Graves Ophthalmopathy Results of Transantral Orbital Decompression Performed Primarily for Cosmetic Indications Vahab Fatourechi, MD/ James A. Garrity, MD/ George B. Bartley, MD, 2 Erik]. Bergstralh, MS, 3 Lawrence W. DeSanto, MD, 4 Colum A. Gorman, MB, BCh l Purpose: Transantral orbital decompression is effective treatment for excessive proptosis and optic neuropathy due to Graves ophthalmopathy. In these sight-threatening circumstances, patients willingly accept the side effects of orbital decompression. When transantral orbital decompression is performed for cosmetic indications, patients' acceptance of side effects may be different. This study reports detailed results of transantral decompression for 34 patients in whom the indications were primarily cosmetic. Methods: The medical records of 34 patients with Graves ophthalmopathy who had transantral orbital decompression primarily for cosmetic indications were reviewed. Preoperative and postoperative physical features of the eyes were compared. Long-term assessment was formulated from follow-up examination and a follow-up questionnaire. Results: The most notable improvement was in the reduction of proptosis (mean decrease, 5.2 mm). The frequency of asymmetry of proptosis, however, did not improve. Asymmetry was more than 1 mm in 44% of patients preoperatively and in 54% postoperatively. Although the palpebral fissure was decreased by an average of 2.7 mm, upper lid retraction became worse in 12 (43%) of 28 eyes. Of 15 patients who had no diplopia preoperatively, continuous diplopia developed postoperatively in 73%. The patients underwent a total of 37 eye muscle operations and 31 eyelid operations after decompression. Of 29 patients who responded to a long-term follow-up questionnaire, 69% were satisfied with the appearance of the eyes and 31 % found it acceptable. No patient was dissatisfied. SymptomatiC diplopia was present in 6.9% of patients at the time of the follow-up questionnaire. Conclusion: Transantral orbital decompression performed for cosmetic indications in Graves ophthalmopathy may need to be followed by eye muscle and lid operations. These procedures result in a high degree of patient satisfaction. However, a small percentage of patients experience persistent diplopia, despite multiple eye muscle procedures. Ophthalmology 1994;101:938-942
Originally received: July 12, 1993. Revision accepted: November 8, 1993. I Division of Endocrinology, Metabolism, and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.
Infiltrative ophthalmopathy is a phenomenon associated with autoimmune thyroid disease. 1,2 It commonly occurs in patients with hyperthyroidism, but it also can occur in patients with euthyroidism and spontaneous hypothy-
Department of Ophthalmology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.
4 Section of Otolaryngology-Head and Neck Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona.
Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.
Reprint requests to Vahab Fatourechi , MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Fatourechi et al . Transantral Orbital Decompression in Graves Ophthalmopathy roidism. 3 Although clinically detectable eye disease develops in 20% to 50% of patients with hyperthyroid Graves disease, only 3% to 5% of patients with Graves disease have severe ophthalmopathy requiring treatment such as immunosuppression, orbital radiation, or surgical decompression. 4 An eye muscle operation may be required for improvement of function and appearance. An eyelid procedure may be needed for protection of the cornea or for enhanced cosmesis. 2 .4 Orbital decompression may be required in severe cases to expand the orbital volume for decompression of the optic nerve or to improve congestive inflammatory orbitopathy. 5-7 When decompression of the orbit is the treatment goal, we have preferred the transantral approach because there is no external scar and because considerable reduction of proptosis may be achieved. g Although the main indications for transantral orbital decompression are optic neuropathy and severe infiltrative ophthalmopathy unresponsive to other measures,4 disfiguring proptosis alone may be a source of psychologic problems in some patients and may require intervention. g,9 Immunosuppressive therapy and orbital radiation are less effective than orbital decompression for improvement of proptosis. 2 In the current study, we report the results of transantral orbital decompression in 34 patients with Graves ophthalmopathy whose primary reason for operation was a desire for improved cosmesis.
Patients and Methods Between November 1, 1969, and May 30, 1989,491 orbital decompressions were performed at our institution on 462 patients with Graves ophthalmopathy. Transantral orbital decompression was the initial decompression procedure on 446 of these patients. However, 18 of these patients had had an orbital decompression elsewhere before coming to the Mayo Clinic and were excluded from this study. The remaining 428 patients had their first orbital decompression (transantral decompression) done at the Mayo Clinic. From these 428 patients, we reviewed the records of 34 patients who underwent bilateral transantral orbital decompression primarily to improve cosmesis and reduce the psychologic stress of disfiguring ophthalmopathy. Patients with a primary surgical indication of optic neuropathy, symptomatic exposure keratitis, or orbital severe inflammatory signs and symptoms were excluded from the current study and are reported separately. 10 Patients who had orbital decompression performed in preparation for subsequent eye muscle or lid operations also were excluded. . Preoperative and postoperative eye studies included measurement of visual acuity, determination of pupillary function, Krahn exophthalmometry, measurement of palpebral fissures, examination of ocular motility, slitlamp biomicroscopy, ophthalmoscopy, and visual fields, if indicated. Eyelid retraction ofless than 2 mm from the limbus was considered mild, 2 to 4 mm was moderate, and more than 4 mm was severe. The techniques of transantral orbital decompression in which the floor and the
medial wall of the orbit are removed and the orbital contents are allowed to prolapse into the opened ethmoid and maxillary sinus, thereby increasing the orbital volume, have been previously reported. 5,g Twenty-six patients had an "early" return visit and complete eye examination within the first 6 months postoperatively. Twenty-three patients had at least one "late" (beyond 6 months) followup visit at a median of 2.2 years (range, 0.5-18.6 years) after operation. One patient had died of myocardial infarction. Twenty-nine patients (88%) responded to a questionnaire (administered in 1989 or 1990) regarding their eye comfort, diplopia, quality of vision, satisfaction with the appearance of the eyes, and overall satisfaction with the status of the eyes at a median of 12.0 years postoperatively.
Results Demographics Of the 34 patients, 30 (88%) were female and 4 (12%) were male. Their median age was 31 years (range, 16-65 years); 24 patients (71 %) were younger than 40 years of age. All patients had a history of hyperthyroidism (verified by abnormal results of thyroid function tests), except for one patient who had euthyroid Graves ophthalmopathy. Twenty-one patients were receiving thyroid replacement therapy for 131I-induced hypothyroidism. Thyroid dermopathy was present in five patients. Systemic corticosteroid therapy had been administered to five patients, two patients had received retrobulbar steroids, and none had undergone orbital radiation therapy. The median time from the onset of eye symptoms to orbital decompression was 4.4 years (range, 1.2-14.6 years). The median hospital stay was 3 days (range, 2-6 days).
Preoperative and Postoperative Eye Findings Preoperative visual acuity was 20/20 in 60 eyes and 20/ 25 in 8 eyes. Information on early postoperative acuity was available for 50 eyes. Postoperative visual acuity was 20/20 in 47 eyes and 20/25 in 3 eyes. Only one eye showed improvement in visual acuity-from 20/25 to 20/20and one eye worsened-from 20/20 to 20/25. No patient had visual field scotoma, papilledema, or choroidal folds, and none had any of these signs during the postoperative follow-up period. Five eyes had minimal exposure keratitis, which improved within the first postoperative year. The average proptosis measurement (mean ± standard deviation) was 25.9 ± 2.0 mm (range, 22-30 mm) preoperatively and 20.7 ± 2.2 mm (range, 15-25 mm) postoperatively. The mean recession of proptosis was 5.2 ± 2.0 mm (range, 0-9.5 mm). The mean absolute exophthalmometric difference between two eyes (balance) was 0.56 mm preoperatively and 0.73 mm after decompression. Preoperatively, 19 patients (56%) had symmetrical exophthalmos, 13 had a I-mm difference between eyes, 1 had a 2-mm difference, and 1 had a 4-mm difference. Postoperatively, of the 26 patients for whom data were
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available, 12 (46%) had symmetrical eyes, 9 had a I-mm difference, and 5 had a 2-mm difference. Twenty-eight eyes had both preoperative and postoperative grading for the degree oflid retraction. On the first postoperative visit, 13 eyes had no change in upper lid retraction scores, 3 had improvement of upper lid retraction, and 12 had apparent worsening of the upper lid retraction. Fifteen eyes showed improvement in the lower lid retraction score, 13 had no change, and none became worse. The data on actual palpebral fissure width were less complete. Fourteen eyes in seven patients had both preoperative and early postoperative measurement of the width of the palpebral fissures. The mean preoperative width was 14.8 mm (range, 9-22 mm). In the early postoperative period, before other corrective procedures, the mean width of the palpebral fissures was 12.2 mm (range, 8-18 mm), and the median change was a reduction of2.7 mm (range, 0-7 mm).
Strabismus, Diplopia, and Eye Muscle and Eyelid Abnormalities Of the 34 patients, 22 (65%) were free of diplopia preoperatively, whereas only 4 (15%) were free of diplopia on the first postoperative visit. Seventeen patients underwent a total of 32 eye muscle operations; as a result, in late follow-up 39% were free of diplopia, 9% had diplopia only when tired, 48% had diplopia on deviant gaze only, and 4% had continuous diplopia adequately corrected with prism. The degree of diplopia preoperatively and at early and late follow-up is shown in Table 1. Nineteen patients had a total of 31 eyelid operations for correction of lid abnormalities. Three patients had neither lid nor eye muscle operation.
Table 1. Degree of Diplopia before Orbital Decompression, at Early «6 months) Postoperative Visit, and at Late Follow-up in 34 Patients with a Cosmetic Indication for Operation Visit, % of Patients Degree of Diplopia Absent Present only when tired Present only on deviant gaze Present, but correctable with prisms Present, not correctable with prisms
Preoperative (n = 34)
Early (n = 26)
Late" (n = 23)
• Examination was done at a median of 2.2 years postoperatively after a total of 32 eye muscle operations in 17 patients.
Table 2. Results of Questionnaire* after Orbital Decompression in 29 Patients Who Had Operation for Cosmetic Improvement Only Question Are your eyes comfortable? Always Mostly Seldom Never How would you describe your vision? Good Fair Poor No useful vision Do you have double vision? Absent Seldom Mostly Always Are you satisfied with the current appearance of your eyes? Very satisfied Satisfied Acceptable Dissatisfied Are you satisfied with the overall status of your eyes? Yes No
% of Patients 27.6 58.6 10.3 3.4 Right
82.8 13.8 3.4 0.0
72.4 20.7 6.9 0.0
62.1 27.6 3.4t 6.9t 37.9 31.0 31.0 0.0 81.5 18.5
* Questionnaire was completed at a median time of 12 years postoperatively.
Adequately corrected with prisms.
Perioperative Surgical Complications Cerebrospinal fluid leak occurred in one patient and was corrected 4 months postoperatively with an external ethmoidectomy approach. None of the patients had development of meningitis, bleeding, visual loss, or any other medical or surgical complications.
Patient Assessment of Eye Status The results of the questionnaire and the patients' assessment of eye status in relation to eye comfort, diplopia, visual status, and satisfaction with eye appearance are shown in Table 2. In 89.7% of the patients, diplopia was either completely absent or infrequent, and in 10.3% diplopia was either constant or present most of the time, although it was correctable with prisms. The eye appearance was satisfactory in 69% of the patients and acceptable in 31 %. Overall, most patients (82%) were satisfied with their current eye status. Reasons for dissatisfaction were persistent numbness of the upper lid, diplopia, and frequent sinus infections. Three patients reported additional eye muscle operations, and five reported additional lid
Fatourechi et al . Transantral Orbital Decompression in Graves Ophthalmopathy operations performed elsewhere after their transantral orbital decompression at our institution. The preoperative and postoperative appearances of the eyes in two patients are shown in Figures 1 and 2.
Discussion Graves ophthalmopathy is usually mild and does not require specific therapy.4,11 In 5% of patients with Graves disease, ophthalmopathy can be a source of ocular discomfort, lacrimation, photophobia, diplopia, and blurring of vision. In extreme instances, compressive optic neuropathy, exposure keratitis, or corneal ulcers may impair vision. Proptosis, globe asymmetry, periorbital edema, lid retraction, strabismus, and chemosis may cause aesthetic disfigurement and create psychologic and social problems.4 Although physicians primarily are concerned about therapy for functional impairment and sight-threatening consequences, the patients, especially when young, often seek therapy to improve appearance and correct disfigurement. The mean age of the patients in our series was 31 years, whereas the mean age for the total population of patients who underwent transantral orbital decompression at the Mayo Clinic for various other indications was 53 years .10 In the absence of significant proptosis or other indications for orbital decompression, eye muscle and eyelid operations are of proven benefit for the improvement of 1213 H ' f . .IS present, appearance.' owever, 1 severe proptOSIS orbital decompression becomes necessary to reduce exophthalmos. 4-7• 1O, 14-18 Transantral decompression has the advantage of having no external surgical scars. Thus, it may be especially suitable if cosmesis is a concern. Although several publications have discussed the efficacy of orbital decompression for the treatment of optic neuropathy and overall improvement of ophthalmopathy, operations done for cosmetic purposes have not been analyzed in detail. However, 4 of the 34 patients in this report previously were described. 8 In our combined ex-
Figure L A, preoperative appearance of eyes in an 18-year-old patient with Graves ophthalmopathy, B, appearance of eyes 19 months later, after transantral decompression and upper lid recession procedure, Strabismus procedure was not required,
Figure 2. A, preoperative appearance of eyes in a young man with Graves ophthalmopathy. B, appearance of eyes 40 days after bilateral transantral orbital decompression. No other procedure was needed in this patient.
perience of 428 patients who underwent transantral decompression over a 20-year period, only 8% had transantral orbital decompression only to address cosmetic concerns. 1O The most notable result in terms of improvement of appearance was reduction of proptosis (mean reduction, 5.2 mm). Asymmetry of proptosis is of cosmetic concern to patients. The symmetry of proptosis (balance) did not change significantly postoperatively. Thus, bilateral transantral orbital decompression does not seem to improve balance. Before operation, only one patient (2.9%) had persistent diplopia. However, the percentage of patients with persistent diplopia increased to 53.9% after decompression. After multiple eye muscle operations, 4.3% of the patients still had persistent diplopia at late follow-up examination, and 6.9% of the patients who answered the questionnaire also complained of persistent diplopia. However, prisms adequately treated symptomatic diplopia. Thus, in patients who do not have strabismus before transantral orbital decompression for improvement of the appearance, postoperative strabismus may develop and cause cosmetic and functional problems and require multiple operations. Hypoglobus, a known complication of decompression in Graves ophthalmopathy as a result of loss of most of the orbital floor, can create cosmetic problems; in one report, 4.6% of patients had significant hypoglobus requiring operation to elevate the globe. 19 This was not a common occurrence in our patients. After transantral decompression, upper lid retraction does not improve and often worsens because the stiff retracted upper lid remains in position as the globe falls away from the lid. Because of sinking of the globe, lower lid retraction improved in 50% of the eyes, and no patient experienced worsening. We noted a 2-mm reduction in the width of palpebral fissures after decompression alone. This result probably relates to the improvement of proptosis and lower lid retraction. Most patients required eye muscle or eyelid operation to achieve the best cosmetic results. Only three patients did not require either of these operations. The most important criterion of success for cosmetic operations is patient satisfaction. Among our patients,
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69% were satisfied with the eye appearance, and 31 % found it acceptable. No patient was dissatisfied with the appearance of the eyes. However, this desirable outcome was achieved by completion of ophthalmic rehabilitation, which included subsequent eye muscle and eyelid operations. In conclusion, transantral orbital decompression performed primarily for cosmetic rehabilitation satisfies many patients. Although it is effective for improving proptosis and lower lid retraction, upper lid retraction and strabismus usually worsen after transantral decompression. In most patients, optimal cosmetic results may require multiple eye muscle and lid procedures.
References 1. Lipman LM, Green DE, Snyder NJ, et al. Relationship of long-acting thyroid stimulator to the clinical features and course of Graves' disease. Am J Med 1967;43:486-98. 2. Char DH. The ophthalmopathy of Graves' disease. Med Clin North Am 1991;75:97-119. 3. Marcocci C, Bartalena L, Bogazzi F, et al. Studies on the occurrence of ophthalmopathy in Graves' disease. Acta EndocrinoI1989;120:473-8. 4. Bahn RS, Gorman CA. Choice of therapy and criteria for assessing treatment outcome in thyroid-associated ophthalmopathy. Endocrinol Metab Clin North Am 1987; 16:391407. 5. Gorman CA, DeSanto LW, MacCarty CS, Riley Fe. Optic neuropathy of Graves's disease. Treatment by transantral or transfrontal orbital decompression. N Eng! J Med 1974;290:70-5. 6. Garrity lA, McCaffrey TV, Gorman CA. Compression and decompression of orbital contents in Graves' ophthalmopathy. Acta Endocrinol (Copen h) 1989;121(suppl 2): 160-8. 7. Carter KD, Frueh BR, Hessburg TP, Musch De. Longterm efficacy of orbital decompression for compressive optic
13. 14. 15. 16. 17.
neuropathy of Graves' eye disease. Ophthalmology 1991 ;98: 1435-42. DeSanto LW, Gorman CA. Selection of patients and choice of operation for orbital decompression in Graves' ophthalmopathy. Laryngoscope 1973;83:945-59. Warren JD, Spector JG, Burde R. Long-term follow-up and recent observations on 305 cases of orbital decompression for dysthyroid orbitopathy. Laryngoscope 1989;99:35-40. Garrity JA, Fatourechi V, Bergstralh EJ, et al. Results of transantral orbital decompression in 428 patients with severe Graves' ophthalmopathy. Am J Ophthalmol 1993;116:53347. Utiger RD. Treatment of Graves' ophthalmopathy [editorial] . N Eng! J Med 1989;321:1403-5. Mourits MPh, Koorneef L, van Mourik-Noordenbos AM, et al. Extraocular muscle surgery for Graves' ophthalmopathy: does prior treatment influence surgical outcome? Br J Ophthalmol 1990;74:481-3. Weisman RA, Savino PJ. Management of endocrine orbitopathy. Otolaryngol Clin North Am 1988;21 :93-102. Thaller SR, Kawamoto HK. Surgical correction of exophthalmos secondary to Graves' disease. Plast Reconstr Surg 1990;86:411-21. Schaefer SD, Merritt JH, Close LG. Orbital decompression for optic neuropathy secondary to thyroid eye disease. Laryngoscope 1988;98:712-6. Bahn RS, Garrity JA, Gorman CA. Clinical review 13: Diagnosis and management of Graves' ophthalmopathy. J Clin Endocrinol Metab 1990;71 :559-63. MacCarty CS, Kenefick TP, McConahey WM, Kearns TP. Ophthalmopathy of Graves' disease treated by removal of roof, lateral walls, and lateral sphenoid ridge: review of 46 cases. Mayo Clin Proc 1970;45:488-93. Hurwitz JJ, Birt D. An individualized approach to orbital decompression in Graves' orbitopathy. Arch Ophthalmol 1985; 103:660-5. Long JA, Baylis HI. Hypog!obus following orbital decompression for dysthyroid ophthalmopathy. Ophthal Plast Reconstr Surg 1990;6: 185-9.