Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy

Abstract

Purpose: To evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO).

Methods: Twenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0).

Results: Forty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 ± 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 ± 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 ± 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 ± 0.8 to 3.8 ± 0.5 mm postoperatively.

Conclusions: The customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.

Keywords: Diplopia; Exophthalmos; Eyelid retraction; Graves ophthalmopathy; Orbital decompression.

Fig. 1. Evaluation of diplopia using the sum of the angles in eight directions (0°, 45°, 90°, 135°, 180°, 225°, 270°, and 315° in binocular single vision field [BSV] charts) of a nondiplopic region in BSV. The sum of the angles in eight directions of a nondiplopic region in BSV was calculated using the following equation: A + B + C + D + E + F + G + H (°). The angle of the nondiplopic region in BSV at A = 0°, B = 45°, C = 90°, D = 135°, E = 180°, F = 225°, G = 270°, and H = 315°. The sum in this BSV chart was evaluated at 303° (42° + 35° + 30° + 38° + 38° + 38° + 45° + 37°).

Fig. 2. The changes in exophthalmometric values measured with Hertel exophthalmometry following customized orbital decompression surgery. ^*p < 0.05.

Fig. 3. The changes in marginal reflex distance (MRD₁) following customized orbital decompression surgery, and comparison of MRD₁ change according to combined lid retraction surgery. Group I = orbital decompression only; group II = orbital decompression + eyelid retraction correction; group III = orbital decompression + strabismus surgery; group IV = orbital decompression + eyelid retraction correction + strabismus surgery. ^*p < 0.05.

Fig. 4. Representative data of patients in the four groups. Pictures taken in upgaze, primary position, down gaze, and extension views and binocular single-vision field preoperatively (left) and postoperatively (right). (A) A 42-year-old male underwent deep lateral decompression (right eye, OD). (Aa) shows preoperative status and (Ab) shows postoperative status. (B) A 47-year-old female underwent lateral decompression (both eyes, OU), transcaruncular orbitotomy with ethmoidectomy (OU), and lower eyelid retraction correction with dermis graft by englove lysis (OU). (Ba) is preoperative status and (Bb) is postoperative status. (C) A 49-year-old female underwent lateral and inferior decompression (left eye, OS) and left medial rectus muscle recession of 8 mm. (Ca) is preoperative status, and (Cb) is postoperative status. (D) A 37-year-old male underwent lateral orbital decompression (OD), posterior Müllerectomy (OD), and right medial rectus muscle recession of 4 mm. (Da) is preoperative status and (Db) is postoperative status.

Fig. 5. Relationships between group and the sum of the angles in eight directions of a nondiplopic region in binocular single-vision field (BSV [°]). Group I = orbital decompression only; group II = orbital decompression + eyelid retraction correction; group III = orbital decompression + strabismus surgery; group IV = orbital decompression + eyelid retraction correction + strabismus surgery. ^*p < 0.05.