral decompression with rim removal group and the balanced decompression with an intact rim group (P = 0.220).Conclusion:The rim removal approach allows a more effective decompression than the intact rim approach. Simple deep lateral decompression with rim removal approach has a similar effect to balanced decompression through an intact rim.

Ultrasonic Bone Removal Versus High-Speed Burring for Lateral Orbital Decompression: Comparison of Surgical Outcomes for the Treatment of Thyroid Eye Disease

To evaluate the efficacy of ultrasonic bone removal during lateral orbital decompression for thyroid eye disease. Retrospective, comparative, interventional case series of lateral orbital decompressions performed by the senior author for thyroid eye disease between July 2005 and July 2008. Patients were excluded if they had other coexisting orbital conditions or concurrent decompression of other orbital walls. Primary outcome measures included visual acuity, proptosis, lagophthalmos, eyelid retraction, and exposure keratopathy. Thirty-six consecutive lateral orbital decompressions performed by the senior author were reviewed. The Sonopet Omni ultrasonic surgical aspirator was used to remove the lateral wall in 18 cases, and a high-speed drill with a cutting burr was used in the other 18 cases. There was no significant difference between the groups in postoperative visual acuity, proptosis reduction, lagophthalmos, eyelid retraction, exposure keratopathy, or surgical complications. The average reduction in proptosis was 3.9 mm (range, 1-6.5 mm) in the Sonopet group and 4.0 mm (range, 1-6 mm) in the drill group (p = 0.86). In our series, the average surgical case time was slightly shorter in the Sonopet group than in the drill group (104 vs. 118 minutes, p = 0.032). Ultrasonic bone removal is a safe and effective alternative to high-speed burring during lateral orbital decompression for thyroid eye disease.

Surgical treatment of dysthyroid orbitopathy

Objectives Orbital decompression for dysthyroid orbitopathy may be performed by open or transnasal endoscopic approaches; however, criteria for the selection of the appropriate surgical technique have not been well-defined. Our goal was to compare the surgical outcomes of orbital decompression techniques employed by the otolaryngology and ophthalmology services at a single institution, so as to clarify the indications and develop a rationale for optimal management. Study Design Case series with chart review. Setting Tertiary care academic medical center. Subjects and Methods Orbital decompressions on 112 orbits of 69 patients from 2001 to 2008 at a tertiary care academic medical center. Results The majority (83%) of orbital decompressions were performed primarily for proptosis, whereas the remainder was indicated for dysthyroid optic neuropathy. Maximum reduction of proptosis was achieved with an endoscopic medial and inferior orbital wall decompression combined with a lateral orbitotomy with fat removal. The average reduction in proptosis was 7.4 mm ± 2.3 mm (primary surgery for proptosis). The endoscopic approach alone provided the least average proptosis reduction but was highly successful in the treatment of dysthyroid optic neuropathy. Conclusions A three-wall decompression using a combined endoscopic and external approach provides the greatest amount of decompression. The endoscopic approach as a single modality is best suited for patients with mild proptosis and for patients with dysthyroid optic neuropathy. Cooperation between otolaryngology and ophthalmology achieves the best care for patients with thyroid eye disease who require surgical treatment.

The application of stereotactic navigation surgery to orbital decompression for thyroid-associated orbitopathy

To describe the application of stereotactic guidance, its preoperative workup, and limitations, if any, during orbital decompression surgery of the lateral orbital wall for thyroid-associated orbitopathy (TAO). Case-controlled series of seven patients who underwent stereotactic-guided surgical navigation during external approach balanced orbital decompression with maximal debulking of the lateral wall. A progressive increase in debulking of the greater wing of sphenoid and exposure of dura was noted in the series. The average proptosis reduction was 9.36 mm. No complications were encountered during any of the cases, nor was there any new onset postoperative diplopia. In all cases, exposure of dura was planned and did not present as a surprise. Stereotactic setup added 10 min to preparation time. Stereotactic guidance improves anatomic localization and precision during orbital decompression, increasing confidence, and reducing surgical stress. The ability to accurately determine the maximal limits of decompression real time, while confirming depth of bone removal, offers the possibility of reduced risk of iatrogenic injury. Stereotactic navigation allows for improved intraoperative localization that may improve the ability to maximally decompress the lateral wall, including the zygoma, orbital roof, and trigone, and extending towards the optic nerve with exposure of dura through smaller incisions.

Outcome of orbital decompression for disfiguring proptosis in patients with Graves’ orbitopathy using various surgical procedures

Aim:To compare the outcome of various surgical approaches of orbital decompression in patients with Graves’ orbitopathy (GO) receiving surgery for disfiguring proptosis.Method:Data forms and questionnaires from consecutive, euthyroid patients with...

Postural visual obscurations in patients with inactive thyroid eye disease; a variant of ‘hydraulic’ disease

This investigation newly describes the characteristics and treatment for a group of patients with inactive thyroid eye disease who presented with recurrent transient visual obscuration, generally related to sudden changes in posture. A retrospective case-note review of an unmatched case series. Clinical records were reviewed for patients with thyroid eye disease, presenting to the Orbital Clinic at Moorfields Eye Hospital with recurrent transient visual obscuration. All patients underwent orbital decompression and the response to this, and other, treatment was reviewed. Six patients (five female) presented to the Orbital Clinic, between the ages of 43 and 66 years (mean 54.7; median 52 years), with recurrent visual obscurations related to postural changes. Transient obscurations had been noted for between 3 weeks and 2 months, the patients having had symptoms of underlying thyroid eye disease for between 6 and 18 months. Five patients had diabetes for between 2 and 45 years, four being controlled with insulin and one with metformin. All patients had increased orbital tension on clinical assessment, intraocular pressures were raised in 5/6, and the optic disc in affected eyes was markedly swollen (with bilateral choroidal folds in two patients). Hertel exophthalmometry ranged from 22 to 27 mm, and there was a global reduction in ocular ductions in all. Bilateral orbital decompression was performed in all patients, although sequentially in one patient: 4/6 patients had three-wall decompression with an average proptosis reduction of 5.8 mm (range 2-8 mm; eight orbits) and 2/6 had decompression of the medial wall and floor alone (mean reduction 6.8 mm, range 5-8 mm; four orbits). In all patients, there was an almost immediate cessation of obscurations, together with a subjective and objective improvement in various visual functions. Optic disc swelling resolved over a few weeks after surgery. The 'hydraulic' variant of thyroid eye disease-characterised by high orbital apex pressures, with secondarily raised episcleral venous and intraocular pressures-may be linked with certain orbital shapes, such as that of Asians. This variant can present with recurrent visual obscuration associated with transient postural hypotension, especially in diabetics-this possibly being due to a microvasculopathy of the orbital or optic nerve circulation.

Endoscopic Orbital Decompression for Graves’ Ophthalmopathy

Graves' ophthalmopathy generates a volume excess for the orbital cavity, which may produce proptosis, pain, exposure keratitis, diplopia, and optic neuropathy. Endoscopic orbital decompression expands the orbital cavity into the ethmoid cavity and medial maxillary sinus. This retrospective study documents the outcomes after endoscopic orbital decompression for patients with Graves' ophthalmopathy. Data collected included demographic information, symptom resolution, complications related to the surgery, reduction in proptosis, subsequent need for eye muscle surgery, and hospital length of stay. Between July 1989 and April 2003, 62 patients were referred for endoscopic orbital decompression (often unilateral). Three patients refused use of their medical records for research purposes. Seventy percent were women; the average age of the study group was 49 years. Preoperatively, 63% of the patients had diplopia and optic neuropathy was noted in 27%. Two patients had a cerebrospinal fluid leak identified and managed during the decompression. No postoperative leaks occurred. Twenty-five percent of patients did not require eye muscle surgery. Forty-eight percent of the patients underwent one procedure to manage diplopia. The average reduction in proptosis was 2.5 mm. Fifty-four percent were managed as an outpatient and 27% underwent a 23-hour observation period. This data supports the safety, efficiency, and efficacy of endoscopic orbital decompression for unilateral and bilateral Graves' ophthalmopathy. Eye muscle surgery frequently will be required to manage diplopia after decompression.

Transantral orbital decompression for Graves' disease.

Seventy-five patients with Graves' disease have been treated by transantral orbital decompression. In the first post-operative month the average reduction in proptosis was 3 mm. In the years following the operation this reduction increased to an average of 4.5 mm. In 32% of the patients without diplopia before surgery, the diplopia that developed afterwards did not disappear, 83% of them were successfully treated by extraocular muscle surgery. Seventy per cent of the patients experienced immediate post-operative improvement of visual acuity. Only three patients remained with anaesthesia of the infra-orbital nerve. A total of 65% of the patients found the operation procedure beneficial while 76% were satisfied with the ophthalmological result. We conclude, that transantral orbital decompression, though with moderate morbidity, gives good results in patients with the orbital complications of Graves' disease.

Results of Transantral Orbital Decompression in 428 Patients With Severe Graves' Ophthalmopathy

We reviewed records from 428 consecutive patients with severe Graves' ophthalmopathy to determine early and late results after transantral orbital decompression. Optic neuropathy was present in 217 (50.7%) patients. Post-operatively, 402 (89%) of 453 eyes with preoperative visual acuity worse than 20/20 improved or remained the same. Visual field scotomas improved or resolved in 245 (91%) of 269 eyes tested pre- and postoperatively. Preoperative papilledema resolved or improved in 99 (94%) of 105 eyes, and preoperative exposure keratitis improved or resolved in 178 (92%) of 195 eyes. Average proptosis reduction was 4.7 mm. Postoperatively, new diplopia developed in 74 (64%) of 116 patients who had no diplopia before orbital decompression, although 300 patients ultimately had strabismus surgery. At late follow-up (N = 293 patients), 226 (77%) had single vision and 44 (15%) had correction with prism. Complications included sinusitis (18 patients), lower eyelid entropion (38 patients), numb lip (23 patients), cerebrospinal fluid leaks (15 patients), and one frontal lobe hematoma (one patient). The average duration of follow-up was 8.7 years. Transantral orbital decompression effectively reduces proptosis and usually corrects optic neuropathy. In other circumstances, the benefits achieved and the side effects incurred must be carefully balanced for each patient before transantral orbital decompression is considered.