Practice Patterns in Orbital Decompression Surgery Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members

Abstract

Introduction: Orbital decompression surgery for thyroid-associated orbitopathy (TAO) has evolved greatly over the past decades with the development of new surgical techniques and strategies for patient management. However, randomized controlled trials comparing surgical approaches are lacking. The goal of this study was to report the current preferred practices among American Society of Ophthalmic Plastic Surgeons (ASOPRS) members for orbital decompression surgery for TAO, including surgical techniques and perioperative patient management.

Methods: An anonymous electronic survey consisting of 21 questions was sent to the current membership of the ASOPRS, leading to 170 responses in total (response rate: 23.7%). Questions regarding preoperative and postoperative care as well as surgical technique were included.

Results: 54.2% of the respondents prefer two-wall surgery as their initial procedure of choice. Of these, 53.8% prefer balanced lateral and medial decompression as the two-walled procedure of choice, and 44.0% prefer the orbital floor and medial wall. Steroids are routinely used preoperatively by 35.9% and postoperatively by 69.2%. Antibiotics are used preoperatively by 32.9% and postoperatively by 56.4% of respondents.

Conclusion: Practice patterns for orbital decompression surgery continue to vary widely among ASOPRS members, but balanced medial and lateral wall decompression has gained in popularity as compared to prior studies. Postoperative steroids are preferred by a majority of members.

Keywords: Decompression surgery; Graves’ orbitopathy; Orbit; Proptosis; Thyroid eye disease.

Fig. 1

Choice of wall for first decompression surgery. Several questions addressed which walls were preferred for a patient’s first decompression surgery. a 54.2% of respondents prefer two-wall decompression as their initial surgery of choice, compared to 23.2% who perform three-wall decompression of the lateral, inferior, and medial orbital walls, and 22.6% who prefer one-wall decompression. b Of the surgeons preferring two-wall decompression, 53.8% prefer balanced lateral and medial decompression, 44.0% prefer the orbital floor and medial wall, and 2.2% prefer the floor and lateral wall. c Of the surgeons who perform one-wall decompression as the initial procedure of choice, 52.6% decompress the medial wall, 36.8% decompress the lateral wall, and 10.5% decompress the floor

Fig. 2

Surgical decompression technique. Several questions addressed aspects of surgical decompression technique. a 68.6% of surgeons do not use intraoperative stereotactic navigation. In contrast, 12.4% of respondents use intraoperative navigation in more than two-thirds of their decompression cases, 2.4% of respondents use navigation in between one-third and two-thirds of their cases, and 16.6% use navigation in less than one-third of their cases. b 17.8% of respondents routinely remove the lateral orbital rim during decompression surgery, 18.3% remove the lateral rim “sometimes,” and 63.9% of surgeons do not remove the lateral rim. c Of surgeons who do remove the lateral rim, 76.7% replace the rim following completion of the procedure, compared to 23.3% who do not

Fig. 3

Preoperative and postoperative management. a The vast majority of respondents obtain preoperative imaging, with 95.9% preferring CT, and 3% choosing MRI. Only 0.6% of surgeons do not obtain preoperative imaging. b Only 35.9% of respondents routinely use preoperative steroids, compared to 69.2% who routinely use postoperative steroids. Similarly, only 32.9% routinely prescribe preoperative antibiotics, and 56.5% prescribe postoperative antibiotics