Balanced Orbital Decompression Research Articles

The Outcomes of Balanced Orbital Decompression for Dysthyroid Optic Neuropathy: Focusing on Choroiretinal Folds with and without Optic Disc Edema.

To assess the outcomes of balanced orbital decompression for chorioretinal folds (CRFs) with and without optic disc edema (ODE) in dysthyroid optic neuropathy (DON). A retrospective, interventional study was performed at Sun Yat-sen Memorial Hospital from April 2018 to November 2021. We collected the medical records of 13 patients (24 eyes) with DON and CRFs. Then, we divided them into the ODE group (15 eyes, 62.5%) and the non-ODE group (NODE group, 9 eyes, 37.5%). The valid ophthalmic examination parameters of 8 eyes in each group after balanced orbital decompression were compared at the 6-month follow-up. The mean best corrected visual acuity (BCVA, 0.29 ± 0.27) and visual field-mean deviation (VF-MD, -6.55 ± 3.71 dB) in the ODE group were significantly worse than those in the NODE group (0.06 ± 0.15 and -3.49 ± 1.56 dB; all p < 0.01). Six months after orbital decompression, all parameters were found to have significantly improved in both groups, including BCVA and VF-MD (all p < 0.05). Moreover, the improvement amplitude of BCVA (p = 0.020) in the ODE group was significantly greater than that in the NODE group. There was no difference in BCVA between the ODE group (0.13 ± 0.19) and the NODE group (0.10 ± 0.13). The disc edema of all eyes (8/8 eyes, 100%) in the ODE group was completely mitigated after orbital decompression. The CRF resolution of 2 eyes (2/8 eyes, 25%) in the ODE group and no eyes in the NODE group was mitigated. Balanced orbital decompression can significantly improve visual functions and eliminate optic disc edema in DON patients, whether CRF relieves or not.

Improvement of Orbital Intramuscular Hemangioma Following Delivery.

A 34-year-old primigravida woman at 26-week gestation presented with gradually progressive right eye proptosis since the early stage of pregnancy. On the first examination, the right eye had 7 mm proptosis, compared with the left eye. Magnetic resonance images demonstrated enlarged inferior and medial recti muscles with tendon involvement. The results of pathological examination of a specimen harvested from the medial rectus muscle lesion 1 month after the delivery corresponded to an intramuscular cavernous hemangioma. Three months after biopsy, the right eye had a 3-mm reduction in proptosis, and magnetic resonance images showed slight reduction in size of the medial rectus muscle lesion. The maximum diameter of the right medial rectus muscle measured on axial images decreased from 13.13 to 9.38 mm. The patient underwent balanced orbital decompression 8 months after the biopsy. At 9-month post-decompression period, the right eye had 3.5-mm proptosis, and the vision was stable.

Transnasal endoscopic orbital decompression in the algorithm of surgical treatment of endocrine ophthalmopathy

To develop an algorithm for the use of transnasal endoscopic orbital decompression (TEOD) in endocrine ophthalmopathy (EOP). The results of 225 TEODs are analyzed. 139 patients with EOP were under observation, who were divided into two groups. Group 1 included 64 patients with an inactive form of EOP, group 2 included 75 patients with EOP complicated by optical neuropathy. Group 2 patients are divided into three subgroups. In the first subgroup there were 36 patients who underwent only TEDO, in the second subgroup there were 17 patients who underwent simultaneous TEOD and lateral bone orbital decompression (LBOD), in the third subgroup there were 22 patients who underwent TEOD and with an interval of 7-14 days - LBOD. After surgery, visual acuity, visual fields and color perception, regression of exophthalmos, as well as the presence of strabismus and diplopia were evaluated. In patients of group 1 (64 patients, 104 TEODs), the average regression rate of exophthalmos was 5.49±1.22. Diplopia was observed in 23 (36%) patients, strabismus - in 18 (28%) patients. The transient nature of diplopia and strabismus was noted in 11% of cases. Patients of the first subgroup showed an increase in visual acuity from 0.4±0.28 to 0.7±0.2 (p<0.05). Strabismus and diplopia were observed in 54% of cases. In the subgroup with step-by-step performed TEOD and LBOD, the increase in visual acuity was more pronounced and amounted to 74% (from 0.78±0.71 to 0.2±0.3 according to LogMAR, p<0.05), postoperative strabismus and diplopia remained at a high level - 40% of the number of surgical operations performed. The best results of improving visual functions were obtained in patients of the second subgroup with simultaneous TEOD and LBOD (balanced orbital decompression): the increase in visual acuity was 79% (from 0.57±0.47 to 0.12±0.2 according to LogMAR, p<0.05). In patients of this subgroup, strabismus develops less frequently (22% of the number of operated orbits). Transnasal endoscopic decompression of the orbit in the inactive form of the disease is indicated for exophthalmos of more than 4-8 mm. In optical neuropathy, transnasal endoscopic orbital decompression is indicated regardless of the initial visual acuity of the patient and should be supplemented with lateral bone orbital decompression with visual acuity below 0.1. The obtained results allowed us to form an algorithm for surgical treatment of patients with endocrine ophthalmopathy and optical neuropathy using transnasal endoscopic orbital decompression as a surgical intervention.

Orbital decompression for thyroid eye disease: surgical treatment outcomes in endocrinological assessment.

Surgical orbital decompression involves removal of one or more of the orbital bony walls in order to gain space for overgrown muscles and adipose tissue, which results in a reduction in pressure on the eye. This observational study aims to perform an endocrinological assessment of the surgical treatment outcomes of thyroid eye disease (TED) patients before and after orbital decompression. This retrospective study included 51 TED patients (84 orbits) who underwent endoscopic orbital decompression (EOD) or balanced orbital decompression. The effect of surgical treatment was evaluated via the clinical activity score (CAS), and modified NOSPECS and EUGOGO classification. Before orbital decompression, the average CAS index was 3.83 ± 1.86 points, whereas the modified NOSPECS score was 3.31 ± 0.97 points. After surgical intervention, the values were as follows: 2.07 ± 1.84 points for CAS and 2.5 ± 0.97 points for modified NOSPECS. The EUGOGO classification before surgery showed that Graves' orbitopathy (GO) was mild, moderate to severe, and sight-threatening in 1%, 25%, and 74% of the orbits, respectively. After surgery, GO was determined to be mild, moderate to severe, and sight-threatening in 24%, 57%, and 19% of the orbits, respectively. Statistical analysis was performed using the R 3.6.2 statistical environment. Inference about the statistical reliability of the parameter was made by calculating the mean and the 95% credibility interval (CI). The severity of TED decreased after orbital decompression. The CAS, and modified NOSPECS and EUGOGO classification showed a statistically reliable postoperative reduction. The drop in activity of the disease after orbital surgery requires careful follow-up.

Proposing a surgical algorithm for graduated orbital decompression in patients with Graves\u2019 orbitopathy

PurposeTo determine the outcome after orbital decompression using a graduated technique, adapting the surgical technique according to individual patients’ disease characteristics.MethodsWe retrospectively examined the postoperative outcome in patients treated with a graduated balanced orbital decompression regarding reduction of proptosis, new onset diplopia and improvement in visual function. 542 patients (1018 orbits) were treated between 2012 and 2020 and included in the study. Clinical examinations including visual acuity, exophthalmometry (Hertel) and orthoptic evaluation were performed preoperatively and at minimum 6 weeks postoperatively. Mean follow-up was 22.9 weeks.ResultsMean proptosis values have significantly decreased after surgery (p < 0.01). In 83.3% of the patients Hertel measurement normalized (≤ 18 mm) after surgery, New onset diplopia within 20° of primary position occurred in 33.0% of patients, of whom 16.0% had preoperative double vision in secondary gaze. Patients suffering from dysthyroid optic neuropathy (DON) had a significant increase in visual acuity (p < 0.01).ConclusionWe demonstrated that individually adapted graduated orbital decompression successfully improves key disease parameters of Graves’ orbitopathy with low morbidity.

A randomized comparative study of inferomedial vs. balanced orbital decompression. Analysis of changes in orbital volume, eyelid parameters, and eyeball position.

The objective of this study is to investigate and compare changes in orbital volume, eyelid parameters, and eyeball position after inferomedial and balanced (medial + deep lateral walls) orbital decompression (OD) in patients with Graves' orbitopathy (GO). Prospective interventional trial. Forty-two patients with inactive GO and clinical indication for OD were randomly assigned to inferomedial or balanced OD. Preoperative and postoperative Hertel exophthalmometry, standardized photography, and computed tomography were used to evaluate upper and lower eyelid margin reflex distances (MRD1 and MRD2), orbital expansion, and changes in eyeball position. Clinical and radiological exophthalmometry improved significantly after OD with both surgical techniques (p < 0.001), but more so with balanced OD (p = 0.02). Concurrent eyeball descent (p = 0.01) and orbital volume expansion (p < 0.001) were observed with both techniques. The mean decompression volume was similar for the medial wall and the lateral wall but significantly smaller for the inferior wall (p < 0.05). Significant correlation coefficients were found for Hertel reduction vs. total decompression volume (p < 0.05). In the multivariate linear analysis, lateral wall decompression volume (LWDV) was predictive of exophthalmos reduction (p < 0.05). The two techniques produced a similar reduction in MRD1 and MRD2. A significant correlation was also found between Hertel reduction and lower lid elevation (p < 0.05). Both inferomedial and balanced OD successfully expanded orbit capacity, but the latter was more efficient at reducing exophthalmos probably due to the inclusion of the lateral wall. Upper and lower eyelid retraction improved after OD, but only lower eyelid elevation was correlated with exophthalmos reduction.

Risk Factors for New Onset Diplopia After Graduated Orbital Decompression.

The aim of the study was to identify possible risk factors for new onset diplopia in 20° of primary position (NOD PP) after orbital decompression. A predisposition for NOD has been established for patients with pre-existing diplopia in secondary gaze; therefore, the authors focused on patients without preoperative diplopia. Retrospective chart review of patients who underwent balanced orbital decompression between 2012 and 2019 due to Graves orbitopathy at the authors' institution. Exclusion criteria were incomplete clinical data set, revision surgery, and medial or lateral decompression only. The following clinical parameters were evaluated preoperatively and postoperatively: Hertel exophthalmometry, objective measurement of misalignment using the prism-cover-test, assessment of the field of binocular single vision, and measurement of monocular excursions. In addition, the diameter of the extraocular eye muscles was measured in all preoperative CT scans. We included 327 patients (612 orbits), 126 patients (242 orbits) had no preoperative diplopia. In patients with NOD PP (34%, n = 43/126), enlargement of the medial rectus muscle and restriction of abduction and elevation were significantly more frequent than in patients with no NOD PP. The degree of exophthalmos decrease positively correlated with postoperative squint angle. We were able to identify the diameter of the medial rectus muscle, restriction of abduction, and elevation as well as an extensive reduction of exophthalmos as risk factors for NOD PP in patients with no preoperative diplopia.

Functional multislice computed tomography of the orbits in diagnosis of incomitant strabismus

To study the value of functional multislice computed tomography (MSCT) of the orbits in examination of patients with complex incomitant strabismus. The study included 34 patients. In 8 (23.5%) out of 34 patients, strabismus occurred as the result of an orbital injury. In some patients, incomitant strabismus was a complication of: retrobulbar injection of drugs (4 cases (11.7%)); endoscopic sinus surgery (6 cases (17.6%)); reconstructive surgery of orbits (7 cases (20.6%)). In 9 cases (26.5%), incomitant strabismus was detected in patients with thyroid eye disease (TED), of them 5 (14.7%) had previously undergone balanced orbital decompression (BOD). All patients underwent functional MSCT of the orbits. Complete absence of the contractile function of the studied muscles was noted in 6 cases with loss of ocular motility in one or several directions of gaze. Contraction of the injured muscle and its fixation in the area of iatrogenic defect in the orbital wall was observed in 6 patients with severe limitation of ocular motility. limitation of the excursion of the inferior and/or medial rectus muscles due to their fixation in the fracture of the orbital wall was observed in 5 patients after orbital trauma. Signs of contracture of the inferior rectus muscle were revealed in 4 cases of strabismus that occurred after retrobulbar anesthesia. Pronounced increase in the lateral dimensions of the extraocular muscles was determined in 4 patients with TED, as well as in patients who had underwent BOD. Displacement of the lateral and medial rectus muscles into the formed bony windows with a change in the vector of their action was observed in patients who had underwent BOD. The data obtained with functional MSCT of the orbits in 34 patients allowed more accurate characterization of the oculomotor disorders and evaluation of the functional state of the extraocular muscles.

Changes in Field of Binocular Single Vision and Ocular Deviation Angle After Balanced Orbital Decompression in Thyroid Eye Disease.

To evaluate influential factors for changes in the binocular single vision (BSV) and ocular deviation angle in the medial direction after bilateral balanced orbital decompression in thyroid eye disease. This retrospective study included 41 patients. The areas of BSV and the angles of medial ocular deviation on the Hess chart were measured. The percentages of pre- and postoperative areas against the normal area (%BSV) and the change in BSV after surgery were calculated. Postoperative change in the angle was calculated by subtraction of the preoperative angle from the postoperative one. Influential factors for the change in BSV and that in the medial deviation angle were evaluated via multivariate linear regression analysis. The maximum cross-sectional area of the medial rectus muscle, preoperative %BSV, and preoperative medial ocular deviation angle were significant factors of change in BSV (adjusted r2 = 0.449, p < 0.001), although age, history of anti-inflammatory treatment, volume of removed orbital fat, findings on CT images, maximum cross-sectional areas of the other rectus muscles, and presence or absence of a periosteal flap did not affect change in BSV (p > 0.050). On the contrary, all variables did not influence postoperative changes in the medial ocular deviation angle (p > 0.050). In balanced orbital decompression, the maximum cross-sectional area of medial rectus muscle, preoperative field of BSV, and medial ocular deviation were significant influential factors for postoperative changes in field of BSV.

First Use of a New Robotic Endoscope Guiding System in Endoscopic Orbital Decompression.

Over the last years, robot-assisted surgery gained in importance in head and neck surgery. In our study, we used a new robotic endoscope guiding system in patients undergoing endoscopic balanced orbital decompression. The aim of the study is to evaluate the feasibility and benefit of a robotic arm in endoscopic orbital surgery. The Medineering Robotic Endoscope Guiding System is a robotic arm designed for holding an endoscope during interventions. An endoscope equipped with a 4K camera was attached at the tip of the robotic arm and placed in the surgical field. The surgeon controlled the movements of the endoscope with foot pedal. Eight patients underwent balanced endoscopic orbital decompression showing typical symptoms of Graves' orbitopathy preoperatively. Balanced decompression was performed via a combined approach transnasally and laterally via a small skin incision. Attaching the endoscope to the robotic guiding system and placing it in the nasal cavity were relatively simple procedures. Setup time was less than 10 minutes. Tool motion and control using the foot pedal were comfortable and adequately precise. Movements of the attached endoscope inside the nose were feasible and allowed 2-hand surgery. The patients did not show any adverse events or complications. The Medineering Robotic Endoscope Guiding System seems to be a safe and effective support in endoscopic skull base surgery especially for orbital decompression, thus allowing 2-hand or even 4-hand settings. To the best of our knowledge, this is the first study describing the successful application of a robotic system in orbital surgery.

Influence of orbital morphology on proptosis reduction and ocular motility after decompression surgery in patients with Graves' orbitopathy.

PurposeOrbital decompression surgery is performed in patients with Graves’ orbitopathy to treat dysthyroid optical neuropathy (DON) and reduce disfiguring proptosis. The intended proptosis reduction can deviate from the postoperative result and changes of motility with consecutive diplopia can occur. We performed a retrospective study to identify anatomical factors in computed tomography (CT), which influence the surgical effect and postoperative ocular motility and diplopia.MethodsPre- and postoperative CT-scans of 125 eyes of 68 patients, who mainly underwent a balanced orbital decompression for disfiguring proptosis (≥18mm Hertel Index), have been analyzed. Proptosis, ductions, misalignment and diplopia were assessed before and after surgery. Medial and lateral orbital wall length, conus angle, depth of ethmoidal sinus, orbital surface, length of medial and orbital defect, depth of tissue prolapse and horizontal muscle diameters were analyzed in CT scans before and after surgery. With linear regression and multivariate analyses these parameters have been correlated with postoperative proptosis, abduction deficit, deviation and binocular single vision (BSV).ResultsProptosis could be reduced by 5.3±2mm. Patients with <5mm proptosis reduction had significantly less often new onset of diplopia compared to patients with >5mm reduction (13% vs. 56%, p = 0.02). Multiple linear regression showed a significant correlation between tissue prolapse and depth of the ethmoidal sinus as well as age (p<0.001, r = 0.71). Proptosis reduction could not be predicted by tissue prolapse, defect length or depth of ethmoidal sinus. The abduction deficit correlated significantly with tissue prolapse and orbital surface area (p<0.001, r = 0.37) but not with the horizontal muscle diameter.ConclusionWe were able to show that orbital morphology influences the outcome of balanced orbital decompression surgery in terms of proptosis reduction and motility. However, the rather low coefficients of correlation show that the surgical outcome cannot be predicted with simple CT measurements, although risk factors for postoperative abduction deficit could be found. Therefore, preoperative planning should consider especially the orbital surface area and depth of ethmoidal sinus. Patients should be informed about the higher risk of diplopia with higher proptosis reduction.

Image- guided balanced orbital decompression for the management of thyroid eye disease: An analysis of outcomes and complications

Background: Thyroid eye disease (TED) commonly presents with proptosis, lid retraction, and diplopia. Multiple surgical techniques have been described to rehabilitate the orbit and to restore vision. Balanced orbital decompression is advocated as a standard surgical technique, and image guidance is encouraged to minimize surgical risks. We evaluated the outcomes of patients who underwent image- guided balanced three walls orbital decompression for TED. Methods: An IRB approved retrospective chart review study was performed on all patients who underwent image-guided balanced orbital decompression between January 2010 and December 2016 at West Virginia University Hospital. Demographics, pre-operative and post-operative clinical data including indications, presence of pre- and post-operative diplopia, and exophthalmometry were abstracted. Results: 169 orbital decompressions in 103 patients were performed. The mean age was 56 years, and the prevalence of pre-operative diplopia was 73%. The incidence of new- onset post-operative diplopia was 5.8%. Among patients who had pre-operative diplopia, 48% had resolution of their diplopia post- operatively. The mean reduction in proptosis was 4.7 mm. No patient experienced intraoperative and/ or postoperative complications. Conclusion: Image-gulded balanced lateral, medial and inferior orbital decompression can result in improvement of visual aculty and resolution of pre- existing .diplopia while allowing for significant reduction in proptosis.

A comparative analysis of piezosurgery and oscillating saw for balanced orbital decompression

ABSTRACTIntroduction: Different minimally invasive surgical approaches to the orbit allow individualized bone resection to reduce proptosis and decompress the optic nerve in patients with Graves’ orbitopathy (GO). This study aims to compare piezosurgery to an oscillating saw used to resect bone from the lateral orbital wall.Methods: In a retrospective study, we analyzed balanced orbital decompressions performed on 174 patients (318 cases) with GO. An oscillating saw was used in 165 cases (saw group) and piezosurgery in 153 cases (piezo group). Peri- and postoperative complications, reduction of proptosis, new onset of diplopia and improvement of visual acuity in cases of pre-operative optic nerve compression were analyzed.Results: We observed no significant differences in the surgical outcome between the two groups. Proptosis reduction was 4.6 mm in the saw group (p < 0.01) and 5.3 mm in the piezo group (p < 0.01). Intraoperative handling of the piezosurgery device was judged superior to the oscillating saw, due to soft tissue conservation and favourable cutting properties. Duration of the surgery did not differ between the groups. No serious adverse events were recorded in both groups.Conclusion: The application of piezosurgery in orbital decompression is more suitable than an oscillation saw due to superior cutting properties such as less damage to surrounding soft tissue or a thinner cutting grove.

Original endoscopic orbital decompression of lateral wall through hairline approach for Graves' ophthalmopathy: an innovation of balanced orbital decompression.

BackgroundOrbital decompression is an important surgical procedure for treatment of Graves’ ophthalmopathy (GO), especially in women. It is reasonable for balanced orbital decompression of the lateral and medial wall. Various surgical approaches, including endoscopic transnasal surgery for medial wall and eye-side skin incision surgery for lateral wall, are being used nowadays, but many of them lack the validity, safety, or cosmetic effect.Patients and methodsEndoscopic orbital decompression of lateral wall through hairline approach and decompression of medial wall via endoscopic transnasal surgery was done to achieve a balanced orbital decompression, aiming to improve the appearance of proptosis and create conditions for possible strabismus and eyelid surgery afterward. From January 29, 2016 to February 14, 2017, this surgery was performed on 41 orbits in 38 patients with GO, all of which were at inactive stage of disease. Just before surgery and at least 3 months after surgery, Hertel’s ophthalmostatometer and computed tomography (CT) were used to check proptosis and questionnaires of GO quality of life (QOL) were completed.FindingsThe postoperative retroversion of eyeball was 4.18±1.11 mm (Hertel’s ophthalmostatometer) and 4.17±1.14 mm (CT method). The patients’ QOL was significantly improved, especially the change in appearance without facial scar. The only postoperative complication was local soft tissue depression at temporal region. Obvious depression occurred in four cases (9.76%), which can be repaired by autologous fat filling.InterpretationThis surgery is effective, safe, and cosmetic. Effective balanced orbital decompression can be achieved by using this original and innovative surgery method. The whole manipulation is safe and controllable under endoscope. The postoperative scar of endoscopic surgery through hairline approach is covered by hair and the anatomic structure of anterior orbit is not impacted.

Lateral Rectus Muscle Expands More Than Medial Rectus Following Maximal Deep Balanced Orbital Decompression.

It has been reported that extraocular muscles can enlarge following orbital decompression in thyroid eye disease. In this article, the authors studied the changes in extraocular muscles size following maximal deep lateral and medial balanced decompression in a large sample of thyroid eye disease patients. Imaging data were reviewed preoperatively and postoperatively. Radiologic proptosis was assessed. Maximal axial muscle width of the medial and lateral recti was measured. Data from 48 consecutive patients (75 orbits) were included. There was a significant increase in the width of both the lateral and medial recti after decompression (p < 0.01). The mean (standard deviation [SD]) change was less for the medial rectus (0.7 mm) than for the lateral (2.7 mm). This difference was significant (p < 0.01). For the lateral rectus, 80% of all decompression surgeries were associated with an increase in width of >1 mm. Mean (SD) proptosis reduction was 8.2 mm (3.4 mm). These results suggest that the extraocular muscles enlarge in the most deep lateral wall decompressions. For decompression as performed in this article, expansion tends to be more commonly found and of a greater magnitude in the lateral rectus compared with medial.

Advances in the management of thyroid eye diseases: An overview.

Thyroid eye disease (TED) remains a notorious ailment for both patients and the treating ophthalmologists. Recent years have witnessed considerable research in the immunopathogenic mechanism of TED that has resulted in an expansion and modification of the available management options. Purpose of this review is to summarise the advances in the management of thyroid ophthalmopathy. A thorough literature search and of the past 10 years web search with words Thyroid ophthalmopathy, recent, advances. Recent VISA classification and new serum markers seem to have potential to give diagnostic as well as therapeutic guidance, gauge treatment response and even identify risk of disease progression. Majority of TED patients can be managed conservatively due to its self-limiting nature but if indicated, still steroids are the preferable medical therapy; however, there is an increasing consensus towards the use of parenteral form as compared to the oral one on account of greater efficacy with lesser side effects. Steroid sparing medications, for example, rituximab, infliximab, etanercept, adalimumab, teprotumumab, tocilizumab, tanshinone, are showing encouraging results and form an area of active research. Radiation therapy remains as an adjunctive modality in active diseases as a nonmedical treatment for TED with some promising data. Surgical intervention may be required in vision threatening conditions or to counteract the sequel of inflammatory phase. Advances in surgical techniques like stereotactic image-guided balanced orbital decompression with endoscopic approach ensure meticulous dissection with minimal trauma.

An update on endoscopic orbital decompression.

Endoscopic orbital decompression is an ever-evolving surgical procedure with modifications as well as new indications for the procedure. The purpose of this review is to update the reader on optimizing patient selection, surgical timing, highlight the latest modifications to surgical technique and to evaluate surgical outcomes that can be achieved. Patient selection, disease pathology, and optimization of technology can lead to improved outcomes. Changes in technology continue to modify surgical techniques and surgical training, working towards decreased surgical complications with improved outcomes. Historically multiple approaches have been used for orbital decompression and this highlights that a balanced orbital decompression usually leads to the best outcome. Orbital decompression has evolved significantly since its inception over 100 years ago. Identifying the right patient, the ideal timing, and the indication for the procedure with utilization of technology can lead to improved outcomes and decreased complications.

The clinical and anatomical rationale of balanced transethmoidal endoscopic and lateral orbital bony decompression in the patients presenting with optic neuropathy caused by thyroid eye disease

The clinical and anatomical rationale of balanced transethmoidal endoscopic and lateral orbital bony decompression in the patients presenting with optic neuropathy caused by thyroid eye disease

Orbital Decompression in the Endoscopic Age: The Modified Inferomedial Orbital Strut.

Postoperative diplopia occurs in up to 45% of patients following orbital decompression for exophthalmos associated with Graves' orbitopathy. We sought to describe outcomes of our balanced orbital decompression strategy that includes the preservation of a modified inferomedial orbital strut (mIOS). Case series with chart review. Academic medical center. A total of 115 consecutive orbital decompressions were performed on 73 patients (42 bilateral) with Graves' orbitopathy. All patients underwent (1) a balanced decompression technique incorporating an endoscopic medial and external lateral decompression and (2) a mIOS technique with preservation of the anterior half of the inferomedial orbital strut. A periorbital periosteal (orbital) sling was utilized in patients (n = 54) without threatened vision loss, proptosis >28 mm, or periorbital disruption to prevent prolapse of the medial rectus muscle. Utilization of the mIOS technique with or without a sling did not adversely affect the reduction in proptosis (5.1 mm with sling vs 5.0 mm without sling; P = .85).The incidence of new-onset postoperative diplopia was 17% (n = 6). The sling was not associated with postoperative diplopia (odds ratio = 0.54, 95% confidence interval: 0.08-3.40, P = .51), while it was associated with resolution of preexisting diplopia (odds ratio = 6.67, 95% confidence interval: 1.06-42.06, P = .04). No intraoperative complications occurred, and no patients suffered a decrement in visual acuity. Balanced orbital decompression utilizing a mIOS in patients with Graves' orbitopathy provides a safe and effective reduction in proptosis with a low rate of new-onset diplopia as compared with historical values. Utilization of an orbital sling may be beneficial in reducing postoperative diplopia in select patients.

Potentials of intraoperative navigation during balanced orbital bony decompression in thyroid eye disease (preliminary results)

Precise instrument localization is of great importance in orbital decompression surgery. Different navigation systems were designed to fulfill this task and gained wide acceptance. to describe principal features and determine advantages of intraoperatively navigated orbital bony decompression. Data on orbital decompression surgery performed with or without intraoperative image guidance is presented. Each time two surgeons were involved - an ophthalmologist (lateral wall decompression) and otolaryngologist (medial wall decompression). In lateral wall decompression, electromagnetic navigation was mostly used to enlarge the created bone window upward and backward, which is particularly challenging in case of bone thinning in the posterior part of its inner rim. In transethmoidal decompression, the image guidance allowed a more extensive removing of the greater sphenoid wing as well as the posterior medial wall where it joins the lateral wall of the sphenoid sinus. As shown by MSCT, lateral rectus muscle dislocation into the created bone window was more significant in navigated procedures. This preliminary data convincingly shows advantages and potentials of the use of electromagnetic navigation in orbital decompression surgery, especially, for optic neuropathy in thyroid eye disease patients.