Wall Decompression Research Articles

Orbital decompression for thyroid associated ophthalmopathy: transnasal endoscopic approach or external orbital approach?

External orbital decompression, including medial wall, inferior wall, lateral wall and orbital fat decompression alone or in combination, has long been considered to be the standard treatment for thyroid related eye diseases. Deep lateral wall orbital decompression has better effect in the balance of eye position, correction of serious exophthalmos and severe oppression optic neuropathy. Recently, however, endoscopic orbital decompression is becoming increasingly popular with the development of endoscopic surgery technique in naso-orbit related diseases. Endoscopic orbital decompression has the advantages of avoiding an external incision scar. Nevertheless, the new method also has some disadvantages, for example, application limited to medial and inferior orbital wall orbital decompression, high incidence of esotropia, need for external lateral wall decompression and expensive cost for equipment. Both surgical approaches have advantages and disadvantages respectively for medial wall and inferior wall decompression. The operative result depends on the individualized surgical design and the experience of the surgeon rather than the choice of the surgical approach. As a result, the choice of the surgical approaches should be specifically based on the patient's conditions, patient's acceptance of the operation, experience of the surgeon and available resources. (Chin J Ophthalmol, 2018, 54: 484-487).

Dysthyroid Optic Neuropathy.

Dysthyroid optic neuropathy (DON) is a serious complication of Graves orbitopathy that can result in irreversible and profound visual loss. Controversy exists regarding the pathogenesis and management of the disease. The authors provide an overview of the current understanding of DON and present a therapeutic guideline. A review of the literature. The mechanism of DON appears to be multifactorial: direct compression of the optic nerve by enlarged extraocular muscles, stretching of the optic nerve by proptosis, orbital pressure, vascular insufficiency, and inflammation. Some or all of these factors may be involved in an individual patient. There has only been one controlled trial comparing high-dose intravenous methylprednisolone to bony orbital decompression for DON. Both 2-wall and 3-wall decompression techniques successfully improve visual functions of patients with DON. There are few case reports/case series that suggest biologic agents may improve visual function in DON. DON is a serious complication of Graves orbitopathy, the diagnosis and management of which is complex and requires a multidisciplinary approach. There is little evidence regarding the optimum management strategy. Based on the current literature, the first line of treatment is intravenous methylprednisolone, with the exact timing and indication of bony orbital decompression still to be determined. In addition, there may be a role for the use of biologic agents that will require a systematic program to determine efficacy.

Changes in optical coherence tomography measurements after orbital wall decompression in dysthyroid optic neuropathy.

The purpose of our study was to assess changes in peripapillary retinal nerve fiber layer (RNFL) thickness after orbital wall decompression in eyes with dysthyroid optic neuropathy (DON). We analyzed peripapillary optical coherence tomography (OCT) images (Cirrus HD-OCT) from controls and patients with DON before and 1 and 6 months after orbital wall decompression. There was no significant difference in mean preoperative peripapillary retinal nerve fiber layer thickness between eyes with DON and controls. The superior and inferior peripapillary RNFL thickness decreased significantly 1 month after decompression surgery compared to preoperative values (p = 0.043 and p = 0.022, respectively). The global average, superior, temporal, and inferior peripapillary RNFL thickness decreased significantly 6 months after decompression surgery compared to preoperative values (p = 0.015, p = 0.028, p = 0.009, and p = 0.006, respectively). Patients with greater preoperative inferior peripapillary RNFL thickness tended to have better postoperative visual acuity at the last visit (p = 0.024, OR = 0.926). Our data revealed a significant decrease in peripapillary RNFL thickness postoperatively after orbital decompression surgery in patients with DON. We also found that greater preoperative inferior peripapillary RNFL thickness was associated with better visual outcomes. We suggest that RNFL thickness can be used as a prognostic factor for DON before decompression surgery.

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.

Rehabilitative orbital decompression for Graves' orbitopathy: results of a randomized clinical trial.

Orbital decompression (OD) is a consolidated procedure for the treatment of exophthalmos in Graves' orbitopathy (GO). The efficacy of the various procedures remains unclear due to the variability of the techniques used. To address this issue, we performed a randomized clinical trial to compare the efficacy of two surgical techniques. The primary endpoint was the reduction in proptosis. Secondary aims were the risk of post-operative diplopia (POD) in primary gaze and other surgical complications. 38 patients (76 orbits) affected with GO were enrolled and randomized into single lateral decompression (LD) (n=19) or balanced medial plus lateral wall decompression (MLD) (n=19). Following surgery, patients were seen for a follow-up ophthalmological evaluation at 6months. Pre-operative diplopia in secondary gaze was present in 13/38 patients (34.2%, 8/19 treated with LD and 5/19 treated with MLD). The reduction of exophthalmos was greater in patients treated with MLD (5.1±1.5mm, range 2-8mm) than in those treated with LD (3.5±1.3mm, range 1-6.5mm) (p=0.01). The overall incidence of POD in primary gaze was 5/38 (13.2%) and all of these patients had pre-operative diplopia in secondary gaze (5/13, 38.5%, vs patients with no pre-operative diplopia p=0.005). Two of 19 patients (10.5%) treated with LD and 3/19 (15.8%) treated with MLD, developed POD in primary gaze, with no statistical difference between the two techniques. MLD provides a better result in terms of proptosis reduction compared to LD. The two techniques used here appear to have a similar safety profile in terms of POD. Pre-operative diplopia in the secondary gaze remains a major risk factor for development of POD.

Deep lateral wall orbital decompression following strabismus surgery in patients with Type II ophthalmic Graves’ disease

ABSTRACTPurpose: Surgical management of ophthalmic Graves’ disease traditionally involves, in order, orbital decompression, followed by strabismus surgery and eyelid surgery. Nunery et al. previously described two distinct sub-types of patients with ophthalmic Graves’ disease; Type I patients exhibit no restrictive myopathy (no diplopia) as opposed to Type II patients who do exhibit restrictive myopathy (diplopia) and are far more likely to develop new-onset worsening diplopia following medial wall and floor decompression. Strabismus surgery involving extra-ocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with Type II patients who have already undergone medial wall and floor decompression and strabismus surgery found, when additional decompression is necessary, deep lateral wall decompression (DLWD) appears to have a low rate of post-operative primary-gaze diplopia.Methods: A case series of four Type II ophthalmic Graves’ disease patients, all of whom had already undergone decompression and strabismus surgery, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with DLWD. Institutional Review Board approval was granted by the University of Kansas.Results: None of the four patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following DLWD.Conclusions: While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Graves’ disease, for proptosis following consecutive strabismus surgery, DLWD appears to be effective with a low rate of recurrent primary-gaze diplopia.

Orbital decompression for thyroid eye disease: methods, outcomes, and complications.

PurposeTo determine the safety and effectiveness of orbital decompression for thyroid eye disease (TED) in our unit. To put this in the context of previously published literature.Patients and methodsA retrospective case review of all patients undergoing orbital decompression for TED under the care of one orbital surgeon (SMS) between January 2009 and December 2015. A systematic literature review of orbital decompression for TED.ResultsWithin the reviewed period, 93 orbits of 55 patients underwent decompression surgery for TED. There were 61 lateral (single) wall decompressions, 17 medial one-and-a-half wall, 11 two-and-a-half wall, 2 balanced two wall, and 2 orbital fat only decompressions. For the lateral (single) wall decompressions, mean reduction in exophthalmometry (95% confidence interval (CI) was 4.2 mm (3.7-4.8), for the medial one-and-a-half walls it was 2.9 mm (2.1-3.7), and for the two-and-a-half walls it was 7.6 mm (5.8-9.4). The most common complications were temporary postoperative numbness (29% of lateral decompressions, 17% of other bony decompressions, OR 0.50, 95% CI 0.12-2.11) and new postoperative diplopia (9% of lateral decompressions, 39% of other bony decompressions, OR 6.8, 95% CI 1. 5-30.9). Systematic literature searching showed reduction in exophthalmometry for lateral wall surgery of 3.6-4.8 mm, with new diplopia 0-38% and postoperative numbness 12-50%. For other bony decompressions, reduction in exophthalmometry was 2.5-8.0 mm with new diplopia 0-45% and postoperative numbness up to 52%.ConclusionDiffering approaches to orbital decompression exist. If the correct type of surgery is chosen, then safe, adequate surgical outcomes can be achieved.

Endoscopic transethmoid orbital medial wall decompression for thyroid associated ophthalmopathy

Objective To evaluate the efficacy of endoscopic transethmoid and orbital medial wall decompression combined with orbital fat decompression for thyroid associated ophthalmopathy (TAO). Methods The data of 17 eyes of 11 patients with TAO were selected and retrospectively analyzed. They receieved endoscopic transethmoid and orbital medial wall decompression combined with orbital fat decompression. All patients were followed up periodically. Results Six months after surgery, the mean reduction in proptosis was (5.24±1.79)mm, the difference was statistically significant between before and after surgery (P<0.05). Postoperatively the difference of exophthalmos between the both eyes was within 2 mm. Corneal epithelial abnormalities decreesed from 14 eyes (82.35%) preoperative to 2 eyes (11.76%) postperative , the difference was statistically significant (P<0.05). And postoperative mean height of palpebral fissure decreased(2.59±0.48)mm, the difference was statistically significant(P<0.05). There was no loss of visual acuity, orbital bleeding or other complication. Conclusion The endoscopic transethmoid orbital medial wall decompression combined with orbital fat decompression is an effective treatment for TAO. Key words: Ophthalmopathy, thyroid associated; Orbital decompression, transethmoid medical wall, endoscopic

Customized Minimally Invasive Orbital Decompression Surgery Improves Lower Eyelid Retraction and Contour in Thyroid Eye Disease.

To investigate the outcome of a customized approach with targeted zygomatic basin bone removal orbital decompression in lower eyelid retraction and contour of patients with thyroid eye disease. In a comparative case series, clinical charts and photos of a consecutive sample of 92 patients with thyroid eye disease submitted to different types orbital decompression were studied. Exophthalmos, midpupil to lower eyelid margin distances (MRD2) at 11 meridians, and globe position were measured and compared according to the types of decompression. Each eyelid was also labeled as within or outside normal limits regarding both contour pattern analysis and MRD2 compared with a control normal range. Eyelid contour and globe position from patients with orbital decompression with zygomatic basin removal were compared with those without basin removal. A total of 105 orbits from 57 patients met the study inclusion criteria. Ninety-eight orbits had lateral orbital wall decompression and in 53% of these cases, bone in the zygomatic basin was removed. Removal of the zygomatic basin did not significantly enhance decrease in proptosis, but significantly induced vertical globe descent and improved MRD2 (p < 0.05). Preoperatively, 37% of the eyelids were in the normal MRD2 range and 18% within the normal contour range. Preoperatively, 77% had normal MRD2 and 55% normal contour range. Our study findings support the practical utility of incorporating a customized approach to orbital decompression, and suggest that an individualized approach with targeted bone removal may obviate the need for additional surgeries such as lower eyelid retraction repair.

A Retrospective Review of Orbital Decompression for Thyroid Orbitopathy with Endoscopic Preservation of the Inferomedial Orbital Bone Strut

To determine incidence of new-onset diplopia, resolution of preexisting diplopia, and impact on proptosis resulting from endoscopic orbital decompression with and without preservation of the inferomedial orbital strut for thyroid orbitopathy. Retrospective review of all patients undergoing endoscopic 2- or 3-wall decompression with or without preservation of the strut for thyroid orbitopathy from January 2012 to June 2015. Twenty-six patients (45 orbits) were included and divided into 4 primary categories: 2-wall decompression with strut preservation (4 orbits, 8%), 2-wall decompression with strut removal (7 orbits, 16%), 3-wall decompression with strut preservation (27 orbits, 60%), and 3-wall decompression with strut removal (7 orbits, 16%). The incidence of new-onset diplopia was 20% (2/10 patients without preoperative diplopia) overall and 16% in the strut preservation group (1/6 patients without preoperative diplopia). Resolution of diplopia occurred in 4 of 16 patients (25%) with preoperative diplopia, and all 4 had been treated with a 3-wall decompression with strut preservation. Resolution of diplopia in the group treated with strut preservation was 36% (4/11 patients with preoperative diplopia), and 0% of the 5 diplopic patients treated without strut preservation. Reduction in proptosis was statistically greater in those treated with strut removal (p = 0.003). This study demonstrates that endoscopic orbital decompression with preservation of the inferomedial bone strut results in a comparable to lower rate of new-onset diplopia compared with other reported techniques. When combined with 3-wall balanced decompression, this technique demonstrates a high rate of resolution of preexisting diplopia.

Can the second lay rescuers evaluate the qualities of bystander CPR performed by the first rescuers and give feedback instruction under on-line communication with dispatchers?

Aim: In dispatcher-assisted CPR (DA-CPR) instruction. It is very difficult for dispatchers to evaluate the hand positions, compression depths and the complete chest wall decompression (recoil). This preliminary study aimed to test a new DA-CPR protocol including on-line instruction to the second rescuers to evaluate the qualities of CPR performed by the first rescuers.

Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves’ orbitopathy

Background: To determine the clinical outcomes and morbidity of endoscopic medial wall combined with transcutaneous lateral orbital wall decompression in Graves’ orbitopathy.Methodology: A retrospective noncomparative case series of patients who underwent surgical decompression for Graves’ orbitopathy at Hospital Universitario de Fuenlabrada between 2004 and 2014 was performed. We reviewed the patients’ charts and analyzed before and after the decompression, the visual acuity (Snellen chart), optic nerve compression (fundoscopy and optic coherence tomography), exophthalmometry (Hertel measurement), ocular motility, diplopia, eyelid surgery needed after decompression and its possible complications.Results: A total of 20 patients (36 orbits) were operated. The mean follow-up was 44 months (range 18–84). Vision improved dramatically in all compressive optic neuropathy cases (5 cases). Hertel measurements improved on average 3.5 mm (range 1.5–4.5). Diplopia was cured in eight patients (40%) and nine patients with severe preoperative diplopia required strabismus surgery after decompression. Eyelid surgery was further needed in 13 patients. Hyaluronic acid injection was the most used technique for the treatment of eyelid retraction (6 out of 13 patients). Only two major complications were observed: one case had a major post-operative epistaxis and another a cerebrospinal fluid leak. Both were resolved without further sequelae.Conclusions: These results suggest that endoscopic medial wall combined with transcutaneous lateral wall orbital decompression is an effective and safe treatment for the symptomatic dysthyroid eye disease with important proptosis or compressive optic neuropathy.

Double Vision After Minimally Invasive Orbital Decompression.

New onset Diplopia following orbital decompression in thyroid eye disease patients is estimated to occur in up to 30% to 40% of decompression patients, mostly related to deep lateral and medial wall decompressions. A retrospective chart review of all minimally invasive (fat and minimal bone orbital decompression performed at the UCLA Stein Eye Institute between 2005 and 2015. Inclusion criteria were thyroid eye disease patients older than 18 years undergoing fat only orbital decompression with no previous muscle surgery. The chart review revealed only 5 patients with new onset diplopia after this surgery. The cases are discussed and a possible mechanism for the diplopia is proposed. Double vision following minimally invasive orbital decompression is rare and the mechanisms are poorly understood.

Geriatric patients are predisposed to strabismus following thyroid-related orbital decompression surgery: A multivariate analysis

ABSTRACTGeriatric patients (age ≥ 65) are prone to complications after surgery and are at risk for severe thyroid eye disease (TED). In this study, we aim to identify preoperative demographic and TED patterns associated with geriatric patients who underwent decompression surgery, to examine the effect of age on postoperative strabismus rates, and to identify factors that may contribute to postoperative strabismus in the geriatric subgroup. We retrospectively reviewed patients who underwent thyroid-related orbital decompression surgery at the Kellogg Eye Center, University of Michigan, between 1999 and 2014. Primary outcome was postoperative strabismus requiring palliation with prisms and/or strabismus surgery. Descriptive, univariate, and multivariable logistic regression analyses were used to define association of geriatric age with postoperative strabismus and determine predictors of postoperative strabismus. Of 241 patients, 41 (17.0%) were geriatric. They were less likely to undergo bilateral decompression (P = 0.012), less likely to be current smokers at time of decompression (P = 0.002), and more likely to have preoperative primary gaze diplopia (P = 0.001). Postoperative strabismus rates for geriatric patients (≥ 65 years of age), ages 50–65, 30–50, and < 30, were 73.2%, 41.3%, 31.9%, and 15.8%, respectively (P = 0.002). On multivariable analysis, geriatric age remained an independent risk factor for postoperative strabismus when compared to each age group (P ≤ 0.001). Among geriatric patients in subgroup multivariable analysis, balanced as opposed to lateral wall decompression (P = 0.038) and shorter TED duration (P = 0.031) were independently predictive of postoperative strabismus.

Calculation of resected orbital wall areas in the treatment of endocrine orbitopathy

PurposeOrbital wall decompression is routinely used to treat proptosis in endocrine orbitopathy. Until now, however, there has been no investigation to measure the area/extent of the removed walls. Materials and methodsThe inner areas of 154 orbital walls (lateral, inferior, medial) which had been resected in 38 patients were measured using pre- and postsurgical computed tomographic data in Brainlab iPlan software. Furthermore the effect of concomitant centrolateral orbital rim advancement was calculated in 48 cases. Surgery was performed after preoperative planning using intraoperative navigation. ResultsThe mean area of resected inferior and medial orbital walls lay at 6.7 cm2 and 6.2 cm2, while the area of the lateral orbital wall was 6.9 cm2. Rotation-advancement of the lateral rim added an area of 1.8 cm2 (∼25% of the lateral orbital wall). Comparison of the pre- and postsurgical computed tomographic data showed excellent conformity of the presurgical planning and postsurgical results. ConclusionsThis investigation is a first step in analyzing the potential surgical effect of bony decompression surgery by stating the metric amount of orbital wall removal. Using these data, further studies will be performed in the future.

Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease

ObjectiveTo examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED). MethodsData on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests. Results145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ2 test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ2 test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ2 test, p = 0.004). ConclusionsTo the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients’ characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.

This issue of Acta

This issue of Acta

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.

Temporal hollowing and other adverse effects after lateral orbital wall decompression.

To evaluate the outcome and late postoperative complications after lateral orbital wall decompression in a series of patients with thyroid eye disease (TED). One hundred and three patients operated in the period 1999-2013 were invited to participate in the study, and 84 were included after a median (range) follow-up time of 124 (13-188)months. The patients were interviewed, and preoperative and postoperative data were collected from hospital records. Photographs ('selfies') were obtained from 64 patients. Wilcoxon signed-rank test was used to evaluate the change in pre- and postoperative data. On average, visual acuity was unchanged with a median value (range) of 1.0 (0.4-1.25) before to 1.0 (0-1.25) after surgery (p=0.5). Intraocular pressure (IOP) was reduced from a median value (range) of 17 (9-26) to 15 (8-23)mmHg (p<0.001). Median (range) Hertel values were 23 (15-30)mm preoperatively and 20 (12-26)mm postoperatively (p<0.001) respectively. Mean (SD) reduction in proptosis was 3.6 (±2.1)mm. Oscillopsia was reported in 24 patients (29%), 42 (50%) experienced a change in temporal sensation, and four (5%) had new-onset diplopia. In 47 patients (56%), some degree of temporal hollowing was reported. Among 64 photographed patients, 38 (59%) had noticeable hollowing on examination of postoperative pictures. There was agreement of the patient's perception of temporal hollowing and the appearance in photographs in 26 of 37 patients (70%). Lateral orbital wall decompression has been considered a safe and effective procedure for treatment of TED. Serious side-effects are infrequent, but in rare circumstances, even blindness may occur. Less serious side-effects are relatively common. Among others, a significant number of the patients developed temporal hollowing after the procedure. The patients must be informed about the possible complications before surgery.