Wall Decompression Research Articles

Piezosurgery for orbital decompression surgery in thyroid associated orbitopathy

The purpose of this study was to assess a piezosurgical device as a novel tool for bony orbital decompression surgery.At a multidisciplinary orbital center, 62 surgeries were performed in 40 patients with thyroid associated orbitopathy (TAO). Within this retrospective case-series, we analyzed the medical records of these consecutive unselected patients. The reduction of proptosis was the main outcome measure.Indications for a two (n = 27, 44%) or three wall (35, 56%) decompression surgery were proptosis (n = 50 orbits, 81%) and optic neuropathy (n = 12, 19%). Piezosurgery enabled precise bone cuts without intraoperative complications. Proptosis decreased from 23.6 ± 2.8 mm (SD) by 3 mm (95% CI: −3.6 to −2.5 mm) after surgery and stayed stable at 3 months (−3 mm, 95% CI: −3.61 to −2.5 mm, p < 0.001, respectively). The effect was higher in those with preoperatively higher values (>24 mm versus ≤24 mm: −3.4 mm versus −2.81 mm before discharge from hospital and −4.1 mm versus −2.1 mm at 3 months: p < 0.001, respectively). After a mean long-term follow-up period of 14.6 ± 10.4 months proptosis decreased by further −0.7 ± 2.0 mm (p < 0.001). Signs of optic nerve compression improved after surgery. Infraorbital hypesthesia was present in 11 of 21 (52%) orbits 3 months after surgery.The piezosurgical device is a useful tool for orbital decompression surgery in TAO. By cutting bone selectively, it is precise and reduces the invasiveness of surgery. Nevertheless, no improvement in outcome or reduction in morbidity over conventional techniques has been shown so far.

Transcranial Orbital Decompression for Progressive Compressive Optic Neuropathy After 3-Wall Decompression in Severe Graves’ Orbitopathy

To determine surgical outcomes after transcranial decompression of the superior orbit in patients with progressive compressive optic neuropathy (CON) secondary to Graves' orbitopathy (GO) who had previously been treated with 3-wall decompression. Approval from the West Virginia University Institution Review Board was obtained. A retrospective review of 4 patients with GO who received bilateral transcranial decompression of the orbits for progressive compressive optic neuropathy after bilateral maximal extracranial 3-wall decompression was performed. The patients were treated by the Multidisciplinary Orbit and Skull Base Services at West Virginia University and the University of Michigan. Bilateral transcranial decompression of the orbit for GO was performed on 8 orbits in 4 patients. All 8 orbits had radiographic evidence of compression of the orbital apex, and all patients had been treated with steroids, orbital radiation, and bilateral 3-wall decompression. Preoperative vision ranged from 20/25 to 20/100, which improved to 20/25 or better in all eyes. The visual field mean deviation improved from a mean of -13.05 to -1.67 dB. Hertel measurements improved from a mean of 19.25 to 15.25 mm. Extraocular motility was essentially unchanged. Two patients were noted to have asymptomatic ocular pulsations. There were no other complications, and all patients remained stable during a follow-up period of 5 years (range 2-8 years). Transcranial decompression is an effective and safe method of salvaging vision when standard treatments fail. This is only the second report of transcranial decompression for refractory compressive optic neuropathy after decompression from a standard approach.

Stereotactic microdebrider in deep lateral orbital decompression for patients with thyroid eye disease.

Stereotactic navigation systems have been used in neurosurgery and otolaryngology with great success. The current investigation illustrates the novel use of a microdebrider with built-in stereotactic guidance in a series of thyroid orbitopathy patients who underwent deep lateral orbital wall decompression surgery. A noncomparative, interventional, retrospective case series of patients who underwent deep lateral deep orbital wall decompression from 2006 to 2013 was conducted in accordance with Institutional Review Board policy and the Declaration of Helsinki. Patient demographics, indications for surgery, pre-, intra-, and postoperative findings along with complications were recorded. One hundred eight deep lateral orbital decompression surgeries were performed in 69 patients using the Straightshot M4 Microdebrider with built-in stereotactic guidance (Medtronics). Seventy-eight cases were in women and 30 cases were in men. The average age was 50.4 years (SD = 11.9 years). Indications for surgery included proptosis, exposure keratopathy, or compressive optic neuropathy. No patient experienced intraoperative complications. Specifically, cerebrospinal fluid leak, visual loss, infection, or unanticipated inflammation were not encountered. The average postoperative follow-up time was 5.35 months. Mean reduction in proptosis was 3.72 mm (SD = 2.1). Visual acuity improved in 32.4% (35/108) of cases. This surgical instrument combines a single handpiece locator, microdebrider, irrigator, retractor, and suction device into one. It enhances anatomical localization during orbital decompression and, with an integrated tissue guard, may decrease the risk of injury to orbital soft tissues. Stereotactic navigation enhances the surgeon's ability to determine the maximal limits of decompression in real time by confirming depth of bone removal and may potentially increase surgeons' confidence in orbital decompression surgery.

Surgical effects of various orbital decompression methods in thyroid-associated orbitopathy: Computed tomography-based comparative analysis

ObjectivesTo evaluate the surgical effects of orbital fat decompression and bony decompression in each orbital wall using computed tomography (CT) in thyroid-associated orbitopathy (TAO). MethodsIn 27 TAO patients (48 orbits) with exophthalmos who underwent orbital wall decompression combined with fatty decompression, we recorded the resected orbital fat volume intraoperatively and estimated the decompression volume of the orbital wall in the deep lateral, medial and inferior walls using postoperative orbit CT images. Then, the correlation between exophthalmos reduction by Hertel reading and decompression volume in each area was analyzed to validate the surgical predictability, surgical efficiency and contribution level to total exophthalmos reduction. ResultsThe decompression volume in orbital fat and the deep lateral wall showed relatively high correlation with exophthalmos reduction (surgical predictability) compared to medial and inferior wall. The surgical efficiency was highest at deep lateral wall (2.704 ± 0.835 mm/cm3), followed by medial wall (0.892 ± 0.527 mm/cm3), orbital fat (0.638 ± 0.178 mm/cm3) and inferior wall (0.405 ± 0.996 mm/cm3). The actual contribution level to total exophthalmos reduction was highest in fatty decompression, followed by deep lateral decompression. ConclusionIn TAO patients with exophthalmos, orbital fat and deep lateral orbital wall are more predictable and contributory surgical targets for postsurgical exophthalmos reduction.

Effect of Orbital Decompression on Diplopia in Thyroid-Related Orbitopathy

To determine the incidence of new-onset diplopia and evolution of preexisting diplopia in patients with thyroid-related orbitopathy undergoing orbital decompression surgery. A retrospective chart review was conducted of patients who had undergone orbital decompression for thyroid-related orbitopathy between 1999 and 2008 in one of the authors' practice (D.J.). A total of 217 orbits in 123 patients were identified. The clinical indication for decompression surgery (i.e., exposure keratitis, optic neuropathy, or improvement of cosmesis) was recorded in each case, as was the presence of pre- and postoperative diplopia. The surgical technique (1-, 2-, or 3-wall decompression) was noted for each patient. Review of the charts of patients who underwent orbital decompression surgery for thyroid-related orbitopathy revealed a preoperative prevalence of diplopia of 26% and a postoperative prevalence of 40.7%. Amongst the patients with preoperative diplopia (n = 32), 28.1% (n = 9) had complete resolution of their diplopia after decompression, while 65.6% (n = 21) remained stable and 6.3% (n = 2) worsened. The incidence of new-onset diplopia was 29.7% in this case series of orbital decompression using a transcaruncular and swinging eyelid approach for medial wall and strut-sparing floor decompression. Rates of new-onset diplopia were significantly higher when periorbita was opened (40.0%, n = 82) compared with when it was left intact (11.8%, n = 37) CONCLUSIONS:: It has previously been reported in the literature that orbital decompression for thyroid-related orbitopathy can cause diplopia in a significant number of cases. This provides the rational for performing orbital decompression prior to strabismus surgery in the management of thyroid-related orbitopathy. In this case series, the authors noted resolution of diplopia in a significant proportion (28.1%) of patients with preexisting diplopia. This is rarely commented on in other articles but is important in the preoperative discussion. An incidence of new-onset diplopia of 29.7% was identified. Opening the periorbita was associated with an increased incidence of new-onset diplopia.

Results of diplopia and strabismus in patients with severe thyroid ophthalmopathy after orbital decompression

Purpose:It has been frequently stated that the orbital decompression, in patients with thyroid ophthalmopathy, does not usually improve extraocular muscles function and that after the operation there is often a deterioration of these functions. The purpose of this article is evaluation of extraocular muscles function after applying personal method of 3 wall orbital decompression.Materials And Methods:Retrospective review of case records of 119 patients with severe thyroid ophthalmopathy seen and treated by the author between December 1986 and December 2010. All patents underwent 3 wall orbital decompression combined with removal of the periorbital, intraorbital and retrobulbar fat. Correction of coexistent eyelid retraction and deformities were also performed.Results:Comparison of preoperative and postoperative results was conducted in 65 patients three months after 3 wall decompression. All patients showed a significant reduction of exophthalmos [5-11 mm, 7.2 mm on average], reduction of intraocular pressure, marked improvement in ocular muscle function as well as considerable reduction in or disappearance of subjective symptoms. There were no cases of subsequent impairment of ocular motility. Strabismus surgery was performed in 6 patients with residual diplopia. There was an improvement in vision in 68% patients who had impaired vision before the operation. Less evident relapse of exophthalmos was recorded in 3 cases only and only one patient required unilateral reoperation.Conclusion:It can be concluded that this method of orbital decompression is logical, based on an understanding of the pathology, has less complication rates, is relatively easy to perform, gives very good functional and aesthetic long term results and allows rapid recovery.

Graded Decompression of Orbital Fat and Wall in Patients with Graves' Orbitopathy

PurposeTo investigate the results of graded decompression of orbital fat and walls in Graves' orbitopathy (GO) considering the degree of proptosis reduction at surgery and preoperative computed tomography (CT) findings.MethodsThis is a retrospective interventional case series. Graded orbital fat and wall decompression was performed in 90 orbits of 55 patients. In patients with enlarged extraocular muscles and minimal orbital fat proliferation in preoperative CT scans, one- or two-wall decompression of posterior orbit was performed with minimal fat excision. In other cases, the maximal amount of fat tissue was removed from the post-septal area to the apex. If the proptosis was not satisfactorily symmetrically reduced at surgery, one- or two-wall decompression was performed successively. Symmetric reduction of proptosis was consistently confirmed intraoperatively to assure that a desired amount of exophthalmos reduction was achieved.ResultsFour types of decompression were performed: fat only (group 1), fat and one-wall (group 2), fat and two-wall (group 3), and two-wall and minimal fat decompression (group 4). The mean preoperative Hertel value (20.6 ± 2.8 mm) was reduced significantly at six months postoperatively (16.1 ± 2.3 mm). Proptosis significantly decreased with a mean of 4.3 ± 1.7 mm, and the reduction was greatest (5.1 ± 2.1 mm) in group 3. In group 1, a significant correlation between Hertel change and the volume of resected orbital fat was found (r = 0.479). Diplopia was newly developed or aggravated postoperatively in eight patients, and six of these patients were in group 3. With the exception of one patient, visual acuity improved to nearly normal postoperatively in all patients with optic neuropathy.ConclusionsGraded orbital decompression of orbital fat and bony walls, as assessed by the degree of proptosis reduction during surgery, was effective and predictable with minimal complications in GO patients with vision-threatening or cosmetically disfiguring proptosis.

Intraocular Pressure Change With Eye Positions Before and After Orbital Decompression for Thyroid Eye Disease

To examine intraocular pressure (IOP) changes in primary and upward gazes before and after orbital decompression in patients with thyroid eye disease. Seventy-eight orbits of 40 patients who underwent orbital decompression between June 2010 and September 2012 were retrospectively reviewed. Subjects were divided in 2 groups according to the number of orbital walls removed: deep lateral orbital wall decompression group (Group A) or balanced decompression group (Group B). IOP was measured using Goldmann applanation tonometry in primary gaze and a 20° upward gaze before and 3 months after surgery. Preoperative IOP in upward gaze (18.7 mm Hg) was higher than in primary gaze (15.7 mm Hg, p < 0.001). Postoperative IOP reduction in upward gaze (3.8 mm Hg) was greater than in primary gaze (1.7 mm Hg, p < 0.001). Although the overall postoperative IOP in upward gaze (14.9 mm Hg) remained higher than in primary gaze (14.0 mm Hg, p = 0.038), the gaze-related IOP demonstrated no significant difference in all subgroups (Group A, p = 0.091; Group B, p = 0.332). IOP in upward gaze was higher prior to orbital decompression, but reduction was greater postoperatively and approximated the IOP in primary gaze.

Functional and Esthetic Outcome after Bony Lateral Wall Decompression with Orbital Rim Removal and Additional Fat Resection in Graves’ Orbitopathy with Regard to the Configuration of the Lateral Canthal Region

Purpose: To investigate whether en bloc resection of the lateral orbital wall, including the orbital rim, during lateral wall decompression surgery in patients with Graves’ orbitopathy (GO) potentially influences the esthetic and functional aspects of the lateral canthal region.Methods: Lateral wall decompression was performed in 30 orbits of 18 patients using an upper lidcrease approach involving complete removal of the lateral orbital wall combined with additional orbital fat resection. Patients undergoing surgery before January 2010 were evaluated retrospectively for exophthalmos, vertical lid aperture, lagophthalmos and eye motility. Patients undergoing surgery after January 2010 were evaluated prospectively in addition for horizontal lid aperture, pupillary distance, lateral movement of the lateral canthus, and the disease-specific GO-QOL questionnaire, including subjective and objective assessments of the appearance of the lateral canthal region.Results: A mean exophthalmos reduction of 3.0 mm was achieved, accompanied by a significant reduction in vertical lid aperture but without significant influence on horizontal eye movements. GO-QOL scores disclosed significant improvements with regard to both visual and psychosocial functioning. Although 3 out of 18 patients reported some temporal hollowing, this was confirmed objectively in only one patient.Conclusions: Our analysis did not demonstrate any impairment of lateral canthal stability or motility functions. Slight scar retraction was objectively confirmed in only one patient, allaying concerns about significant temporal hollowing. Given the good overall esthetic and functional results of this surgical technique, we advocate lateral wall decompression with resection of the orbital rim in GO patients with mild-to-moderate exophthalmos.

Strabismus After Inferior-Medial Wall Orbital Decompression in Thyroid-Related Orbitopathy

Purpose: To evaluate the rate and pattern of new-onset diplopia after inferior-medial wall orbital decompression in thyroid-related orbitopathy (TRO) patients.Methods: Medical records of TRO patients who underwent orbital floor and medial wall decompression at the Goldschleger Eye Institute, Sheba Medical Center between 1/1986 and 12/2007 were reviewed and analyzed. Main outcome measures: primary- and down-gaze diplopia, strabismus (prism diopter [PD]).Results: Fifty-one TRO patients (30 females, mean age of 51 years) underwent 102 bilateral inferior-medial wall orbital decompressions. Preoperatively, 29 patients (57%) reported primary gaze diplopia. Of these, 13 patients (45%) had persistent or worsened diplopia postoperatively, all of which required strabismus surgery. Fifteen patients had no primary gaze diplopia preoperatively. Of these, five patients (33%) had new-onset diplopia postoperatively, and only one patient (7%) required strabismus surgery. No data regarding pre-existing diplopia were available in seven patients. Orbital decompression had a significant effect on horizontal ocular deviations with increasing esotropic shift. Primary position esotropia increased from 11.1 (± 22.5) PD preoperatively to 23.8 (± 20.5) PD after surgery (p = 0.01, paired samples t-test). No severe complications were encountered in this group of patients.Conclusions: Inferior-medial wall orbital decompression is associated with a relatively high rate of new-onset diplopia of up to 33%. Patients with pre-existing primary and/or downgaze diplopia are more likely to have persistent symptoms postoperatively that may require strabismus surgery.

Endoscopic Orbital Decompression: When and How?

Objective: 1) Identify acute and chronic indications for orbital and/or optic nerve decompression. 2) Review known techniques for endoscopic orbital decompression. 3) Evaluate the necessity to include inferior orbital wall/orbital floor. 4) Compare and contrast the endoscopic technique in comparison to various open methods. Method: Retrospective review of all patients that underwent endoscopic orbital decompression procedures between 2009 and 2011. Data analysis included review of perioperative clinical findings, operative technical details, radiology data, and outcomes. Results: A total of 15 orbital decompressions were performed. All patients underwent endoscopic medial orbital wall decompression, 2 included the orbital floor. The majority of the patients had allergic fungal sinusitis as their primary diagnosis for surgical indication (n = 7, 47%). Neoplasms (n = 5, 33%) and Graves disease (n = 3, 20%) were the remaining diagnoses. Restricted ocular motility, proptosis, and diplopia were the most common presentations indicating surgery (n = 13, 11 and 8, respectively). Resolution of diplopia was observed in all patients, but delayed in Graves patients (2-3 months). Proptosis improved in 7 patients (64%), without any significant difference among those including orbital floor. Conclusion: The endoscopic technique for orbital decompression is a safe and less invasive alternative to currently used open approaches. Sufficient medial wall decompression may yield sufficient outcomes, precluding the need for including the orbital floor. Further objective outcomes data is needed to compare proptosis among various modes of endoscopic decompression techniques.

Surgical decompression in endocrine orbitopathy. Visual evoked potential evaluation and effect on the optic nerve

Endocrine orbitopathy (EO) represents the most frequent and important extrathyroidal stigma of Graves disease. This chronic autoimmune condition involves the orbital contents, including extraocular muscles, periorbital connective-fatty tissue and lacrimal gland. The increase of fat tissue and the enlargement of extraocular muscles within the bony confines of the orbit leads to proptosis, and in the most severe cases optic neuropathy, caused by compression and stretching of the optic nerve. The congestion and the pressure of the enlarged muscles, constrict the nerve and can lead to reduced sight or loss of vision with the so called “orbital apex syndrome”. Generally surgical treatment of EO, based on fat and/or orbital wall expansion, is possible and effective in improving exophthalmos and diplopia.Since there are limited reports focussing on optic neuropathy recovery after fat and/or orbital walls decompression the Authors decided to perform a retrospective analysis on a series of patients affected by EO.The study population was composed of 10 patients affected by EO and presenting to the Unit of Cranio Maxillofacial Surgery, Center for Craniofacial Deformities & Orbital Surgery St. Anna Hospital and University, Ferrara, Italy, for evaluation and treatment. A complete Visual Evoked Potentials (VEP) evaluation was performed. There were seven women and three men with a median age of 55years. Optic nerve VEP amplitude and latency were recorded as normal or pathological. Abnormal results were scored as moderate, mild and severe. Differences in VEP pre and post-operatively were recorded as present or absent (i.e. VEP Delta). Pearson chi square test was applied.There were 20 operated orbits. The first VEP evaluation was performed 3.2months before surgery and post-operative VEP control was done after a mean of 18.7months. Fat decompression was performed in all cases and eight patients had also bony decompression.VEP amplitude and latency were affected in 10 and 15 cases before operation and six and nine after surgery, respectively. VEP amplitude and latency significantly improved after orbital decompression.Fat and orbital wall decompression are of paramount importance not only to improve exophthalmos and diplopia in patients affected by EO but also as rescue surgery for severe cases where optic neuropathy caused by stretching of the optical nerve is detected by VEP. Imaging and functional nerve evaluation are mandatory in all cases of EO.

Transcutaneous Medial Canthal Tendon Incision to the Medial Orbit

The surgical approach to the medial orbit allows superior exposure of the medial orbital wall and nasal bones, extending to the orbital apex, with excellent cosmetic results. This is a retrospective database study of all patients (N = 98) undergoing a transcutaneous medial canthal tendon incision in practice during 2009. This 1.5- to 2.0-cm incision is made just anterior to, in the same plane as, and shaving the anterior ramus of the medial canthal tendon. After exposing the origin of the anterior ramus of the medial canthal tendon, the periorbita along with the attached medial canthal tendon is elevated, exposing the entire medial orbital wall from the orbital strut to the trochlea. Anterior dissection allows access to the nasal bones to the dorsum of the nasal bridge. The parameters studied in this report were the complication rates (including scarring requiring revision, telecanthus, diplopia related to the technique, and injury to the optic nerve or other orbital structures) and photographic evidence of the final cosmetic result of this approach. During 2009, 173 surgical procedures were performed through the transcutaneous medial canthal tendon incision. The procedures comprised 89 fracture repairs of the nasal or ethmoid complex, 2 naso-orbito-ethmoid fracture repairs, 4 cases of isolated nasal fracture repair, 37 medial wall decompressions for ophthalmic Graves disease, 13 cases of subperiosteal abscess drainage, and 28 dacyrocystorhinostomies using a slightly modified incisional position. The inferior oblique was not cut or released in any of these cases. There were no observed cases of medial canthal webbing, injury to orbital structures, telecanthus, optic neuropathy, or iatrogenically induced diplopia related to the technique. By definition, the authors' follow-up time is limited to less than 2 years in each case; however, all complications, which the authors have considered for this report, would have been readily observable in this postoperative period. The small incision, transcutaneous medial canthal approach offers excellent and safe exposure of the medial wall, nose, and the orbital apex. The authors differentiate this transcutaneous medial canthal tendon incision from the less cosmetically acceptable, larger and more anterior Lynch incision. This medial canthal tendon incision has, and continues to be, a workhorse in the authors' approach to the medial orbit and nose while offering unparalleled exposure with an excellent safety and complication profile.

Do mannequin chests provide an accurate representation of a human chest for simulated decompression of tension pneumothoraxes?

Tension pneumothorax (TPX) is an uncommon but life-threatening condition. It is important that this uncommon presentation, managed by needle decompression, is practised by paramedics using a range of educationally sound and realistic mannequins. The objective of this study is to identify if the chest wall thickness (CWT) of training mannequins used for chest decompression is an anatomically accurate representation of a human chest. This is a two-part study. A review of the literature was conducted to identify chest wall thickness in humans and measurement of chest wall thickness on two commonly used mannequins. The literature search was conducted using the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE databases from their beginning until the end of May 2012. Key words included chest wall thickness, tension pneumothorax, pneumothorax, thoracostomy, needle thoracostomy, decompression, and needle test. Studies were included if they reported chest wall thickness. For the literature review, 4 461 articles were located with 9 meeting the inclusion criteria. Chest wall thickness in adults varied between 1.3 cm and 9.3 cm at the area of the second intercostal space mid clavicular line. The Laerdal(®) manikin in the area of the second intercostal space mid clavicular line, right side of the chest was 1.1 cm thick with the left 1.5 cm. The MPL manikin in the same area or on the right side of the chest was 1.4 cm thick but on the left 1.0 cm. Mannequin chests are not an accurate representation of the human chest when used for decompressing a tension pneumothorax and therefore may not provide a realistic experience.

Transcaruncular Medial Wall Orbital Decompression: An Effective Approach for Patients with Unilateral Graves Ophthalmopathy

Purpose. To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. Methods. Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. Results. The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). Conclusions. Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results.

A review of combined orbital decompression and lower eyelid recession surgery for lower eyelid retraction in thyroid orbitopathy

Background/aimsEyelid retraction in thyroid orbitopathy is traditionally managed with staged surgery after orbital decompression. We review the benefit of concurrent inferior retractor recession at the time of orbital decompression when...

Orbital Floor Abscess Secondary to Sinusitis in an Immunocompromised Patient

A 65-year-old man with a history of renal transplantation presented with facial pain, purulent nasal discharge, and periorbital swelling. Signs of optic nerve compromise developed and persisted despite medial orbital wall decompression. Further imaging revealed an orbital floor abscess secondary to direct communication of a maxillary pseudomonal sinusitis. Full recovery was achieved after further surgical drainage via an endoscopic endonasal approach. Failure to improve after surgical decompression is an indication for repeat imaging. Immunocompromised patients can present atypically. Orbital floor abscess secondary to sinusitis without an underlying odontogenic or traumatic cause has not previously been reported. The authors highlight the importance of clinical vigilance, serial imaging, microbiological investigations, and early surgical intervention in high-risk patients.

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.

The Management of Patients with Thyroid Eye Disease After Bilateral Orbital 3 Wall Decompression

Introduction: Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. Orbital decompression surgery may cause and/or worsen a pre-existing ocular motility disorder.Methods: A retrospective review was carried out of all bilateral 3 wall orbital decompressions for severe thyroid eye disease performed between January 2002 and December 2004 by one surgeon. Subsequent surgeries were recorded.Results: Seventy-four patients were identified, 59 (80%) females and 15 (20%) males. Mean age at the time of decompression was 46 years. Fifteen (20%) patients complained of diplopia due to strabismus prior to decompression surgery and 20 (27%) developed new diplopia postsurgery. Twenty patients (27%) required no further intervention following decompression surgery; the remainder underwent an average of 2.5 procedures. Strabismus surgery was performed in 32 (43%) patients. The mean time from the decompression to first strabismus surgery was 12 months. Forty-three (58%) patients underwent lid surgery. The mean time from decompression to first lid surgery was 16 months.Conclusion: This study demonstrates how this group of complex patients required multiple surgical procedures within an extended timescale, therefore requiring several in- and outpatient visits.

Advantageous Surgeon’s Position in Deep Lateral Orbital Wall Decompression

The deep lateral orbital wall decompression is now the first surgical approach in orbital decompression (). Although it is a popular procedure with few complications and satisfactory results, tips for bone removal depend on each surgeon’s experience. Here, I present differences of surgical effects, depending on the surgeon’s standing positions.