Critical Appraisal on Orbital Decompression for Thyroid Eye Disease: A Systematic Review and Literature Search

Abstract

IntroductionOrbital decompression is the indicated procedure for addressing exophthalmos and compressive optic neuropathy in thyroid eye disease. There are an abundance of techniques for removal of orbital bone, fat, or a combination published in the scientific literature. The relative efficacy and complications of these interventions in relation to the specific indications remain as yet undocumented. We performed a systematic review of the current published evidence for the effectiveness of orbital decompression, possible complications, and impact on quality of life.MethodsWe searched the current databases for medical literature and controlled trials, oculoplastic textbooks, and conference proceedings to identify relevant data up to February 2015. We included randomized controlled trials (RCTs) comparing two or more interventions for orbital decompression.ResultsWe identified only two eligible RCTs for inclusion in the review. As a result of the significant variability between studies on decompression, i.e., methodology and outcome measures, we did not perform a meta-analysis. One study suggests that the transantral approach and endonasal technique had similar effects in reducing exophthalmos but the latter is safer. The second study provides evidence that intravenous steroids may be superior to primary surgical decompression in the management of compressive optic neuropathy requiring less secondary surgical procedures.ConclusionMost of the published literature on orbital decompression consists of retrospective, uncontrolled trials. There is evidence from those studies that removal of the medial and lateral wall (balanced) and the deep lateral wall decompression, with or without fat removal, may be the most effective surgical methods with only few complications. There is a clear unmet need for controlled trials evaluating the different techniques for orbital decompression. Ideally, future studies should address the effectiveness, possible complications, quality of life, and cost of each intervention.

The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy

“…Different techniques of decompression [118], lid lengthening and cosmetic surgery can be applied depending on the severity of the orbitopathy, anatomical background, concomitant diseases, patient expectations and social/cultural background. No technique fits all.…”

Dysthyroid optic neuropathy: update on pathogenesis, diagnosis, and management

“…The transcaruncular approach allows for quick, safe access to the orbital apex for removal of the medial and inferior walls[43,89,99]. It allows for more medial wall exposure than the transcutaneous approach, but it avoids adverse structural or functional consequences associated with a cutaneous incision.…”

“…This technique allows for a graded approach to removing the ethmoidal air cells and the inferior wall to preserve as much of the maxillo-ethmoidal strut as desired, lowering the risk of new-onset postoperative diplopia[43,89]. A meta-analysis of techniques for DON surgical decompression described the transcaruncular approach as easy and safe access to the orbital apex[99]. …”

Cutting‐edge endonasal surgical approaches to thyroid ophthalmopathy

“…Clinical ramifications include severe proptosis, lid retraction with exposure keratitis, diplopia, compressive myopathy, and in severe cases, compressive optic neuropathy (CON) and vision loss. GO is typically characterized by two phases—an active inflammatory phase followed by a chronic, or fibrotic, phase …”

“…Unfortunately, the overwhelming majority of literature published on this subject is retrospective in nature and heterogenous in design. Thus, a comparison of outcomes across techniques has not yet proven feasible . Nonetheless, the available literature supports the rapid ascension of the endonasal endoscopic approach as one of the more versatile techniques in orbital decompression surgery.…”