Evolution of thyroid eye disease decompression-dysthyroid optic neuropathy

Abstract

Orbital decompression surgery and medical therapy for thyroid eye disease (TED) have evolved over the past 150 years and afforded the opportunity to restore pre-disease appearance and visual function. This manuscript explores the past 150 years of surgical innovation for the treatment of TED. The "Age of Surgical Heroism" spans the time from 1888 to 1979 during which the pioneers of orbital decompression developed lateral orbitotomy, transcranial decompression, paranasal sinus decompression, and transantral decompression despite an incomplete understanding of the pathophysiology of both TED and a limited ability to non-invasively assess their patients. The "Age of Surgical Refinement" dawned with the development of computed tomography and represents the years 1979-2000. During this time, the "swinging eyelid" approach for two- and three-wall decompressions was introduced, a combined orbital-extradural four wall decompression procedure was developed, fat decompression was explored, and endoscopic decompression techniques were advanced. At the beginning of the 21st century, our understanding of the orbital pathophysiology of TED evolved significantly. Clinicians recognized the age-related phenotype of TED based largely on the relative contribution of extraocular muscle enlargement vs. orbital fat expansion. The "Modern Age" of Customized Orbital Decompression features both "medical decompression" during the active phase of TED and, in the stable phase, customized surgical plans incorporating individual patients' anatomy, orbital pathology, and surgical goals that collectively maximize therapeutic benefit while minimizing therapeutic morbidity.

Fig. 1

Custom orbital decompression by indication. If the indication is proptosis and a 6 mm or more decompression is warranted, for a patient with large EOMs, we recommend a three-wall decompression of the lateral wall, medial wall, floor, and fat decompression. In a patient with small EOMs, we recommend a fat decompression plus the lateral wall. For patients with proptosis but requiring < 6 mm of decompression, if the EOMs are large, we recommend a lateral wall plus medial and floor but sparing the strut. If the EOMs are small, we recommend a fat decompression with the lateral wall. If the decompression desired is 3–4 mm and the EOMs are small to medium fat decompression alone is indicated. When the indication for decompression is DON, if the patient is in the active phase, we recommend a medial wall and floor decompression including the strut followed by radiotherapy. For patients in the stable phase, we recommend a medial wall and floor decompression including the strut. Surgeons may add lateral wall and fat decompression if there is excess proptosis