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C-modified osteotomy for bilateral advancement of the orbital rim in Graveś orbitopathy: a technical note
Int. J. Oral Maxillofac. Surg. 2008; 37: 853–857 doi:10.1016/j.ijom.2008.05.012, available online at http://www.sciencedirect.com
Technical note Reconstructive surgery
C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note
R. Gonza´lez-Garcı´a1, J. Sastre-Pe´rez1, F. J. Rodrı´guez-Campo1, L. Naval-Gı´as1, F. Monje2 1 Department of Oral and Maxillofacial-Head and Neck Surgery, University Hospital La Princesa, Autonoma University, c/ Diego de Leo´n 62, 28006, Madrid, Spain; 2Department of Oral and Maxillofacial-Head and Neck Surgery, University Hospital Infanta Cristina, Badajoz, Spain
R. Gonza´lez-Garcı´a, J. Sastre-Pe´rez, F. J. Rodrı´guez-Campo, L. Naval-Gı´as, F. Monje: C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note. Int. J. Oral Maxillofac. Surg. 2008; 37: 853–857. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The authors present a modification of the classical three-wall orbital decompression for the treatment of Graves’ orbitopathy. It consists of two ‘C’ osteotomies for the bilateral projection of the superolateral, lateral and inferolateral orbital rims, associated with the removal of the lateral orbital walls. This technique is performed following a coronal approach. Ultrasound cutting instruments were used for the osteotomies. They avoided lesion of surrounding soft tissues, such as the duramater and the periorbital tissues. Stabilization of the advanced structure was achieved by interposition of autologous bone graft obtained from the outer cortex of the calvaria. An extreme advancement of the orbital rim with resolution of diplopia, ocular pain and eyelid incompetence was obtained. Using this procedure, a good functional and aesthetic outcome was achieved.
Graves’ orbitopathy is an autoimmune disorder not directly associated with the over-expression of thyroid hormones. Bahn2 has suggested a possible role of CD4+ T cells in the recognition of antigens shared by both thyroid and orbital tissues. Lymphocytes secrete cytokines that stimulate fibroblasts for synthesis and secretion of glucose-amine-glycans, which ultimately allow accumulation of fluid in the periorbital space, muscles and retro-orbital space. Initial clinical symptoms include epiphora, photophobia, eye0901-5027/090853 + 05 $30.00/0
lid retraction and conjunctival injection. The chronic process is accompanied by exophthalmos, compression of the optic nerve and neuropathy. The goal of treatment for Graves´ orbitopathy is to reduce the inflammation of the periorbital soft tissues and orbital congestion. Several management options have been proposed, such as corticoids, immunotherapy and radiotherapy. Their use is debatable in the management of the active phase of the disease, and not beneficial for the inactive phase. Surgical treatment
Keywords: graves’ orbitopathy; proptosis; osteotomy; orbital decompression; bone graft. Accepted for publication 9 May 2008 Available online 7 July 2008
offers an alternative for these challenging cases. Orbital decompression can be achieved by removal of two, three or four orbital walls and associated lipectomy. Different procedures for osteotomy of the orbital rims have been reported1, with some success, although they are rarely used in clinical practice. The patient in this study presented with severe exophthalmos, diplopia, keratitis due to severe ocular exposition, and significant aesthetic deformity. The patient underwent a C-modified osteotomy for the
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
854
Gonza´lez-Garcı´a et al.
Fig. 1. Preoperative clinical view. A Lateral view. B Frontal-upper view.
advancement of the orbital rim, with restitution of osseous integrity using autologous calvarial bone grafts. The technique is described and its advantages with other surgical treatments compared. Case report
A 65-year old man with a 3-year history of Graves’ disease and controlled thyroid function presented with bilateral ocular pain with lateral movements, diplopia and eyelid incompetence. On physical examination, conjunctival injection, keratitis, eyelid oedema and significant aesthetic deformity with proptosis were observed. Significant eyelid incompetence with corneal exposition beyond the sclerocorneal limbus was also present (Fig. 1). Measurements from the anterior pole of the eye to the orbital rim were obtained in a 2-mm section computed tomography (CT) scan. Preoperative measurements of proptosis in the CT scan were
24.37 mm and 25.50 mm for the right and left eye, respectively. Preoperative transverse orbital diameters were 41.02 mm and 41.04 mm for the right and left eye, respectively (Fig. 2). A significant increase in extraocular muscle volume, periorbital fat and connective tissue was observed. Neither optic nerve compression nor associated neuropathy was observed. Diagnosis of Graves´ ophthalmopathy with functional involvement was made. Owing to the unfavorable evolution of the ophthalmopathy, an orbital decompression with removal of the lateral wall and a C-modified osteotomy for bilateral advancement of the orbital rim was performed. The postoperative follow-up was uneventful. Postoperative measurements of proptosis were 15.35 mm and 16.28 mm for the right and left eye, respectively. Postoperative transverse orbital diameters were 46.65 mm and 44.0 mm for the right and left eye, respec-
tively (Fig. 2). These data confirmed the increase in orbital cavity dimensions and amelioration of proptosis. Twelve months following surgery, the patient remains asymptomatic without diplopia or pain. Eyelid competence and adequate ocular motility was achieved. Palpebral oedema and conjunctival injection have disappeared (Fig. 3). Surgical technique
Under general anesthesia and nasotracheal intubation, a coronal approach was used to reach both supraorbital rims, roots of zygomatic archs, lateral orbital walls and inferior orbital rims. Careful subperiostic dissection of the nasal pyramid was performed to facilitate medial dissection of both inferior orbital rims. The supraorbital nerves were freed by means of two small osteotomies of the supraorital rims. Prior to orbital rim osteotomies, a careful subperiosteal dissection of the most
Fig. 2. A Preoperative CT scan; note PA and transverse orbital measurements. B Postoperative CT scan; note new PA and transverse orbital measurements. C Postoperative CT scan; three-quarters view of a 3D-reconstruction.
C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note
855
Fig. 3. Postoperative clinical view. A Frontal view. B Lateral view.
external side of the roof, lateral wall and floor of the orbits was performed. Orbital contents were protected with malleable valves. By means of ultrasound cutting instruments, two vertical osteotomies from the medium point of both supraorbital rims were performed. These osteo-
tomies continued laterally in a 908 fashion, 1 cm parallel to the supraorbital rim. Osteotomies of both lateral orbital rims were performed with an oscillating saw. Osteotomies of both inferior orbital rims were also performed using an oscillating saw, beginning lateral to the infra-
orbital formamen and continuing laterally to connect with the osteotomies of both lateral orbital rims (Fig. 4). Following these manoeuvres, another osteotomy along the most external side of the roof, lateral wall and floor of each orbit was performed, in order to include
Fig. 4. A Surgical view of the supraorbital osteotomy. B Osteotomy of the outer side of the right lateral orbital wall. C Advancement of the left orbital rim and fixation of calvarian bone grafts with miniplates. D Advancement of the right orbital rim and fixation of calvarian bone grafts with miniplates.
856
Gonza´lez-Garcı´a et al.
both superolateral and inferolateral walls together with the orbital rim. Both blocks were then completely freed and advanced. Following this procedure, ostectomy of both lateral walls was performed with forceps. Subsequent herniation of the orbital fat was achieved following incision of the periorbital periostium laterally. Bilateral interposition of calvarial bone grafts was performed between the advanced orbital rims and frontal bone and zygoma. The size of the bone grafts was adjusted to the required advancement. Titanium miniplates were used to stabilize the bone grafts and the osteotomized segments (Fig. 4). The authors consider that orbital rim advancement is dependent on a pronounced advancement of the lateral side of the C osteotomy. This manoeuvre maintains a maximal area of bone contact in the medial side and thus, better stabilization. Once correct adaptation of soft tissues over the reconstruction was checked, closure of the coronal approach in layers was performed. Discussion
Surgical planning for the treatment of Graves’ ophthalmopathy has undergone significant changes since the early decompression orbitotomies of the last century. The prime indication for surgery was visual deficit. With the advent of safer approaches, indications for surgery have grown rapidly, and proptosis and aesthetic deformity have become major indications. The authors prelude surgical management of patients with moderate proptosis in whom corneal integrity is not disrupted, but significant aesthetic deformity is present. Surgery is mandatory for patients with severe proptosis and corneal exposure. In the authors’ opinion, four major indications should be established: ocular nerve neuropathy; severe orbital inflammation; severe exophthalmos; and significant aesthetic deformity. In 1911, Dollinger described the lateral orbitotomy. In 1931, Haffzinger described an approach through the orbital roof with associated craniotomy. Ethmoidectomy and partial removal of the medial orbital wall was popularized by SEWALL2. In 1957, WALSH & OGURA11 described the transantral approach for the removal of the medial orbital wall and the floor of the orbit. Some other techniques include the endoscopic approach, zygomatic bone osteotomy with removal of the floor of the orbit and medial wall, and three to four wall removal3. The authors consider that severe cases may benefit from wide surgical treatment, to reduce oedema in orbital
fat and facilitate orbital expansion to neighbouring areas. The transantral approach has been widely used, with acceptable results regarding improvement of visual acuity. GARRITY et al.4 in a series of 428 orbital decompressions, encountered 65% of patients with better visual accuracy at the end of the procedure. The paranasal endoscopic approach allows safer and more accurate bone resection, with less morbidity in sinusal and orbital regions, although significant limitations are present, such as the inadequate exposition of the lateral wall and the impossibility of removing significant quantities of bone in the floor of the orbit, due to the interposition of the infraorbital nerve. In the authors’ opinion, the endoscopic approach for decompression of the medial orbital wall must be performed only by a surgeon expert in paranasal endoscopy to minimize damage to the optic nerve and the risk of subsequent blindness. Endoscopic decompression of the medial orbital wall may generate new onset diplopia or may worsen diplopia due to retropulsion of the globe into the orbit. Some authors7,9,12 report 15–63% diplopia rates following decompression surgery. METSON and SAMAHA8 have described a modification of the traditional endoscopic technique with preservation of a horizontal band of orbital fascia above the medial rectus muscle, to prevent extrusion of the orbital content to the ethmoidal cells. Preservation of a bone bridge between the medial orbital wall and the floor of the orbit in the transantral approach is a reliable technique to prevent inferomedial displacement of the ocular globe. This technique is hardly feasible in the endoscopic approach. In the authors’ opinion, these problems are avoided with the C-modified osteotomy for the advancement of the orbital rim, since the integrity of the inferomedial osseous component is preserved. Ocular globe position is not disturbed in the vertical dimension and most of the orbital floor and roof is preserved, with less risk of enophthalmos, diplopia and disturbance of the anterior cranial fossa. The technique also allows reduction of severe proptosis, greater than 5 mm, which is hardly achievable using traditional orbital decompression techniques. Other authors10 propose orbital fat removal in combination with the removal of the lateral and medial orbital walls. This technique seems to avoid the incidence of persistent postoperative diplopia, in comparison with three-wall orbitotomy. In the authors’ opinion, it is sufficient for most cases with moderate proptosis, but not for
severe cases, such as that presented here. With the proposed technique, the authors think medial orbital removal is unnecessary for most cases. GOLDBERG et al.5 propose the coronal approach and lateral orbitotomy as first options for the treatment of proptosis up to 6 mm. In accordance with these and other authors6, the present authors consider the coronal approach to be a safe and reliable technique for orbital decompression in Graves´ ophthalmopathy. The authors disagree with Goldberg et al. regarding the order of the performance of the lateral orbitotomy, which should occur after the C-modified osteotomy for advancement of the orbital rim. It is simpler to perform the osteotomy of the orbital rim first and then remove the lateral orbital wall with forceps. Patients with advanced orbitopathy obtain functional and aesthetic benefits from the bilateral ‘specular’ design of the orbital osteotomies. The C-modified osteotomy for the advancement of the orbital rim allows enlargement of the potential space for lateral expansion. A clear decrease of eyelid retraction and proptosis is obtained, with subsequent easier closure of the palpebral cleft. In the present case, the authors performed the lateral orbital wall removal together with the removal of the superolateral and inferolateral orbital walls and the advancement of the orbital rim in a single block. This technique is a modification of the classical technique consisting of the removal of the lateral, superior and inferior orbital walls for the treatment of severe exophthalmos. Using this technique, preservation of the structural integrity of most of the orbital floor is achieved, and the risk of potential postsurgical diplopia is substantially decreased. In relation to restoration of bone integrity following the advancement of the orbital rim, the use of the outer cortex of calvarial bone provides adequate stability for the advanced block. Grafting cortical bone avoids collapse of the structure due to pressure from the periorbital soft tissues. In the opinion of the authors, the use of calvarial cortical bone makes the maintenance of the obtained advancement more predictable. Fixation with miniplates is much more stable than with other types of bone grafts. The use of the coronal approach for harvesting the bone graft obviates the necessity for a second surgical field and the associated morbidity. In summary, the authors propose Cmodified osteotomy for bilateral advancement of the orbital rim, superolateral and inferolateral orbital walls, together with
C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note lateral orbitotomy and interposition of calvarial bone graft, as a reliable technique for the treatment of Graves´ orbitopathy. This technique decreases the risk of postsurgical diplopia secondary to removal of the medial wall and the floor of the orbit. It also allows a significant increase of the orbital volume. The stability of the reconstructed structures supports the use of this technique as a predictable method for the reduction of proptosis.
4.
5.
References 1. Almeida F, Eslava JM, Sa´nchez-Ja´uregui. Pezzi M, Martı´nez-Lage JL. Osteotomı´a de avance orbitario para el tratamiento del exoftalmos endocrino severo. Rev Esp Cir Oral Maxilofac 2005: 27: 93–99. 2. Bahn RS. Thyrotropin receptor expression in orbital adipose/connective tissues from patients with thyroid-associated ophthalmopathy. Thyroid 2002: 12: 193–195. 3. Baldeschi L, Wakelkamp IM, Lindeoom R, Prummel M, Wiersinga
6.
7. 8.
WM. Early versus late orbital decompression in Graves’ orbitopathy: a retrospective study in 125 patients. Ophthalmology 2006: 113: 874– 878. Garrity JA, Fatourechi V, Bergstralh EJ, Bartley GB, Beatty CW, Desanto W, Gorman CA. Results of transantral orbital decompression in 428 patients with severe Graves´ ophthalmopathy. Am J Ophthalmol 1993: 116: 533– 547. Goldberg RA, Weinberg DA, Shorr N, Wirta D. Maximal, three-wall, orbital decompression through a coronal approach. Ophthalmic Surg Lasers 1997: 28: 832–843. Kalmann R, Mourits MP, van der Pol JP, Koorneef L. Coronal approach for rehabilitve orbital decompression in Graves´ophthalmopathy. Br J Ophthalmol 1997: 81: 41–45. Metson R, Dallow R, Shore J. Endoscopic orbital decompression. Laryngoscope 1994: 104: 950–957. Metson R, Samaha M. Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique. Laryngoscope 2002: 112: 1753– 1757.
857
9. Shephard KG, Levin PS, Terris DJ. Balanced orbital decompression for Graves´ophthalmopathy. Laryngoscope 1998: 1648–1653. 10. Unal M, Leri F, Konuk O, Hasanreisoglu B. Balanced orbital decompression combined with fat removal in Graves ophthalmopathy: do we really need to remove the third wall? Ophthal Plast Reconstr Surg 2003: 19: 112–118. 11. Walsh TE, Ogura JH. Transantral orbital decompression for malignant exophtalmos. Laryngoscope 1957: 67: 544–549. 12. Wright ED, Davidson J, Codere F, Desrosier M. Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia. J Otolaryngol 1999: 28: 252–256. Address: Rau´l Gonza´lez-Garcı´a c/Los Ye´benes 35 8C 28047 Madrid Spain E-mail: [email protected]
Technical note Reconstructive surgery
C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note
R. Gonza´lez-Garcı´a1, J. Sastre-Pe´rez1, F. J. Rodrı´guez-Campo1, L. Naval-Gı´as1, F. Monje2 1 Department of Oral and Maxillofacial-Head and Neck Surgery, University Hospital La Princesa, Autonoma University, c/ Diego de Leo´n 62, 28006, Madrid, Spain; 2Department of Oral and Maxillofacial-Head and Neck Surgery, University Hospital Infanta Cristina, Badajoz, Spain
R. Gonza´lez-Garcı´a, J. Sastre-Pe´rez, F. J. Rodrı´guez-Campo, L. Naval-Gı´as, F. Monje: C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note. Int. J. Oral Maxillofac. Surg. 2008; 37: 853–857. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The authors present a modification of the classical three-wall orbital decompression for the treatment of Graves’ orbitopathy. It consists of two ‘C’ osteotomies for the bilateral projection of the superolateral, lateral and inferolateral orbital rims, associated with the removal of the lateral orbital walls. This technique is performed following a coronal approach. Ultrasound cutting instruments were used for the osteotomies. They avoided lesion of surrounding soft tissues, such as the duramater and the periorbital tissues. Stabilization of the advanced structure was achieved by interposition of autologous bone graft obtained from the outer cortex of the calvaria. An extreme advancement of the orbital rim with resolution of diplopia, ocular pain and eyelid incompetence was obtained. Using this procedure, a good functional and aesthetic outcome was achieved.
Graves’ orbitopathy is an autoimmune disorder not directly associated with the over-expression of thyroid hormones. Bahn2 has suggested a possible role of CD4+ T cells in the recognition of antigens shared by both thyroid and orbital tissues. Lymphocytes secrete cytokines that stimulate fibroblasts for synthesis and secretion of glucose-amine-glycans, which ultimately allow accumulation of fluid in the periorbital space, muscles and retro-orbital space. Initial clinical symptoms include epiphora, photophobia, eye0901-5027/090853 + 05 $30.00/0
lid retraction and conjunctival injection. The chronic process is accompanied by exophthalmos, compression of the optic nerve and neuropathy. The goal of treatment for Graves´ orbitopathy is to reduce the inflammation of the periorbital soft tissues and orbital congestion. Several management options have been proposed, such as corticoids, immunotherapy and radiotherapy. Their use is debatable in the management of the active phase of the disease, and not beneficial for the inactive phase. Surgical treatment
Keywords: graves’ orbitopathy; proptosis; osteotomy; orbital decompression; bone graft. Accepted for publication 9 May 2008 Available online 7 July 2008
offers an alternative for these challenging cases. Orbital decompression can be achieved by removal of two, three or four orbital walls and associated lipectomy. Different procedures for osteotomy of the orbital rims have been reported1, with some success, although they are rarely used in clinical practice. The patient in this study presented with severe exophthalmos, diplopia, keratitis due to severe ocular exposition, and significant aesthetic deformity. The patient underwent a C-modified osteotomy for the
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
854
Gonza´lez-Garcı´a et al.
Fig. 1. Preoperative clinical view. A Lateral view. B Frontal-upper view.
advancement of the orbital rim, with restitution of osseous integrity using autologous calvarial bone grafts. The technique is described and its advantages with other surgical treatments compared. Case report
A 65-year old man with a 3-year history of Graves’ disease and controlled thyroid function presented with bilateral ocular pain with lateral movements, diplopia and eyelid incompetence. On physical examination, conjunctival injection, keratitis, eyelid oedema and significant aesthetic deformity with proptosis were observed. Significant eyelid incompetence with corneal exposition beyond the sclerocorneal limbus was also present (Fig. 1). Measurements from the anterior pole of the eye to the orbital rim were obtained in a 2-mm section computed tomography (CT) scan. Preoperative measurements of proptosis in the CT scan were
24.37 mm and 25.50 mm for the right and left eye, respectively. Preoperative transverse orbital diameters were 41.02 mm and 41.04 mm for the right and left eye, respectively (Fig. 2). A significant increase in extraocular muscle volume, periorbital fat and connective tissue was observed. Neither optic nerve compression nor associated neuropathy was observed. Diagnosis of Graves´ ophthalmopathy with functional involvement was made. Owing to the unfavorable evolution of the ophthalmopathy, an orbital decompression with removal of the lateral wall and a C-modified osteotomy for bilateral advancement of the orbital rim was performed. The postoperative follow-up was uneventful. Postoperative measurements of proptosis were 15.35 mm and 16.28 mm for the right and left eye, respectively. Postoperative transverse orbital diameters were 46.65 mm and 44.0 mm for the right and left eye, respec-
tively (Fig. 2). These data confirmed the increase in orbital cavity dimensions and amelioration of proptosis. Twelve months following surgery, the patient remains asymptomatic without diplopia or pain. Eyelid competence and adequate ocular motility was achieved. Palpebral oedema and conjunctival injection have disappeared (Fig. 3). Surgical technique
Under general anesthesia and nasotracheal intubation, a coronal approach was used to reach both supraorbital rims, roots of zygomatic archs, lateral orbital walls and inferior orbital rims. Careful subperiostic dissection of the nasal pyramid was performed to facilitate medial dissection of both inferior orbital rims. The supraorbital nerves were freed by means of two small osteotomies of the supraorital rims. Prior to orbital rim osteotomies, a careful subperiosteal dissection of the most
Fig. 2. A Preoperative CT scan; note PA and transverse orbital measurements. B Postoperative CT scan; note new PA and transverse orbital measurements. C Postoperative CT scan; three-quarters view of a 3D-reconstruction.
C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note
855
Fig. 3. Postoperative clinical view. A Frontal view. B Lateral view.
external side of the roof, lateral wall and floor of the orbits was performed. Orbital contents were protected with malleable valves. By means of ultrasound cutting instruments, two vertical osteotomies from the medium point of both supraorbital rims were performed. These osteo-
tomies continued laterally in a 908 fashion, 1 cm parallel to the supraorbital rim. Osteotomies of both lateral orbital rims were performed with an oscillating saw. Osteotomies of both inferior orbital rims were also performed using an oscillating saw, beginning lateral to the infra-
orbital formamen and continuing laterally to connect with the osteotomies of both lateral orbital rims (Fig. 4). Following these manoeuvres, another osteotomy along the most external side of the roof, lateral wall and floor of each orbit was performed, in order to include
Fig. 4. A Surgical view of the supraorbital osteotomy. B Osteotomy of the outer side of the right lateral orbital wall. C Advancement of the left orbital rim and fixation of calvarian bone grafts with miniplates. D Advancement of the right orbital rim and fixation of calvarian bone grafts with miniplates.
856
Gonza´lez-Garcı´a et al.
both superolateral and inferolateral walls together with the orbital rim. Both blocks were then completely freed and advanced. Following this procedure, ostectomy of both lateral walls was performed with forceps. Subsequent herniation of the orbital fat was achieved following incision of the periorbital periostium laterally. Bilateral interposition of calvarial bone grafts was performed between the advanced orbital rims and frontal bone and zygoma. The size of the bone grafts was adjusted to the required advancement. Titanium miniplates were used to stabilize the bone grafts and the osteotomized segments (Fig. 4). The authors consider that orbital rim advancement is dependent on a pronounced advancement of the lateral side of the C osteotomy. This manoeuvre maintains a maximal area of bone contact in the medial side and thus, better stabilization. Once correct adaptation of soft tissues over the reconstruction was checked, closure of the coronal approach in layers was performed. Discussion
Surgical planning for the treatment of Graves’ ophthalmopathy has undergone significant changes since the early decompression orbitotomies of the last century. The prime indication for surgery was visual deficit. With the advent of safer approaches, indications for surgery have grown rapidly, and proptosis and aesthetic deformity have become major indications. The authors prelude surgical management of patients with moderate proptosis in whom corneal integrity is not disrupted, but significant aesthetic deformity is present. Surgery is mandatory for patients with severe proptosis and corneal exposure. In the authors’ opinion, four major indications should be established: ocular nerve neuropathy; severe orbital inflammation; severe exophthalmos; and significant aesthetic deformity. In 1911, Dollinger described the lateral orbitotomy. In 1931, Haffzinger described an approach through the orbital roof with associated craniotomy. Ethmoidectomy and partial removal of the medial orbital wall was popularized by SEWALL2. In 1957, WALSH & OGURA11 described the transantral approach for the removal of the medial orbital wall and the floor of the orbit. Some other techniques include the endoscopic approach, zygomatic bone osteotomy with removal of the floor of the orbit and medial wall, and three to four wall removal3. The authors consider that severe cases may benefit from wide surgical treatment, to reduce oedema in orbital
fat and facilitate orbital expansion to neighbouring areas. The transantral approach has been widely used, with acceptable results regarding improvement of visual acuity. GARRITY et al.4 in a series of 428 orbital decompressions, encountered 65% of patients with better visual accuracy at the end of the procedure. The paranasal endoscopic approach allows safer and more accurate bone resection, with less morbidity in sinusal and orbital regions, although significant limitations are present, such as the inadequate exposition of the lateral wall and the impossibility of removing significant quantities of bone in the floor of the orbit, due to the interposition of the infraorbital nerve. In the authors’ opinion, the endoscopic approach for decompression of the medial orbital wall must be performed only by a surgeon expert in paranasal endoscopy to minimize damage to the optic nerve and the risk of subsequent blindness. Endoscopic decompression of the medial orbital wall may generate new onset diplopia or may worsen diplopia due to retropulsion of the globe into the orbit. Some authors7,9,12 report 15–63% diplopia rates following decompression surgery. METSON and SAMAHA8 have described a modification of the traditional endoscopic technique with preservation of a horizontal band of orbital fascia above the medial rectus muscle, to prevent extrusion of the orbital content to the ethmoidal cells. Preservation of a bone bridge between the medial orbital wall and the floor of the orbit in the transantral approach is a reliable technique to prevent inferomedial displacement of the ocular globe. This technique is hardly feasible in the endoscopic approach. In the authors’ opinion, these problems are avoided with the C-modified osteotomy for the advancement of the orbital rim, since the integrity of the inferomedial osseous component is preserved. Ocular globe position is not disturbed in the vertical dimension and most of the orbital floor and roof is preserved, with less risk of enophthalmos, diplopia and disturbance of the anterior cranial fossa. The technique also allows reduction of severe proptosis, greater than 5 mm, which is hardly achievable using traditional orbital decompression techniques. Other authors10 propose orbital fat removal in combination with the removal of the lateral and medial orbital walls. This technique seems to avoid the incidence of persistent postoperative diplopia, in comparison with three-wall orbitotomy. In the authors’ opinion, it is sufficient for most cases with moderate proptosis, but not for
severe cases, such as that presented here. With the proposed technique, the authors think medial orbital removal is unnecessary for most cases. GOLDBERG et al.5 propose the coronal approach and lateral orbitotomy as first options for the treatment of proptosis up to 6 mm. In accordance with these and other authors6, the present authors consider the coronal approach to be a safe and reliable technique for orbital decompression in Graves´ ophthalmopathy. The authors disagree with Goldberg et al. regarding the order of the performance of the lateral orbitotomy, which should occur after the C-modified osteotomy for advancement of the orbital rim. It is simpler to perform the osteotomy of the orbital rim first and then remove the lateral orbital wall with forceps. Patients with advanced orbitopathy obtain functional and aesthetic benefits from the bilateral ‘specular’ design of the orbital osteotomies. The C-modified osteotomy for the advancement of the orbital rim allows enlargement of the potential space for lateral expansion. A clear decrease of eyelid retraction and proptosis is obtained, with subsequent easier closure of the palpebral cleft. In the present case, the authors performed the lateral orbital wall removal together with the removal of the superolateral and inferolateral orbital walls and the advancement of the orbital rim in a single block. This technique is a modification of the classical technique consisting of the removal of the lateral, superior and inferior orbital walls for the treatment of severe exophthalmos. Using this technique, preservation of the structural integrity of most of the orbital floor is achieved, and the risk of potential postsurgical diplopia is substantially decreased. In relation to restoration of bone integrity following the advancement of the orbital rim, the use of the outer cortex of calvarial bone provides adequate stability for the advanced block. Grafting cortical bone avoids collapse of the structure due to pressure from the periorbital soft tissues. In the opinion of the authors, the use of calvarial cortical bone makes the maintenance of the obtained advancement more predictable. Fixation with miniplates is much more stable than with other types of bone grafts. The use of the coronal approach for harvesting the bone graft obviates the necessity for a second surgical field and the associated morbidity. In summary, the authors propose Cmodified osteotomy for bilateral advancement of the orbital rim, superolateral and inferolateral orbital walls, together with
C-modified osteotomy for bilateral advancement of the orbital rim in Graves´ orbitopathy: a technical note lateral orbitotomy and interposition of calvarial bone graft, as a reliable technique for the treatment of Graves´ orbitopathy. This technique decreases the risk of postsurgical diplopia secondary to removal of the medial wall and the floor of the orbit. It also allows a significant increase of the orbital volume. The stability of the reconstructed structures supports the use of this technique as a predictable method for the reduction of proptosis.
4.
5.
References 1. Almeida F, Eslava JM, Sa´nchez-Ja´uregui. Pezzi M, Martı´nez-Lage JL. Osteotomı´a de avance orbitario para el tratamiento del exoftalmos endocrino severo. Rev Esp Cir Oral Maxilofac 2005: 27: 93–99. 2. Bahn RS. Thyrotropin receptor expression in orbital adipose/connective tissues from patients with thyroid-associated ophthalmopathy. Thyroid 2002: 12: 193–195. 3. Baldeschi L, Wakelkamp IM, Lindeoom R, Prummel M, Wiersinga
6.
7. 8.
WM. Early versus late orbital decompression in Graves’ orbitopathy: a retrospective study in 125 patients. Ophthalmology 2006: 113: 874– 878. Garrity JA, Fatourechi V, Bergstralh EJ, Bartley GB, Beatty CW, Desanto W, Gorman CA. Results of transantral orbital decompression in 428 patients with severe Graves´ ophthalmopathy. Am J Ophthalmol 1993: 116: 533– 547. Goldberg RA, Weinberg DA, Shorr N, Wirta D. Maximal, three-wall, orbital decompression through a coronal approach. Ophthalmic Surg Lasers 1997: 28: 832–843. Kalmann R, Mourits MP, van der Pol JP, Koorneef L. Coronal approach for rehabilitve orbital decompression in Graves´ophthalmopathy. Br J Ophthalmol 1997: 81: 41–45. Metson R, Dallow R, Shore J. Endoscopic orbital decompression. Laryngoscope 1994: 104: 950–957. Metson R, Samaha M. Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique. Laryngoscope 2002: 112: 1753– 1757.
857
9. Shephard KG, Levin PS, Terris DJ. Balanced orbital decompression for Graves´ophthalmopathy. Laryngoscope 1998: 1648–1653. 10. Unal M, Leri F, Konuk O, Hasanreisoglu B. Balanced orbital decompression combined with fat removal in Graves ophthalmopathy: do we really need to remove the third wall? Ophthal Plast Reconstr Surg 2003: 19: 112–118. 11. Walsh TE, Ogura JH. Transantral orbital decompression for malignant exophtalmos. Laryngoscope 1957: 67: 544–549. 12. Wright ED, Davidson J, Codere F, Desrosier M. Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia. J Otolaryngol 1999: 28: 252–256. Address: Rau´l Gonza´lez-Garcı´a c/Los Ye´benes 35 8C 28047 Madrid Spain E-mail: [email protected]