Orbital Decompression In Graves Research Articles

Preoperative Risk Factors for Proptosis Recurrence After Rehabilitative Orbital Decompression in Graves’ Orbitopathy Patients

PurposeRehabilitative orbital decompression treats disfiguring exophthalmos in Graves’ orbitopathy (GO) patients. This study aimed to identify risk factors associated with the postoperative recurrence of proptosis after orbital decompression. DesignRetrospective case-control study MethodsThis retrospective review included patients with GO who underwent rehabilitative orbital decompression for disfiguring proptosis in an inactive state with a low clinical activity score (0-2) between Jan 2017 and Dec 2020 by a single surgeon. Exophthalmos was measured using a Hertel exophthalmometer, and recurrence was defined as an increase of 2 mm or more after decompression during the follow-up period. The association between preoperative variables and proptosis recurrence was analyzed using multivariable logistic regression. ResultsOf the total 217 patients, eleven (5.1%) developed recurrence of proptosis during the follow-up period (range 3-30, mean 15.6 months). Univariate logistic regression analysis identified thyroid-stimulating hormone receptor antibody (TRAb) and thyroid-stimulating immunoglobulin (TSI) as significant factors for recurrence with age, sex, smoking, disease duration, orbital radiotherapy, and total thyroidectomy history being non-significant. TRAb remained significant in a multivariate logistic regression analysis (OR 1.06; p=0.014). Receiver operating characteristic (ROC) curve analysis revealed an area under curve 0.86 with a sensitivity 90.9% and specificity 82.0% at TRAb level 7.96 IU/L. ConclusionPreoperative TRAb and TSI are valuable markers to predict proptosis recurrence after orbital decompression. These results may help surgeons to decide the optimal timing for orbital decompression to lessen the risk of postoperative recurrence of proptosis.

Endoscope-navigation-assisted orbital decompression for graves' orbitopathy.

To compare the surgical outcomes of endoscope-navigation (EN)-assisted orbital decompression and non-EN-assisted orbital decompression for Graves' orbitopathy (GO) and to assess the potential clinical advantage of EN in orbital decompression surgery. This retrospective cohort study was performed on 227 orbits of 147 GO patients who underwent EN-assisted orbital decompression (185 orbits) or non-EN-assisted orbital decompression (42 orbits). Assessment included proptosis reduction, best-corrected visual acuity (BCVA), diplopia, ocular restriction and surgical complications. The proptosis reduction in the EN group was 0.9 mm greater than that in the non-EN group in the entire cohort (p = 0.004) and 1.0 mm greater than that in the non-EN group in the propensity score matching cohort (p = 0.025) at 2 years postoperatively. In all, 78.2% of orbits with sight-threatening GO in the EN group and 52.6% of orbits in the non-EN group showed BCVA improvement (p = 0.026). The proportion of patients with improvement in diplopia was significantly greater in the EN group than in the non-EN group (p = 0.026). EN offers anatomical localization and deep-seated tissue visualization in orbital decompression and significantly improves the surgical outcomes for GO.

Comparison of the effects of orbital decompression in Graves' ophthalmopathy

Abstract Introduction Graves' disease is an autoimmune disorder. One of the symptoms is an overgrowth of the soft tissues of the orbit. Orbital involvement can cause exophthalmos, diplopia, or vision loss. Treatment strategies include a surgical approach that limits the ailments mentioned above. Decompression can be achieved by reducing the amount of enlarged tissues (fat removal) or increasing the space for enlarged tissues (bone removal). Numerous authors discuss the advantages and disadvantages of various techniques in terms of reducing the exophthalmos, the number and persistence of complications, and the long-term prognosis. Materials and Methods A literature search of PubMed and the Poznan University of Medical Sciences Main Medical Library resources from 1993–2022 was performed. Thirty articles were reviewed with attention to the surgical treatment of Graves' ophthalmopathy. Results The main surgical techniques include fat decompression and bone wall decompression. The results of exophthalmos fat removal are characterized by a significant decrease in proptosis (5.45mm) with a small percentage of newly formed diplopia (9%). Bone reduction in the lateral wall of the orbit shows similar effects: reducing exophthalmos (4.33mm) and the newly formed diplopia, as with fat removal (3.7%). Bone reduction in the medial- lateral wall, medial- inferior- lateral wall, and medial–inferior wall shows a decrease in proptosis ( 4.9 mm, 4.6 mm, 3.77 mm) and a higher percentage of new-onset diplopia (18%, 15%, 28%). Conclusion The smallest amount of newly formed diplopia at the highest proptosis reduction occurs with the self-removal of fat or resection of the lateral orbital wall.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES:To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves’ orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.METHODS:Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.RESULTS:Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).CONCLUSIONS:IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Impact of the ethmoid volume on endoscopic medial wall decompression outcomes in Graves’ orbitopathy

Background Endoscopic orbital decompression is a well-established technique for Graves orbitopathy treatment. Aims Measurement of the ethmoid volume and its correlation with proptosis reduction in patients undergoing endoscopic orbital decompression for Graves’ orbitopathy. Methods We retrospectively reviewed clinical charts of 209 patients (319 orbits) operated by a surgeon at our institution between 1998 and 2019. Results Average age was 46.9 years. About 83.3% of the patients were female, 54.6% were smokers, 93.8% were euthyroid at the time of decompression, 3.8% were hypothyroid and 2.4% were hyperthyroid. About 77.5% of the patients underwent bilateral surgery, the remainder and unilateral. Subsequent stages included strabismus surgery in 22.5% patients, Müllerectomy 37.8%, with or without canthoplasty (14.8 vs. 23%). Mean proptosis reduction was 4.61 mm. Mean ethmoid volume was 5.57 mm3. Ethmoid volume had a moderate positive correlation with proptosis reduction (r s = 0.49, p < .001). Further investigation, statistically significant moderate correlation was found only in the small (SE) and big (BE) ethmoid groups. Conclusion We advise evaluating ethmoid sinus pneumatization on computed tomography before decompression to estimate possible anatomical limitations. Additional wall decompression might be advocated in most severe cases.

Quantification of effective orbital volume and its association with axial length of the eye. A 3D-MRI study

Objective: To measure the effective orbital volume (EOV) from magnetic resonance images, and investigate its relationship with axial length (AL) in those parameters. Methods: Cross-sectional, 3D-MRI study. 54 eyes of 54 patients (25 males) were included in this work. Patient weight, height and head circumference were also measured. Orbital and eyeball volumes were calculated after image segmentation. The difference between those values volume was assessed, estimating the EOV for each eye. Results: Mean eyeball volume was 7.83 ± 2.27 mm3, mean orbital volume 26.81 ± 0.59 mm3 and EOV 21.64 ± 0.19 mm3. The orbital volume was significantly higher in the male group (Wilcoxon signed-rank tests Z=-1.51, p<0.001; Z=-3.57, p<0.001 respectively). EOV was significantly correlated with AL in both males (r=-0.71, p<0.001) and females (r=-0.73, p<0.001), whereas it was also significantly associated with patient height (r=0.261, p=0.03). Associations between EOV and other age, axial and anthropometric characteristics were not statistically significant. Conclusions: Findings of this study could be of valuable importance in various clinical situations in which quantification of orbital volume is needed, such as orbital decompression in Graves' orbitopathy, volume restoration in orbital fractures or other orbital reconstructive surgery. In surgical interventions, clinical relationships should be carefully taken under consideration to avoid iatrogenic injury. Abbreviations: EOV = Effective orbital volume, AL = Axial length, ROI = Region of interest.

Outcome of orbital decompression in graves’ disease using surgical navigation

Outcome of orbital decompression in graves’ disease using surgical navigation

Цветное допплеровское сканирование как метод оценки эффективности декомпрессии орбиты у пациентов с эндокринной офтальмопатией

Цветное допплеровское сканирование как метод оценки эффективности декомпрессии орбиты у пациентов с эндокринной офтальмопатией

Changes in pupillary distance after fat versus bony orbital decompression in Graves’ orbitopathy

ObjectiveTo report changes in pupillary distance (PD) after orbital decompression in patients with Graves’ orbitopathy (GO). DesignRetrospective comparative case series. ParticipantsA total of 59 cases who underwent the same type of orbital decompression on both eyes. MethodsThe medical records of 111 patients who underwent orbital decompression were reviewed retrospectively. Fifty-nine patients without restrictive myopathy who underwent the same procedure on both eyes were included. Patients were divided into the following 3 groups by procedure: only fat decompression (group 1, n = 18), fat and medial wall decompression (group 2, n = 11), and fat, medial, and inferior wall decompression (group 3, n = 30). Preoperative and postoperative PD and proptosis were measured. ResultsPD shortened by 2.9 mm in group 1 (p < 0.001), 2.4 mm in group 2 (p < 0.001), and 3.5 mm in group 3 (p < 0.001). Proptosis improved by 3.5 mm in group 1 (p < 0.001), 3.5 mm in group 2 (p < 0.001), and 4.6 mm in group 3 (p < 0.001). PD changes were not significantly different between the groups (p = 0.328). The change in PD was significantly correlated with the mean amount of proptosis reduction (r = 0.374, p = 0.003). ConclusionsPD shortened after orbital decompression in patients with fat proliferative GO. The change in PD was not related to the type of orbital decompression, but rather to the amount of proptosis reduction. Postoperative changes in PD should be considered when performing orbital decompression.

Trends in Orbital Decompression Techniques of Surveyed American Society of Ophthalmic Plastic and Reconstructive Surgery Members.

To assess current members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) regarding preference in surgical techniques for orbital decompression in Graves' disease. A 10-question web-based, anonymous survey was distributed to oculoplastic surgeons utilizing the ASOPRS listserv. The questions addressed the number of years of experience performing orbital decompression surgery, preferred surgical techniques, and whether orbital decompression was performed in collaboration with an ENT surgeon. Ninety ASOPRS members participated in the study. Most that completed the survey have performed orbital decompression surgery for >15 years. The majority of responders preferred a combined approach of floor and medial wall decompression or balanced lateral and medial wall decompression; only a minority selected a technique limited to 1 wall. Those surgeons who perform fat decompression were more likely to operate in collaboration with ENT. Most surgeons rarely remove the orbital strut, citing risk of worsening diplopia or orbital dystopia except in cases of optic nerve compression or severe proptosis. The most common reason given for performing orbital decompression was exposure keratopathy. The majority of surgeons perform the surgery without ENT involvement, and number of years of experience did not correlate significantly with collaboration with ENT. The majority of surveyed ASOPRS surgeons prefer a combined wall approach over single wall approach to initial orbital decompression. Despite the technological advances made in the field of modern endoscopic surgery, no single approach has been adopted by the ASOPRS community as the gold standard.

Surgical complications in orbital decompression for Graves' orbitopathy.

SUMMARYThe objective of this study is to analyse the complications of orbital decompression in Graves' orbitopathy. The clinical records of 946 patients who had been operated on with orbital decompression for Graves' orbitopathy were reviewed and the intra- and post-operative complications with minimum follow-up of six months were analysed. An extensive review of the literature was carried out to compare results. In the case-series reported here the most frequent complications were: wasting of the temporal region (100%) in patients operated on using a coronal approach; permanent hypoesthesia of V2 (13%) and V1 (8%) in patients operated on with an upper eyelid incision. In only one patient was a total monolateral lesion of V2 reported. The most severe complications consisted in reduction of visual acuity in 5 patients, and CSF leak with cerebral complications in 2 patients, who were operated on with a non-endoscopic endonasal approach. Three patients had intra-operative haemorrhages and 3 patients had post-operative haemorrhages requiring further surgical intervention. The incidence of symptomatic sinusitis/mucoceles was 0.75%. In conclusion, orbital decompression carried out with endoscopic endonasal technique and via transpalpebral accesses appears to be associated with a low incidence of complications. Knowledge of the causes of the possible complications in the different surgical approaches can definitely help to reduce their incidence.

A novel method for measuring outcome of orbital decompression in Graves’ orbitopathy

SummaryTo evaluate the outcome of a graded bone removal rehabilitative infero‐medial orbital decompression in Graves’ orbitopathy (GO) by means of a novel stratified appraisal (NSA) versus the traditional group analysis (TGA). This retrospective follow‐up study included all the orbits decompressed (06/1999–12/2005), at the Department of Ophthalmology University of Amsterdam by one surgeon (L.B.), using the technique under evaluation. NSA assessed or quantified: (i) the invasiveness of surgery, allowing to calculate a mean index of invasiveness per orbit (MIIO) and per patient (MIIP) (25% ≤ values ≤ 100%); (ii) at ≥ 6 months postoperatively surgical targets (desired exophthalmos reduction, improvement of retroocular tension, reduction of peri‐orbital puffiness, resolution of lagophthalmos) were scored as achieved or not allowing to calculate a mean index of targets achieved per orbit (MITAO) and per patient (MITAP) (0 ≤ values ≤ 1); (iii) an index of diplopia (ID) (decompression‐induced / decompressio‐cured diplopia); (iv) demographics and preoperative characteristics were compared after stratification of the included orbits for surgical target; surgical outcomes were assessed after stratification for amount of desired exophthalmos reduction and invasiveness of surgery. TGA examined the entire series as a single homogeneous cohort independently of the different targets and invasiveness of surgery. NSA and TGA were compared and complications noted. 151 orbits of 84 patients (78% female, mean age 45.5 ± 9.7 years) were included. The NSA detected differences among groups within the studied cohort, the overall achievement of surgical targets was high, indices precisely quantified the extent of applied surgery and surgical results, at variance with results obtained with TGA. A negligible complication rate was recorded. The NSA may represent a step forward towards a more comprehensive and accurate evaluation of decompression surgery outcomes.

Electromagnetic Image-Guided Orbital Decompression: Technique, Principles, and Preliminary Experience with 6 Consecutive Cases

Purpose: To assess the feasibility of routine use of electromagnetic image guidance systems in orbital decompression.Methods: Six consecutive patients underwent stereotactic-guided three wall orbital decompression using the novel Fusion ENT Navigation System (Medtronic), a portable and expandable electromagnetic guidance system with multi-instrument tracking capabilities. The system consists of the Medtronic LandmarX System software-enabled computer station, signal generator, field-generating magnet, head-mounted marker coil, and surgical tracking instruments.In preparation for use of the LandmarX/Fusion protocol, all patients underwent preoperative non-contrast CT scan from the superior aspect of the frontal sinuses to the inferior aspect of the maxillary sinuses that includes the nasal tip.Results: The Fusion ENT Navigation System (Medtronic™) was used in 6 patients undergoing maximal 3-wall orbital decompression for Graves’ orbitopthy after a minimum of six months of disease inactivity. Preoperative Hertel exophthalmometry measured more than 27 mm in all patients. The navigation system proved to be no more difficult technically than the traditional orbital decompression approach.Conclusion: Electromagnetic image guidance is a stereotactic surgical navigation system that provides additional intraoperative flexibility in orbital surgery. Electromagnetic image-guidance offers the ability to perform more aggressive orbital decompressions with reduced risk.

Improvement From No Light Perception after Orbital Decompression for Graves' Optic Neuropathy

Improvement From No Light Perception after Orbital Decompression for Graves' Optic Neuropathy

Balanced orbital decompression in Graves' orbitopathy

Graves' ophthalmopathy is an inflammatory disease of the orbital tissues that especially affects extraocular muscles and fat. Orbital decompression is performed to reverse compressive neuropathy and reduce proptosis. The most widely used technique is the inferomedial orbital decompression, which may provide an insufficient decompression in patients with serious proptosis. A balanced decompression of the medial and lateral orbital walls provides >5 mm of proptosis reduction with a low occurrence of postoperative diplopia.

Rehabilitative orbital decompression for Graves’ orbitopathy: risk factors influencing the new onset of diplopia in primary gaze, outcome and patients’ satisfaction. A large retrospective study.

Rehabilitative orbital decompression for Graves’ orbitopathy: risk factors influencing the new onset of diplopia in primary gaze, outcome and patients’ satisfaction. A large retrospective study.

Orbital decompression for Graves’ orbitopathy in England

The purpose of this study was to obtain data on orbital decompression procedures performed in England, classed by hospital and locality, to evaluate regional variation in care. Data on orbital decompression taking place in England over a 2-year period between 2007 and 2009 were derived from CHKS Ltd and analysed by the hospital and primary care trust. In all, 44% of these operations took place in hospitals with an annual workload of 10 or fewer procedures. Analysis of the same data by primary care trust suggests an almost 30-fold variance in the rates of decompression performed per unit population. Expertise available to patients with Graves' orbitopathy and rates of referral for specialist care in England appears to vary significantly by geographic location. These data, along with other outcome measures, will provide a baseline by which progress can be judged.

Retrobulbar Ocular Blood Flow Changes after Orbital Decompression in Graves' Ophthalmopathy Measured by Color Doppler Imaging

To evaluate if decompression surgery produces changes in retrobulbar blood flow parameters in Graves' ophthalmopathy (GO). Retrobulbar blood vessels of 26 eyes (14 patients) that underwent orbital bone decompression between June 2009 and May 2010 were measured prospectively using color Doppler ultrasound before and after surgery. The disease was inactive in all patients enrolled according to the European Group on Graves' Orbitopathy. Patients were classified with mild, moderate-to-severe, or sight-threatening disease. All patients underwent a full ophthalmic examination including intraocular pressure and Hertel measurement. An age-matched control group included 20 eyes of 20 healthy volunteers. The resistance indexes (RIs) in the central retinal artery (CRA) and ophthalmic artery (OA) were significantly higher in patients with GO preoperatively than in the control group (P < 0.001, P = 0.001 respectively). After decompression surgery, a significant decrease in RIs occurred in the CRA (5%) and OA (6%) (P = 0.002, P < 0.001 respectively). Proptosis was decreased a median of 6 mm (range, 4-7). Three-wall decompression surgery resulted in a significantly greater reduction in exophthalmos (median 7 mm) compared with two-wall surgery (median 5 mm) and one-wall surgery (2.5 mm). Although no significant correlation was found, the RIs decreased more with major reductions in exophthalmos. In inactive moderate-to-severe GO, the RIs of the CRA and OA are higher than in normal subjects. The authors hypothesized that increased RIs of inactive GO may be due to orbital extrinsic compression of vascular structures because decompression surgery leads to decreases in the RIs of both the CRA and OA.

A Quantitative Approach to Orbital Decompression in Graves' Disease Using Computer-Assisted Surgery: A Compilation of Different Techniques and Introduction of the “Temporal Cage”

Since 1911, when Dollinger first described surgical orbital decompression, many different techniques and approaches have been described, including 1-, 2-, and 3-wall decompressions with orbital fat removal. The indications for surgical treatment have been widened and include additional to optic neuropathy severe proptosis causing exposure keratopathy and disfigurement. Popular techniques for surgical decompression are the transantral or transpalpebral approach to the medial wall and orbital floor. Sometimes theses approaches are combined with lateral canthotomy incisions for access to the lateral wall ("3-wall decompression"). This report shows a compilation of different techniques using computer-assisted surgery for a 3-wall decompression with the introduction of the "temporal cage" in patients suffering from Graves' disease and the combination with zygomatic bone osteotomy. Twelve patients suffering from Graves' disease presented for surgical treatment in our clinic. For surgical planning, a computed tomographic scan with navigation markers was carried out. The navigation was planned with voxel-based navigation software (VoXim or BrainLab). Of the patients, 1 had unilateral and 11 had bilateral decompressions. Of the 11 patients with bilateral procedures, 1 patient underwent simultaneous and 10 underwent sequential procedures. The 3-wall decompression in all cases was performed by transconjunctival approach. Temporary double vision could be observed in all cases. There was a significant reduction in proptosis. It was concluded that this approach and the computer-assisted surgery would be the operation of first choice when there is an indication for orbital decompression.

Mesure de la pression intraorbitaire avant, pendant et après décompression orbitaire osseuse dans l’orbitopathie dysthyroïdienne

In Graves' orbitopathy, the volumetric increase of the oculomotor muscles and orbital fat leads to exophthalmia and a rise in orbital pressure. This rise in pressure may be implicated in the appearance of a compressive optic neuropathy. To investigate this increase in pressure and its variations accompanying surgical decompression, systematic measurements were taken before, during, and after every case of orbital decompression in Graves' disease. The intraorbital pressure before the surgical procedure was 14.05 mmHg ± 9.19 for a normal value estimated in the literature at 4 mmHg ± 1.5 (statistically significant difference, P<0.0001). In the group presenting a compressive optic neuropathy (NO), the preoperative pressure was 26.8 mmHg ± 7.85 versus 9.8 mmHg ± 4.2 in the group without NO: the pressure was significantly higher in the group with NO (P<0.001). After orbital decompression (one to three walls depending on the severity of the exophthalmia), the pressure was measured at 4.3 mmHg ± 2.53 for the entire series: 6.4 mmHg ± 2.07 in the group with NO versus 3.6 mmHg ± 2.32 in the group without NO (significant difference, P<0.05). The total decrease in pressure induced by the surgery was 9.75 mmHg ± 7.55 and was significantly greater for the group with NO: reduction of 20.4 mmHg versus 6.2 mmHg for the group without NO (P<0.001). The reduction in pressure was greater after collapse of the first wall (floor) than after collapse of following walls for all groups (P<0.001). The maximum pressure observed during the intervention (caused by the instruments) was measured at 78.3 mmHg ± 23.47 without pupillary changes. This study shows that the intraorbital pressure is increased in Graves' orbitopathy and more in serious forms with compressive optic neuropathy. Orbital decompression, as its name indicates, provides decompression and a return to a near-normal orbital pressure situation. Compressive optic neuropathy does not result only from the direct compression of the oculomotor muscles on the optic nerve, but also from an overall rise in the pressure level within the orbital cavity. Intraorbital pressure is increased in Graves' orbitopathy, participating in the appearance of compressive optic neuropathy. Orbital decompression provides a significant reduction in intraorbital pressure.