- Email: [email protected]
Orbital Decompression in Graves’ Ophthalmopathy by Medial and Lateral Wall Removal
Otolaryngology–Head and Neck Surgery (2005) 133, 185-189
Orbital Decompression in Graves’ Ophthalmopathy by Medial and Lateral Wall Removal Stefano Sellari-Franceschini, MD, Stefano Berrettini, MD, Amelia Santoro, MD, Marco Nardi, MD, Salvatore Mazzeo, MD, Luigi Bartalena, MD, Barbara Mazzi, MD, Maria Laura Tanda, MD, and Claudio Marcocci, MD, Aldo Pinchera, MD, Pisa and Varese, Italy OBJECTIVE: The objective of this study is to describe a technique for balanced orbital decompression and to analyze the results. METHODS AND MATERIALS: We conducted a retrospective study of 140 patients (276 orbits). Orbital decompression was carried out by removal of the medial orbital wall by ethmoidectomy and complete removal of the lateral wall by bringing out the entire sphenoid wing together with part of the zygomatic bone down to the inferior orbital fissure. RESULTS: One hundred thirty-six patients underwent bilateral decompression, 4 patients underwent monolateral decompression. Proptosis was reduced on average by 5.3 mm; 28 (20%) patients showed onset or worsening of diplopia. CONCLUSIONS: Medial and lateral approach allows a balanced orbital decompression. As some patients may present different degrees of proptosis and visual impairment, we stress the importance of carefully weighing the preoperative conditions of the individual patient when choosing the surgical approach. © 2005 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved.
D
ecompressive orbitotomy represents an established treatment of Graves’ Ophthalmopathy when steroids do not arrest or reverse the process. Decompression can be carried out by removal of the intraconal fat1 or the orbital walls.2-9 The most commonly used technique is two wall decompression as described by Walsh
From the Department of Neuroscience, Ia ENT division (Drs SellariFranceschini, Berrettini and Santoro) and Ophthalmology Division (Dr Nardi), the Department of Oncology, Transplants, and Advanced Technologies in Medicine, Diagnostic and Interventional Radiology Division (Dr Mazzeo), and the Department of Endocrinology and Metabolism, Orthopaedics and Traumatology, Occupational Medicine (Drs Mazzi, Marcocci, and Pinchera), University of Pisa, and the Department of Clinical and Biological Science (Drs Bartalena and Tanda), University Insubria, Varese.
and Ogura.2 This technique, both in its original as well as modified endoscopic10 formulation, affords good results in terms of reducing the proptosis. However, it also involves a large risk of postoperative diplopia,4-11 which some authors even consider a normal sequela of such surgery.12 Some authors claim that in some cases the procedure requires opening of the lateral wall as well, though they provide neither the relevant indications13 nor the technique for its execution.10,12 Graham et al7 suggest balanced decompression by medial and lateral orbital wall surgery; 2 horizontal osteotomies are carried out on the lateral wall. The osteotomized lateral wall was removed and placed in a new more anterolateral position by lag screw fixation. The bone of the greater wing of the sphenoid can be drilled down through the diploe to the opposite cortex to further expand orbital volume. Goldberg et al8 maintain that lateral wall decompression should produce less new postoperative strabismus than balanced orbital decompression. Another widely-used technique is the 3 walls decompression reported by Mourits et al5 and Kalmann et al14; reportedly, the results are good and have a low incidence of postoperative diplopia. The present report describes the technique that we have adopted; it offers the advantage of providing access to all 4 of the orbit’s bony walls, through various surgical approaches that are both very precise and not very invasive. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, New York, September 19-22, 2004. Reprint requests: Stefano Sellari-Franceschini, MD, Dipartimento di Neuroscienze, Sez. Otorinolaringoiatria Universitaria Ia, Ospedale S. Chiara – Via Savi 10 56100 Pisa, Italy. E-mail address: [email protected].
0194-5998/$30.00 © 2005 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved. doi:10.1016/j.otohns.2005.02.006
186
Otolaryngology–Head and Neck Surgery, Vol 133, No 2, August 2005
Table 1 Patients data
Total
No diplopia
Postoperative diplopia extreme gaze direction diplopia
72
54
10
8
41
16
15
10
27
2
6
19
Pts without preop diplopia Pts with preop extreme gaze direction diplopia Pts with preop primary position diplopia
Moreover, the walls can be removed by degrees, taking the patient’s needs into account.
MATERIALS AND METHODS A total of 276 orbital decompressions were performed with this technique on 140 patients between December 1998 and June 2003; 45 men and 95 women with a mean age of 46.6 years (range, 20 to 67). Four patients underwent a monolateral procedure (Table 1). Preoperative patient evaluation included examination of visual acuity, binocular visual field, intraocular pressure measurements, extraocular muscle function, fundoscopic examination, and measurement of exophthalmos. All patients were euthyroid at the time of surgery. Computer tomographs of the orbits and sinuses were obtained in the axial and coronal planes. All patients were advised that orbital decompression potentially constituted the first in a series of procedures, the possible subsequent ones being muscle surgery for correction of diplopia and corrective eyelid surgery.
SURGICAL TECHNIQUE The purpose of the intervention is to remove the medial and the lateral walls of the orbit together with the lateral part of the roof, the lateral part of the floor, and as needed the posterior part of the floor with the aim of balancing the decompression and adapting it to the needs of the patient (Fig 1). The surgery is performed with the patient under general anesthesia. The first stage of the surgical procedure consists of ethmoidectomy performed while preserving the middle turbinate and, at the outset, the lamina papyracea. Afterward the maxillary sinus is opened through the middle meatus until the orbital floor, the medial wall, and the angle between the 2 walls have been exposed. At this point, the lamina papyracea is removed by separating it from the periorbita with an elevator. Initially, only the posterior half of the lamina papyracea is removed completely. If needed, the removal of lamina papiracea may be wider, always
Primary diplopia
leaving its anterior part not too close the nasofrontal canal and according to Abramoff et al,15 to reduce the risk of postoperative diplopia. These authors, in their study of postoperative motility disturbances, conclude that to prevent ocular motility disturbances as much as possible, it may be advisable to avoid extending osteotomies to the orbital rim. In very serious cases, we may approach the floor, ensuring that only the posterior part is removed. The next stage consists of ab externo exposure of the lateral wall. Initially, we had opted for a coronal approach that allowed for excellent exposure of the lateral wall, but it was found to be too traumatic and poorly tolerated by patients. For this reason, we later came to prefer gaining access through an eyebrow incision, which is far less traumatizing, and from February 2003 we have used a crease lid incision. After displacing the globe medially, a drill fitted with cutting and diamond burrs is used to remove the sphenoid wing as far back as the dura mater of the middle cranial fossa. The angle between the dura mater of the anterior and middle cranial fossae is exposed. Demolition of the lateral aspect of the roof and of the lower segment of the lateral wall down to inferior orbital fissure is carried out to the extent dictated by the needs of the individual case (Fig 2). The medial face of the temporal muscle is then exposed laterally. After bone demolition has been completed, the periorbita is incised. The fibrous connections of the adipose tissue are then carefully severed with scissors or a sickle lancet, being
Figure 1
Balanced medial and lateral orbital decompression.
Sellari-Franceschini et al
Orbital Decompression in Graves’ Ophthalmopathy. . .
187
mary position diplopia in 8. Of the 140 patients, ocular motility improved in 24, remained unchanged in 88, and worsened in 28 patients (Table 1).
COMPLICATIONS
Figure 2 The dura mater of the middle and anterior cranial fossae has been folded back. The lateral section of the orbital roof (frontal bone), the greater sphenoidal wing, and the zygomatic body have been removed. Note the wide space gained for the lateral expansion of the eye.
careful in the upper section not to injure the supraorbital nerve and generally not to cause deviation of the eyeball. The adipose tissue can be partly removed for the purposes of greater decompression and/or balancing of the decompression between the 2 sides. The intraconal fat of the inferotemporal quadrant is generally easy to remove and its removal has a minimal effect on the position of the eyeball. In bilateral forms, bilateral bone demolition is performed first, attempting in the process to bring the 2 eyeballs to the same level. Opening the periorbita and remodeling the adipose tissue are performed alternatively on the 2 sides, always beginning with the worst side where reduction of the proptosis is often more difficult. If 1 of the 2 eyeballs tend to deviate medially, its displacement can be countered by reshaping or removing fat from the lateral compartment; in this event, decompression should be interrupted, especially in patients not presenting preoperative diplopia and/or optic nerve involvement.
RESULTS Follow-up interval ranged from 6 months to 4 years, but proptosis, diplopia, and other postoperative orthoptic examinations were recorded 6 months after surgery. One hundred thirty-six patients underwent bilateral decompression; in 4, it was monolateral. Proptosis was reduced on average by 5.3 ⫾ 2.89 (range, 2.5 to 8 mm). Primary position diplopia was present preoperatively in 27 patients; in 8 of them motility improved postoperatively and in 19 it was unchanged. Diplopia in the extreme directions of gaze only was present preoperatively in 41 patients; postoperatively it disappeared in 16 patients, remained unchanged in 15, and worsened in 10 patients. Seventy-two patients had normal motility preoperatively; postoperatively, motility was unchanged in 54 patients, whereas extreme-position diplopia appeared in 10 and pri-
We observed 2 major intraoperative (rhinoliquorrhea) and 1 major postoperative (meningitis) complications. No cellulitis and no damage to the first or second branches of the trigeminal nerve occurred. Minor liquorrhea, due to very slight damage to the dura of the middle cranial fossa, occurred intraoperatively in few cases; retrobulbar fat closed any fistulae so it should not be considered a major complication. Postoperative minor complications encountered were temporary anesthesia or hypoesthesia of the skin of the lateral aspect of the forehead above the skin incision.
DISCUSSION Graves’ ophthalmopathy is an inflammatory disease of the orbital tissues that especially affects extraocular muscles and fat. After the inflammation has resolved, the extraocular muscles usually remain enlarged as a result of fibrosis and fatty degeneration.14 The most frequently described complication is postoperative ocular imbalance with diplopia. The most widely used technique is the inferomedial orbital decompression2,4,10,12 which, even with the creation of a strut at the ethmoid-maxillary junction, still carries such a high percentage of postoperative diplopia4,8 that some authors do not even consider it to be a complication.12 Afterward balanced decompression with the opening of the lateral wall also was proposed. Mourits et al5 describe a technique that calls for coronal access, medialization of the lamina papyracea, opening of the lateral wall “just enough for a fingertip to fit through,” and fracture of the orbital floor. Reportedly, the results are good and have a low incidence of postoperative diplopia, but the coronal access is not always well accepted by patients. Graham et al7 suggest a balanced decompression that needs the lateralization of the “outfractured” lateral wall. Also Goldberg et al8 maintain the necessity of performing a balanced decompression in many cases but even the lateral wall decompression should produce less new postoperative strabismus than balanced orbital decompression. The difficulty in comparing results of different techniques is due to different degrees of preoperative seriousness of the disease. Each patient presents us with peculiar preoperative conditions with regard to the degree of proptosis, extraocular muscle involvement, presence of optic neuropathy, diplopia, and cosmetic problems. Thus decompression should be adapted to the patient’s needs6 and the surgeon should be able to open any orbital wall. The technique we report is free from disfigurement of the orbital profile and provides a direct approach to any of the
188
Otolaryngology–Head and Neck Surgery, Vol 133, No 2, August 2005
Figure 3
Wide 4-wall decompression of orbit apex.
4 walls with a higher degree of accuracy and a lower risk of complications. Complete boring of the sphenoid wings up to the orbital roof and part of the zygomatic bone provides better balancing of the corrections obtained through the ethmoidectomy and reduces the need to open the floor.8 In fact, in our experience as well, removal of the floor, especially the medial-anterior half, is the main cause of postoperative diplopia. The proposed technique is particularly effective in patients with relatively
Figure 4
serious proptosis or optic neuropathy, as the bone decompression of the posterior part of the orbit is thorough. In our opinion, lateral bone demolition can be performed by a translid approach, which is much less traumatic than the coronal approach, and far superior cosmetically. In the present study, new postoperative diplopia developed in 18 (25% of patients with normal eye motility preoperatively) patients, but only 8 (11%) patients developed primary and/or reading position diplopia postoperatively.
Pre- and postoperative visual fields.
Sellari-Franceschini et al
Orbital Decompression in Graves’ Ophthalmopathy. . .
Figure 5 Zygomatic bone has been spared in order to avoid exacerbating pre-existing diplopia.
Ten (24%) of 41 patients with extreme directions of gaze diplopia worsened, while 16 (39%) improved. Eight (30%) of 27 patients with primary and/or reading position diplopia improved postoperatively. Balanced decompression considering the extraocular muscle involvement allowed a worsening of eye imbalance only in 20% of cases and improvement in 17% of cases. Nineteen percent of the patients operated on presented primary and/or reading position diplopia preoperatively and only 26% of patients postoperatively. The technique allows operating on all the orbital walls, thereby making it possible to balance the reduction of the proptosis while attempting to avoid deviation of the eyeball. By opening the periorbita and remodeling the fat medially and laterally, progressive reduction and balancing of the proptosis can be achieved. If 1 of the eyes tends to diverge, this deviation can be corrected by remodeling or removing some fat. However, further decompression is not attempted in order to avoid causing certain diplopia, except in those patients in whom the seriousness of the neuropathy dictates decompression as much as possible to eliminate compression of the optic nerve (Figs 3 and 4). The degree of demolition of the ethmoid, lateral walls, roof, and lateral aspect of the floor may be graded according to the degree of preoperative proptosis and diplopia. In the most extreme cases of proptosis, the posterior part of the floor can be removed transnasally. Those patients who underwent complete sphenoid and ethmoid demolition experienced adequate proptosis reduction with less need for floor ablation. In some particular situations, the surgeon can elect to leave some segments of a bony wall intact in order to avoid exacerbating pre-existing diplopia (Fig 5) or, in any event, attempt to effect a balanced decompression, keeping in mind the different involvement of the individual extraocular muscles.
CONCLUSIONS The aim of orbital decompression is to reduce proptosis and to avoid a postoperative strabismus, which remains a significant
189
complication of all bony orbital expansion techniques. The technique presented allows the surgeon to achieve a fine balance between medial and lateral decompression, while involving little trauma for patients and a low incidence of postoperative diplopia. In patients with neuropathy due to compression of the optic nerve, all 4 walls can be removed only in the posterior portion of the orbit. The possibility of removing all of the walls, either wholly or in part, as well as some adipose tissue, allows for adapting the technique to the needs of the individual, with the ultimate aim of attaining the maximum decompression in patients with serious neuropathy or limiting the degree of proptosis reduction in order to avoid postoperative diplopia. The opening of the periorbita and the remodeling of adipose tissue called for by the technique remain as potential causes of postoperative diplopia, though 0.5 to 1 cc of fat can be removed inferior to the lateral rectus muscle with only a modest risk of causing diplopia.
REFERENCES 1. Olivari N. Transpalpebral decompression of endocrine ophthalmopathy (Graves’ disease) by removal of intraorbital fat: experience with 147 operations over 5 years. Plast Reconstr Surg 1991;87:627– 43. 2. Walsh TE, Ogura JH. Transantral orbital decompression for malignant exophthalmos. Laryngoscope 1957;67:544 –9. 3. Hurwitz JJ, Birt D. An individualized approach to orbital decompression in Graves’ orbitopathy. Arch Ophthalmol 1985;104:660 –5. 4. Garrity JA, Fatourechi V, Bergstralh EJ, et al. Results of transantral orbital decompresion in 428 patients with severe Graves’ ophthalmopathy. Am J Ophthlmol 1993;116:533– 47. 5. Mourits PhM, Koorneef L, Wiersinga WM, et al. Orbital decompression for Graves’ ophthalmopathy by inferomedial, by inferomedial plus lateral, and by coronal approach. Ophthalmology 1990; 97:637– 41. 6. Maroon JC, Kennerdell JS. Radical orbital decompression for severe dysthyroid exophthalmos. J Neurosurg 1982;56:260 – 6. 7. Graham SM, Brown CL, Carter KD, et al. Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease. Laryngoscope 2003;113(7):1206 –9. 8. Goldberg RA, Perry JD, Hortaleza V, et al. Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy. Ophthal Plast Reconstr Surg 2000;16(4):271–7. 9. Rootman J, Stewart B, Goldberg RA. Orbital surgery: a conceptual aproach, 1st ed. Philadelphia: Lippincott-Raven Publisher; 1995. p. 353– 84. 10. Kennedy DW, Goodstein ML, Miller NR, et al. Endoscopic transnasal orbital decompression. Arch Otolaryngol Head Neck Surg 1990;116: 275– 82. 11. May A, Fries U, Reimold I, et al. Microsurgical endonasal decompression in dysthyroid orbitopathy.Acta Otolaryngol (Stockh) 1999; 119:826 –31. 12. Metson R, Dallow RC, Shore JW. Endoscopic orbital decompression. Laryngoscope 1994;104:950 –7. 13. Metson R, Shore JW, Gliklich RE, et al. Endoscopic orbital decompression under local anesthesia. Otolaryngol Head Neck Surg 1995; 113:661–7. 14. Kalmann R, Mourits PhM, Van der Pol JP, et al. Coronal approach for rehabilitative orbital decompression in Graves’ ophthalmopathy. Br J Ophthalm 1997;81:41–5. 15. Abràmoff MD, Kalmann R, de Graaf MEL, et al. Rectus extraocular muscle paths and decompression surgery for Graves orbitopathy: mechanism of motility disturbances. IOVS 2002;43:300 –7.
Orbital Decompression in Graves’ Ophthalmopathy by Medial and Lateral Wall Removal Stefano Sellari-Franceschini, MD, Stefano Berrettini, MD, Amelia Santoro, MD, Marco Nardi, MD, Salvatore Mazzeo, MD, Luigi Bartalena, MD, Barbara Mazzi, MD, Maria Laura Tanda, MD, and Claudio Marcocci, MD, Aldo Pinchera, MD, Pisa and Varese, Italy OBJECTIVE: The objective of this study is to describe a technique for balanced orbital decompression and to analyze the results. METHODS AND MATERIALS: We conducted a retrospective study of 140 patients (276 orbits). Orbital decompression was carried out by removal of the medial orbital wall by ethmoidectomy and complete removal of the lateral wall by bringing out the entire sphenoid wing together with part of the zygomatic bone down to the inferior orbital fissure. RESULTS: One hundred thirty-six patients underwent bilateral decompression, 4 patients underwent monolateral decompression. Proptosis was reduced on average by 5.3 mm; 28 (20%) patients showed onset or worsening of diplopia. CONCLUSIONS: Medial and lateral approach allows a balanced orbital decompression. As some patients may present different degrees of proptosis and visual impairment, we stress the importance of carefully weighing the preoperative conditions of the individual patient when choosing the surgical approach. © 2005 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved.
D
ecompressive orbitotomy represents an established treatment of Graves’ Ophthalmopathy when steroids do not arrest or reverse the process. Decompression can be carried out by removal of the intraconal fat1 or the orbital walls.2-9 The most commonly used technique is two wall decompression as described by Walsh
From the Department of Neuroscience, Ia ENT division (Drs SellariFranceschini, Berrettini and Santoro) and Ophthalmology Division (Dr Nardi), the Department of Oncology, Transplants, and Advanced Technologies in Medicine, Diagnostic and Interventional Radiology Division (Dr Mazzeo), and the Department of Endocrinology and Metabolism, Orthopaedics and Traumatology, Occupational Medicine (Drs Mazzi, Marcocci, and Pinchera), University of Pisa, and the Department of Clinical and Biological Science (Drs Bartalena and Tanda), University Insubria, Varese.
and Ogura.2 This technique, both in its original as well as modified endoscopic10 formulation, affords good results in terms of reducing the proptosis. However, it also involves a large risk of postoperative diplopia,4-11 which some authors even consider a normal sequela of such surgery.12 Some authors claim that in some cases the procedure requires opening of the lateral wall as well, though they provide neither the relevant indications13 nor the technique for its execution.10,12 Graham et al7 suggest balanced decompression by medial and lateral orbital wall surgery; 2 horizontal osteotomies are carried out on the lateral wall. The osteotomized lateral wall was removed and placed in a new more anterolateral position by lag screw fixation. The bone of the greater wing of the sphenoid can be drilled down through the diploe to the opposite cortex to further expand orbital volume. Goldberg et al8 maintain that lateral wall decompression should produce less new postoperative strabismus than balanced orbital decompression. Another widely-used technique is the 3 walls decompression reported by Mourits et al5 and Kalmann et al14; reportedly, the results are good and have a low incidence of postoperative diplopia. The present report describes the technique that we have adopted; it offers the advantage of providing access to all 4 of the orbit’s bony walls, through various surgical approaches that are both very precise and not very invasive. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, New York, September 19-22, 2004. Reprint requests: Stefano Sellari-Franceschini, MD, Dipartimento di Neuroscienze, Sez. Otorinolaringoiatria Universitaria Ia, Ospedale S. Chiara – Via Savi 10 56100 Pisa, Italy. E-mail address: [email protected].
0194-5998/$30.00 © 2005 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved. doi:10.1016/j.otohns.2005.02.006
186
Otolaryngology–Head and Neck Surgery, Vol 133, No 2, August 2005
Table 1 Patients data
Total
No diplopia
Postoperative diplopia extreme gaze direction diplopia
72
54
10
8
41
16
15
10
27
2
6
19
Pts without preop diplopia Pts with preop extreme gaze direction diplopia Pts with preop primary position diplopia
Moreover, the walls can be removed by degrees, taking the patient’s needs into account.
MATERIALS AND METHODS A total of 276 orbital decompressions were performed with this technique on 140 patients between December 1998 and June 2003; 45 men and 95 women with a mean age of 46.6 years (range, 20 to 67). Four patients underwent a monolateral procedure (Table 1). Preoperative patient evaluation included examination of visual acuity, binocular visual field, intraocular pressure measurements, extraocular muscle function, fundoscopic examination, and measurement of exophthalmos. All patients were euthyroid at the time of surgery. Computer tomographs of the orbits and sinuses were obtained in the axial and coronal planes. All patients were advised that orbital decompression potentially constituted the first in a series of procedures, the possible subsequent ones being muscle surgery for correction of diplopia and corrective eyelid surgery.
SURGICAL TECHNIQUE The purpose of the intervention is to remove the medial and the lateral walls of the orbit together with the lateral part of the roof, the lateral part of the floor, and as needed the posterior part of the floor with the aim of balancing the decompression and adapting it to the needs of the patient (Fig 1). The surgery is performed with the patient under general anesthesia. The first stage of the surgical procedure consists of ethmoidectomy performed while preserving the middle turbinate and, at the outset, the lamina papyracea. Afterward the maxillary sinus is opened through the middle meatus until the orbital floor, the medial wall, and the angle between the 2 walls have been exposed. At this point, the lamina papyracea is removed by separating it from the periorbita with an elevator. Initially, only the posterior half of the lamina papyracea is removed completely. If needed, the removal of lamina papiracea may be wider, always
Primary diplopia
leaving its anterior part not too close the nasofrontal canal and according to Abramoff et al,15 to reduce the risk of postoperative diplopia. These authors, in their study of postoperative motility disturbances, conclude that to prevent ocular motility disturbances as much as possible, it may be advisable to avoid extending osteotomies to the orbital rim. In very serious cases, we may approach the floor, ensuring that only the posterior part is removed. The next stage consists of ab externo exposure of the lateral wall. Initially, we had opted for a coronal approach that allowed for excellent exposure of the lateral wall, but it was found to be too traumatic and poorly tolerated by patients. For this reason, we later came to prefer gaining access through an eyebrow incision, which is far less traumatizing, and from February 2003 we have used a crease lid incision. After displacing the globe medially, a drill fitted with cutting and diamond burrs is used to remove the sphenoid wing as far back as the dura mater of the middle cranial fossa. The angle between the dura mater of the anterior and middle cranial fossae is exposed. Demolition of the lateral aspect of the roof and of the lower segment of the lateral wall down to inferior orbital fissure is carried out to the extent dictated by the needs of the individual case (Fig 2). The medial face of the temporal muscle is then exposed laterally. After bone demolition has been completed, the periorbita is incised. The fibrous connections of the adipose tissue are then carefully severed with scissors or a sickle lancet, being
Figure 1
Balanced medial and lateral orbital decompression.
Sellari-Franceschini et al
Orbital Decompression in Graves’ Ophthalmopathy. . .
187
mary position diplopia in 8. Of the 140 patients, ocular motility improved in 24, remained unchanged in 88, and worsened in 28 patients (Table 1).
COMPLICATIONS
Figure 2 The dura mater of the middle and anterior cranial fossae has been folded back. The lateral section of the orbital roof (frontal bone), the greater sphenoidal wing, and the zygomatic body have been removed. Note the wide space gained for the lateral expansion of the eye.
careful in the upper section not to injure the supraorbital nerve and generally not to cause deviation of the eyeball. The adipose tissue can be partly removed for the purposes of greater decompression and/or balancing of the decompression between the 2 sides. The intraconal fat of the inferotemporal quadrant is generally easy to remove and its removal has a minimal effect on the position of the eyeball. In bilateral forms, bilateral bone demolition is performed first, attempting in the process to bring the 2 eyeballs to the same level. Opening the periorbita and remodeling the adipose tissue are performed alternatively on the 2 sides, always beginning with the worst side where reduction of the proptosis is often more difficult. If 1 of the 2 eyeballs tend to deviate medially, its displacement can be countered by reshaping or removing fat from the lateral compartment; in this event, decompression should be interrupted, especially in patients not presenting preoperative diplopia and/or optic nerve involvement.
RESULTS Follow-up interval ranged from 6 months to 4 years, but proptosis, diplopia, and other postoperative orthoptic examinations were recorded 6 months after surgery. One hundred thirty-six patients underwent bilateral decompression; in 4, it was monolateral. Proptosis was reduced on average by 5.3 ⫾ 2.89 (range, 2.5 to 8 mm). Primary position diplopia was present preoperatively in 27 patients; in 8 of them motility improved postoperatively and in 19 it was unchanged. Diplopia in the extreme directions of gaze only was present preoperatively in 41 patients; postoperatively it disappeared in 16 patients, remained unchanged in 15, and worsened in 10 patients. Seventy-two patients had normal motility preoperatively; postoperatively, motility was unchanged in 54 patients, whereas extreme-position diplopia appeared in 10 and pri-
We observed 2 major intraoperative (rhinoliquorrhea) and 1 major postoperative (meningitis) complications. No cellulitis and no damage to the first or second branches of the trigeminal nerve occurred. Minor liquorrhea, due to very slight damage to the dura of the middle cranial fossa, occurred intraoperatively in few cases; retrobulbar fat closed any fistulae so it should not be considered a major complication. Postoperative minor complications encountered were temporary anesthesia or hypoesthesia of the skin of the lateral aspect of the forehead above the skin incision.
DISCUSSION Graves’ ophthalmopathy is an inflammatory disease of the orbital tissues that especially affects extraocular muscles and fat. After the inflammation has resolved, the extraocular muscles usually remain enlarged as a result of fibrosis and fatty degeneration.14 The most frequently described complication is postoperative ocular imbalance with diplopia. The most widely used technique is the inferomedial orbital decompression2,4,10,12 which, even with the creation of a strut at the ethmoid-maxillary junction, still carries such a high percentage of postoperative diplopia4,8 that some authors do not even consider it to be a complication.12 Afterward balanced decompression with the opening of the lateral wall also was proposed. Mourits et al5 describe a technique that calls for coronal access, medialization of the lamina papyracea, opening of the lateral wall “just enough for a fingertip to fit through,” and fracture of the orbital floor. Reportedly, the results are good and have a low incidence of postoperative diplopia, but the coronal access is not always well accepted by patients. Graham et al7 suggest a balanced decompression that needs the lateralization of the “outfractured” lateral wall. Also Goldberg et al8 maintain the necessity of performing a balanced decompression in many cases but even the lateral wall decompression should produce less new postoperative strabismus than balanced orbital decompression. The difficulty in comparing results of different techniques is due to different degrees of preoperative seriousness of the disease. Each patient presents us with peculiar preoperative conditions with regard to the degree of proptosis, extraocular muscle involvement, presence of optic neuropathy, diplopia, and cosmetic problems. Thus decompression should be adapted to the patient’s needs6 and the surgeon should be able to open any orbital wall. The technique we report is free from disfigurement of the orbital profile and provides a direct approach to any of the
188
Otolaryngology–Head and Neck Surgery, Vol 133, No 2, August 2005
Figure 3
Wide 4-wall decompression of orbit apex.
4 walls with a higher degree of accuracy and a lower risk of complications. Complete boring of the sphenoid wings up to the orbital roof and part of the zygomatic bone provides better balancing of the corrections obtained through the ethmoidectomy and reduces the need to open the floor.8 In fact, in our experience as well, removal of the floor, especially the medial-anterior half, is the main cause of postoperative diplopia. The proposed technique is particularly effective in patients with relatively
Figure 4
serious proptosis or optic neuropathy, as the bone decompression of the posterior part of the orbit is thorough. In our opinion, lateral bone demolition can be performed by a translid approach, which is much less traumatic than the coronal approach, and far superior cosmetically. In the present study, new postoperative diplopia developed in 18 (25% of patients with normal eye motility preoperatively) patients, but only 8 (11%) patients developed primary and/or reading position diplopia postoperatively.
Pre- and postoperative visual fields.
Sellari-Franceschini et al
Orbital Decompression in Graves’ Ophthalmopathy. . .
Figure 5 Zygomatic bone has been spared in order to avoid exacerbating pre-existing diplopia.
Ten (24%) of 41 patients with extreme directions of gaze diplopia worsened, while 16 (39%) improved. Eight (30%) of 27 patients with primary and/or reading position diplopia improved postoperatively. Balanced decompression considering the extraocular muscle involvement allowed a worsening of eye imbalance only in 20% of cases and improvement in 17% of cases. Nineteen percent of the patients operated on presented primary and/or reading position diplopia preoperatively and only 26% of patients postoperatively. The technique allows operating on all the orbital walls, thereby making it possible to balance the reduction of the proptosis while attempting to avoid deviation of the eyeball. By opening the periorbita and remodeling the fat medially and laterally, progressive reduction and balancing of the proptosis can be achieved. If 1 of the eyes tends to diverge, this deviation can be corrected by remodeling or removing some fat. However, further decompression is not attempted in order to avoid causing certain diplopia, except in those patients in whom the seriousness of the neuropathy dictates decompression as much as possible to eliminate compression of the optic nerve (Figs 3 and 4). The degree of demolition of the ethmoid, lateral walls, roof, and lateral aspect of the floor may be graded according to the degree of preoperative proptosis and diplopia. In the most extreme cases of proptosis, the posterior part of the floor can be removed transnasally. Those patients who underwent complete sphenoid and ethmoid demolition experienced adequate proptosis reduction with less need for floor ablation. In some particular situations, the surgeon can elect to leave some segments of a bony wall intact in order to avoid exacerbating pre-existing diplopia (Fig 5) or, in any event, attempt to effect a balanced decompression, keeping in mind the different involvement of the individual extraocular muscles.
CONCLUSIONS The aim of orbital decompression is to reduce proptosis and to avoid a postoperative strabismus, which remains a significant
189
complication of all bony orbital expansion techniques. The technique presented allows the surgeon to achieve a fine balance between medial and lateral decompression, while involving little trauma for patients and a low incidence of postoperative diplopia. In patients with neuropathy due to compression of the optic nerve, all 4 walls can be removed only in the posterior portion of the orbit. The possibility of removing all of the walls, either wholly or in part, as well as some adipose tissue, allows for adapting the technique to the needs of the individual, with the ultimate aim of attaining the maximum decompression in patients with serious neuropathy or limiting the degree of proptosis reduction in order to avoid postoperative diplopia. The opening of the periorbita and the remodeling of adipose tissue called for by the technique remain as potential causes of postoperative diplopia, though 0.5 to 1 cc of fat can be removed inferior to the lateral rectus muscle with only a modest risk of causing diplopia.
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