Aric Vaidya, Patricia Ann L. Lee, Yoshiyuki Kitaguchi, Hirohiko Kakizaki & Yasuhiro Takahashi
To evaluate spontaneous decompression of the medial orbital wall and orbital floor in thyroid eye disease using new measurement methods and to analyze the influential factors.
This retrospective study included 86 patients (172 sides). Regarding evaluation of spontaneous medial orbital decompression, an anteroposterior line was drawn between the posterior lacrimal crest and the junction between the ethmoid bone and corpus ossis sphenoidalis. The bulged and/or dented areas from that line were measured. Regarding evaluation of spontaneous orbital floor decompression, the length of the perpendicular distance from a line that was drawn between the inferior orbital rim and the orbital process of palatal bone to the tip of the superior bulge of the orbital floor was measured.
Multivariate linear regression analysis revealed that the maximum cross-sectional areas of the superior rectus/levator palpebrae superioris complex (P = 0.020) and medial rectus muscle (P = 0.028) were influential factors for spontaneous decompression of medial orbital wall (adjusted r2 = 0.090; P < 0.001), whereas the number of cycles of steroid pulse therapy (P = 0.002) and the maximum cross-sectional area of the inferior rectus muscle (P = 0.007) were the ones for that of the orbital floor (adjusted r2 = 0.096; P < 0.001).
We believe that the identification of multiple influential factors of spontaneous decompression of the medial orbital wall and orbital floor will be helpful for better understanding and planned management of thyroid eye disease patients undergoing orbital decompression surgery.
Victor Vlad Costan, Constantin-Catalin Ciocan-Pendefunda, Mihai Liviu Ciofu, Otilia Boisteanu, Daniel Vasile Timofte, Liliana Gheorghe, Camelia Bogdanici & Cristina Preda
The purpose of this study is to share our experience on the use of different orbital decompression techniques, as well as the principles followed for deciding the most case-appropriate procedure that ensured the most favorable outcomes.
We reviewed the Graves’ ophthalmopathy cases operated over the course of 14 years, regarding the presenting signs, the imaging evaluation, the degree of exophthalmos, the type of surgical orbital decompression performed, and the postoperative outcomes.
All 42 patients identified presented with proptosis, with 92.8% cases of bilateral proptosis. The main addressing concern was functional in 54.8% cases and aesthetic in 45.2% patients. CT was used for the preoperative evaluation in all cases. In total, 81 orbits were operated. The orbital decompression surgery involved only the orbital fat in 7.4% of orbits and associated fat and bone decompression in the other 92.6% of orbits. The postoperative results were favorable in all cases regarding both appearance and function, with minimal postoperative complications.
The adequate selection of the most suitable procedure based on the characteristics of each case is the prerequisite for a successful surgery. We found that the association of fat and bone decompression of various extents is most permissive in tailoring the degree of decompression to the existing requirements.
Aylin Garip Kuebler, Caroline Wiecha, Lukas Reznicek, Annemarie Klingenstein, Kathrin Halfter, Siegfried Priglinger & Christoph Hintschich
To evaluate the effectiveness of steroid-pulse therapy and three-wall orbital decompression in patients with dysthyroid optic neuropathy (DON).
Twenty-five patients (46 eyes) with a diagnosis of DON between 2008 and 2015 were included in the study. The first group (7 patients, 16 eyes) consisted of patients with a steroid-pulse treatment only and the second group (18 patients, 30 eyes) included patients with medical and surgical decompression.
Twenty patients were female; five patients were male. After the diagnosis of DON, all patients were treated with steroid-pulse treatment (intravenous 500 mg prednisolon twice/week for 4 weeks, 250 mg twice/week for 2 weeks) as a first-line treatment (medical decompression). In 30 eyes (18 patients) out of 46 eyes, (25 patients) an orbital decompression was needed to preserve the optic nerve function. In those therapy-resistant cases (surgical decompression group), the orbital decompression led to statistically significant improvements in best-corrected visual acuity (BCVA), protan and tritan value of the color vision (p = 0.007, p < 0.0001, p = 0.019, respectively, comparison of first visit to last visit).
According to our data, the mild cases of DON with better initial visual acuity (in our case series mean: 0.3 logMAR) seem to respond well to steroid treatment. However, therapy-resistant cases with an impaired initial BCVA (in our case series, mean: 0.6 logMAR) seem to need the surgery to preserve the optic nerve function. In conclusion, this retrospective study confirms the effectiveness of surgical decompression in therapy-resistant cases of DON.
Roshmi Gupta, Rwituja Thomas, Fatema Almukhtar, Anjali Kiran
Purpose: To describe visual morbidity in thyroid orbitopathy in Asian Indians and the factors influencing its onset. Methods: A retrospective chart review was performed for patients with thyroid related orbitopathy seen between May 2014 and April 2019. Three hundred and one patients were included in the study. Relevant history, clinical findings, investigations, and treatment were documented. Results: Nineteen percent of patients had at least 1 visual morbidity feature such as compressive optic neuropathy, exposure keratopathy or diplopia, requiring intravenous glucocorticoid. Male gender, older age, and diabetes were the significant risk factors for high visual morbidity (all P < 0.05). Systemic thyroid status, degree of proptosis, and duration of disease were not significant. Average dose of intravenous glucocorticoid needed was 3.8 g; 24 (7.9%) patients required orbital decompression, and 13 (4.3%) needed eyelid surgery. At the last follow-up, 97% of patients had vision 6/12 or better in both eyes. Conclusion: There is significant visual morbidity found in Indian patients with TED, even with moderate proptosis and systemic control of thyroid status. This is the first set of data on the subject.
Álvaro Bengoa-González, Bianca-Maria Laslӑu, Agustín Martín-Clavijo, Enrique Mencía-Gutiérrez, Elena Salvador & María-Dolores Lago-Llinás
Purpose: To share our experience on deep lateral wall rim-sparing orbital decompression for the prevention of further spontaneous globe subluxation, in patients with shallow orbits and eyelid laxity.
Methods: This is a retrospective, interventional case series review. We report the results of deep lateral wall rim-sparing orbital decompression in 7 patients with recurrent spontaneous globe subluxation, operated in our department between 2010 and 2016. The orbital morphology was established by computed tomography scan images, and all patients with shallow orbit configuration and who in addition had eyelid laxity were included. Patients with thyroid eye disease were excluded.
Results: No significant intraoperative and postoperative complications were encountered. In all cases, the patients were satisfied with the aesthetic result and none reported further episodes of globe subluxation.
Conclusions: Deep lateral wall rim-sparing orbital decompression is a safe and effective decompressive procedure associated with minimal complications, which can be performed successfully in patients with spontaneous globe subluxation associated with shallow orbits with enough eyelid laxity.
Limongi, Roberto Murillo; Feijó, Eduardo Damous; Rodrigues Lopes e Silva, Marlos; Akaishi, Patrícia; Velasco e Cruz, Antônio Augusto; Christian Pieroni-Gonçalves, Allan; Pereira, Filipe; Devoto, Martin; Bernardini, Francesco; Marques, Victor; Tao, Jeremiah P.
To report a multicenter large case series of orbital decompression for non-thyroid eye disease proptosis.
Retrospective chart review of cases of orbital decompression performed by 9 experienced orbital surgeons from different countries from 2014 to 2017 for non-thyroid eye disease proptosis. Patients were divided into 3 groups: 1) negative vector (high axial length or shallow orbit), 2) inflammatory, and 3) tumor. Types of orbital decompression and Hertel exophthalmometry (preoperative and minimum 6 months postoperative) were recorded. Charts were also assessed for serious complications. The amount of exophthalmometry improvement was recorded according to the above groups.
The analysis included 41 orbits of 29 patients (14 women and 15 men) with a mean age of 38.9 years (ranging from 9 to 74; standard deviation (SD) 15.66). There were 17 orbits of 11 patients in the negative vector group, 16 orbits of 10 patients in the inflammatory group, and 8 orbits of 8 patients in the tumor group. The mean reduction of proptosis was 2.95 mm in the negative vector group, 2.54 mm in the inflammatory group, and 5.75 mm in the tumor group. There were no serious complications.
Orbital decompression was safe and effective in reducing proptosis for non-thyroid eye disease indications in this series. The amount of exophthalmometry improvement was less in the inflammatory orbitopathy group compared with other proptosis etiology groups.
Orbital decompression may have a role in improving proptosis in non-thyroid eye disease entities.
Yoshiyuki Kitaguchi, Yasuhiro Takahashi & Hirohiko Kakizaki
To examine the predictability of exophthalmos reduction using preoperative computed tomography (CT) in deep lateral orbital wall decompression for Graves’ orbitopathy.
This was a retrospective, observational, case-control study conducted at a single institution. Forty-three patients (43 orbits) who were treated with deep lateral decompression with (27 patients) and without (16 patients) fat removal. Multivariate linear regression analyses were used to identify factors influencing exophthalmos reduction 3 months postoperatively. Variables investigated included age; smoking history; history of corticosteroid therapy and/or radiotherapy; preoperative diplopia; width, depth, and height of the greater wing of the sphenoid bone (trigone); and volume of fat removed. The influence of these parameters on the area of the orbital opening was also analyzed.
Trigone width and amount of fat removed were positively correlated with exophthalmos reduction (both, P < .050); none of the other variables exhibited significant correlations. The predictive equation for postoperative reduction in Hertel exophthalmometric values was 0.57 + 0.15 × trigone width (mm) + 1.1 × fat removed (cm3). Depth and height were positively correlated (both, P < .050) and width was negatively correlated (P = .0045) with orbital opening area.
Trigone width and amount of fat removed were positive predictors of exophthalmos reduction after deep lateral decompression. Trigone width was inversely associated with orbital width, and results showed that larger exophthalmos reductions could be achieved in narrower orbits. This CT-based prediction method will assist preoperative decision-making regarding additional fat removal and/or removal of another orbital wall.
David S Curragh & Dinesh Selva
Intraoperative handling and manipulation of orbital fat remains a challenge to orbital surgeons. We present a case series of endoscopic orbital fat decompression with medial orbital wall decompression for proptosis management in Grave’s orbitopathy, describing a technique for fat excision using a laryngeal skimmer blade, reporting clinical and surgical outcomes, and complications.
All patients who underwent endoscopic orbital fat decompression, with medial orbital wall decompression, for proptosis management in Grave’s orbitopathy between 2011 and 2018, under the care of a single surgeon, were included in this retrospective interventional case series.
Nineteen patients were included in this study. Using a laryngeal skimmer blade, orbital fat was excised endoscopically at the time of medial orbital wall decompression. The mean volume of orbital fat excised was 1.45 ± 0.63 ml and the mean reduction in proptosis was 4.5 ± 1.02 mm. There were no intraoperative complications.
In this study, we describe our experience of using a laryngeal skimmer blade as a method of excising orbital fat for orbital decompression in patients with proptosis secondary to Grave’s orbitopathy.
Kerstin Stähr, Anja Eckstein, Laura Holtmann, Anke Schlüter, Meaghan Dendy, Stephan Lang & Stefan Mattheis
Introduction: 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.
Milind N. Naik, Ankita Nema, Mohammad Hasnat Ali & Mohammad Javed Ali
Purpose: To compare efficacy and safety of mechanical drill and piezoelectric technology in the prevention of infraorbital nerve hypoaesthesia during orbital floor decompression.
Methods: Single-centre, non-randomized prospective, interventional case series. We enrolled 24 patients who underwent 3-wall orbital decompression. A total of 13 patients underwent floor decompression using 5-mm diamond dusted Piezoelectric tip (Synthes GmbH, Oberdorf, Germany), whereas 11 patients underwent conventional mechanical decompression of the floor using Stryker Core handpiece with 5-mm diamond dusted tip (Stryker, USA) and a Kerrison’s bone ronguer. All surgeries were performed by a single surgeon (MNN) using standard surgical technique. The infraorbital nerve hypoesthesia was measured pre-operatively, and post-operatively on day 1, at 1 week, 6 weeks, 3 months, and final follow-up by an independent observer. Hypoaesthesia was graded on a simple numerical scale: 0 defined as “normal”, 1 defined as “minimally reduced”, 2 defined as “grossly reduced but perceptible”, and 3 defined as “total loss”.
Results: The average follow-up after surgery was 16 months (range 13–48 months). The average score in the mechanical drilling group at day 1, week 6, week 12 and final follow-up was 1.9, 1.2, 0.7, and 0.6, respectively (p < 0.001). For the Piezo group, the average scores were 0.3, 0.2, 0.1, and 0.1, respectively. No procedure related complications were noted, and the average surgical time for floor decompression was comparable (p > 0.5).
Conclusions: Piezoelectric technology is effective in orbital floor removal by minimizing infraorbital nerve hypoaesthesia.