eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Orbital Decompression for Graves Disease: Follow-up

Author: Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Coauthor(s): Adam J Cohen, MD, Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation; Andrew Marc Marlowe, MD, Private Practice, Sarasota, Florida; David J Terris, MD, FACS, Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia; Peter Levin, MD, Associate Clinical Professor, Department of Ophthalmology, Stanford University Medical Center
Contributor Information and Disclosures

Updated: Nov 10, 2008

Outcome and Prognosis

Shepard et al collected retrospective data from a 3-year study period (January 1994 to December 1996) at an academic practice.12 The surgical procedures were customized to address the indications (ie, visual changes, corneal exposure, diplopia, disfigurement). In cases of optic nerve compression, care was taken to extend the surgical decompression as far posteriorly as possible. All endoscopic decompressions were performed by a board-certified otolaryngologist; lateral wall decompressions were performed by an oculoplastic ophthalmologist.

Results

Seven women and 4 men underwent surgical management for Graves ophthalmopathy; a total of 18 orbits were decompressed. Medial wall and lateral decompressions were performed in all cases. Inferior wall decompression was accomplished in 11 orbits. Six additional procedures were performed (2 septoplasties, 2 turbinate trims, 2 orbital rim implants). Five patients (7 orbits) underwent surgical decompression for visual changes (3 afferent pupillary defects, 2 cases of color vision loss). All 5 patients had been treated with oral steroids, and 2 patients had received previous orbital radiation.

The mean improvement in exophthalmos was 4.5 mm (by Hertel measurement). All had improved vision postoperatively. The incidence of newly onset postoperative diplopia was 40% (2 of 5). Three patients had persistent preoperative diplopia. Both patients with iatrogenic diplopia underwent successful strabismus surgery and treatment with prism glasses. No other complications were noted.

The remaining 6 patients (11 orbits) underwent decompression for cosmetic improvement and/or exposure keratitis. One patient had undergone previous radiation for Hodgkin disease, but no history of orbital radiation was present in this group. The mean decompression for this group was 4.7 mm based on Hertel measurement. Because surgical procedures were performed for cosmesis rather than threatened vision in this group, the medial strut between the ethmoid cavity and the orbital floor was preserved. None of the patients who underwent cosmetic decompression developed new postoperative diplopia. One patient developed mild postoperative sinusitis that responded to antibiotics and decongestants.

No other complications were noted. An example of the cosmetic improvement achieved in this group of patients is shown in Image 1. Preoperative and postoperative CT scans that demonstrate expansion of the bony orbit are shown in Image 2. A second patient who also had significant exposure keratitis required orbital rim implants in addition to decompression, and preoperative and postoperative pictures are provided in Image 3.

Future and Controversies

Severe orbital manifestations of Graves disease early in the disease course often respond to high-dose corticosteroid therapy. If this is unsuccessful, external beam radiation therapy at a dose of 20 Gy may be considered. When orbital findings have been present for a long time, they are less likely to respond to medical management because of fibrosis of the involved tissues.

Endoscopically assisted orbital decompression was first described by Kennedy et al in 1990 (13 orbits), suggesting both safety and efficacy of the procedure when performed by otolaryngologists trained in endoscopic techniques.13 In 1995, Metson et al reported on 29 cases of endoscopic orbital decompression performed under local anesthesia, confirming the benefit of this less invasive method for medial wall decompression.14 They advocate operating on a single orbit at a time when bilateral decompression is necessary.

A more recently introduced philosophy is the concept of balanced decompression. In 1995, Goldberg et al suggested that decompression should be performed both medially and laterally to achieve a symmetric and balanced anatomic result. Currently, the method for lateral decompression extends posteriorly into the sphenoid bone, giving a greater decompression than removal of the anterior wall alone. The authors favor the concept of balanced decompression with the newer endoscopic approach and with an effort to provide a customized surgical management dictated in part by the indications for surgery.

Therefore, in this series, among patients who underwent decompression for cosmesis via an endoscopic approach, the incidence of new-onset postoperative diplopia was zero. This is not always the case. This was attributed, in part, to the balanced approach to decompression (ie, both medial and lateral walls are decompressed, allowing a balanced release of orbital tissues) and to preservation of the medial strut between the ethmoid cavity and the inferior orbital decompression. Goldberg et al have reported that preservation of this strut, in addition to balancing the decompression, maintains globe position, minimizing the risk of postoperative diplopia.

Concurrent decompression surgery and Muller muscle recession was reported by Ben Simon et al, with reasonable results.15  However, in a more recent article, Goldberg, one of the authors of the Ben Simon article, delineates a more traditional staged approach progressing from decompression to muscle surgery, lid surgery, and then soft tissue procedures.9

Decompression surgery timing is still debated, especially if the optic nerve is not acutely compromised. Baldeschi et al reported that early decompression for rehabilitative surgery had a higher risk of causing diplopia and did not improve outcomes when compared with later surgery.16 Baldeschi et al also reported that radiation treatment did not adversely affect decompression results based on a retrospective review over a 10-year period.17 The group they studied had surgery for aesthetic reasons and no diplopia preoperatively. 

However, decompression surgery has an abundance of risks. Goh and McNab reported a 30% increase in postdecompression diplopia over an 11-year period.18

Conclusions

Medial wall decompression with preservation of the medial strut between the ethmoid cavity and the inferior wall, balanced with lateral wall decompression and with or without inferior wall decompression, may provide effective reduction of exophthalmos without a high risk for new-onset postoperative diplopia, especially in patients who are having surgery for cosmetic indications. The authors think that this combined approach to surgery for patients with Graves ophthalmopathy, incorporating both an otolaryngologist with endoscopic experience and an oculoplastic surgeon, provides for ideal surgical management.

 


More on Orbital Decompression for Graves Disease

Overview: Orbital Decompression for Graves Disease
Workup: Orbital Decompression for Graves Disease
Treatment: Orbital Decompression for Graves Disease
Follow-up: Orbital Decompression for Graves Disease
Multimedia: Orbital Decompression for Graves Disease
References
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Further Reading

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Keywords

Graves disease, orbital decompression, orbital decompression for Graves disease, Grave’s disease, Graves eye disease, Grave disease, Graves' orbitopathy, Graves' ophthalmopathy, endocrine orbitopathy, endocrine ophthalmopathy, endocrine-related proptosis, Graves disease treatment, thyroid ophthalmopathy, thyroid orbitopathy, thyroid-related orbitopathy, thyroid-related ophthalmopathy, thyroid eye disease, thyroid-associated orbitopathy, thyroid-related immune orbitopathy, orbital decompression for Graves' disease, exophthalmos, proptosis, thyroid Graves, thyroid ophthalmopathy

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Contributor Information and Disclosures

Author

Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Cohen, MD, Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Andrew Marc Marlowe, MD, Private Practice, Sarasota, Florida
Andrew Marc Marlowe, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Tinnitus Association, Florida Medical Association, Medical Society of the State of New York, Sarasota County Medical Society, and Vestibular Disorders Association
Disclosure: Nothing to disclose.

David J Terris, MD, FACS, Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia
David J Terris, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Association for the Advancement of Science, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, Federation of American Societies for Experimental Biology, International Association of Endocrine Surgeons, Phi Beta Kappa, Radiation Research Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

Peter Levin, MD, Associate Clinical Professor, Department of Ophthalmology, Stanford University Medical Center
Peter Levin, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Ophthalmic Plastic and Reconstructive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Terance (Terry) Ted Tsue, MD, Vice-Chairman for Administrative Affairs, Professor, Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine
Terance (Terry) Ted Tsue, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, Association for Research in Otolaryngology, Johns Hopkins Medical and Surgical Association, Missouri State Medical Association, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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