Characterization and Outcomes of Repeat Orbital Decompression for Thyroid-Associated Orbitopathy

Abstract

Orbital decompression for thyroid-associated orbitopathy (TAO) is commonly performed for disfiguring proptosis, congestion, and optic neuropathy. Although one decompression typically achieves goals, a small percentage requires repeat decompression. We performed a 10-year retrospective chart review of all orbital decompressions for TAO at a single tertiary referral institution. Four-hundred and ninety-five orbits (330 patients) were decompressed for TAO, with 45 orbits (37 patients) requiring repeat decompression. We reviewed the repeat cases for indications, clinical activity scores, approach, walls decompressed, and outcomes. Nine percent of orbits required repeat decompression for proptosis (70%), optic neuropathy (25%) or congestion (45%). Sixty-four percent were for recurrence of disease, 36% were for suboptimal decompression. Three incisional approaches were used: lateral upper eyelid crease, inferior transconjunctival, and transcaruncular, with inferior transconjunctival being most common. Of the three walls removed, deep lateral, inferior, and medial, the deep lateral wall was most common (51%). A repeat lateral decompression was the most frequent pattern. Of 37 patients requiring repeat decompression, 40% had diplopia prior to repeat, and an additional 24% developed diplopia after the repeat. Whereas previous studies published by our group cited only 2.6% of deep lateral wall orbital decompressions leading to new-onset primary gaze diplopia, repeat orbital decompressions have a much higher rate of post-operative diplopia. The new onset primary gaze diplopia after repeat decompression group had a higher average preoperative CAS (3.3 vs. 2.4, p < 0.01), higher mean blood loss (56 vs. 19 mL, p = 0.04), more frequent medial wall decompressions (47% vs. 29%, p = 0.33), and greater proptosis reduction (2.4 vs. 1.7 mm, p = 0.24).

Long-term outcomes of orbital fat decompression in Graves’ orbitopathy

“…The incidence of secondary decompression in this study was 0.6% (10 of 1604 eyes) that occurred much lower than 13.8%9 and 9%24 reported in bony decompression. Our cases with secondary decompression had ~2 mm larger preoperative proptosis (23.7±2.1 mm) than those without (21.1±1.6 mm) suggesting that the extent of preoperative proptosis may be a crucial factor to determine proptosis recurrence after orbital fat decompression.…”

Thyroid-Related Orbital Decompression Surgery: A Multivariate Analysis of Risk Factors and Outcomes

“…Our incidence rate is similar to the 9% reported in a descriptive study in 2014. 22 Proptosis and exposure keratopathy were the most common indications for secondary decompression. As expected, larger preoperative proptosis confers increased hazard for secondary decompression, suggesting that more surgeries are necessary to correct larger preoperative proptosis.…”

Preoperative clinical features of reactivated of Graves’ orbitopathy after orbital decompression

“…9,12 With the evolution in surgical techniques over the past few decades, orbital decompression has come to be performed not only in cases of compressive ON and exposure keratitis that are nonresponsive to medical treatment but also in cases of cosmetic disfigurement and orbital congestion. 13,14 Thus, the number of orbital decompression procedures being performed has increased over time. However, since there has been a clinical hypothesis that surgery itself can activate antigen-presenting cells and orbital fibroblasts that produce proinflammatory cytokines, 15 the probability of reactivation of GO due to orbital decompression has also increased.…”