Multidisciplinary approach to orbital decompression. A review

Abstract

Endoscopic orbital surgery has become a highly evolving multidisciplinary surgical field thanks to development in technical skills of ophthalmologists and otolaryngologists. These advances expanded the clinical application of orbital decompression, with a growing body of literature describing the multidisciplinary management of thyroid eye disease and compressive optic neuropathy, since 1990. Although techniques have improved considerably, only few Randomized Control Trials (RCT) provide evidence to support recommendations in clinical practice. This review provides an overview of the current knowledge of orbital decompression to clarify which is the most standardized therapeutic strategy. In the literature, we observed several approaches with contradicting results and the comparison of different surgical techniques was biased by inclusion of patients at different stage of disease (active or inactive), different surgical indications (dysthyroid neuropathy or disfiguring proptosis) and measures of outcomes (such as different system for ocular motility evaluation). The timing of surgical decompression is one of the debated issues. One RCT focusing on Graves' orbitopathy showed how intravenous corticosteroids achieve better visual recovery than surgical orbital decompression; but in case of absent or poor response to medical therapy the patient should undergo surgery within two weeks. There is slight evidence that the removal of the medial and lateral wall (so-called balanced decompression) with or without fat removal could be the most effective surgical technique, with low complication rate, but an increasing number of authors are promoting, for selected cases, a pure endoscopic surgical approach (with removal of medial and infero-medial orbital wall), less invasive than the balanced one; the latter indicated to more severe proptosis or diplopia after endoscopic procedure. Three-wall decompression is chosen for high degrees of proptosis, but complications are more frequent. Timing of surgical orbital decompression, in particular when a concomitant optic neuropathy is present, is still to be determined. Additional ophthalmological procedures are needed to restore normal eye function and cosmesis. Strabismus surgery to address diplopia and lowering the position of the upper eyelid represent some of the additional steps for the final rehabilitation of Graves' orbitopathy. The main clinical outcomes including visual acuity, proptosis, and new-onset diplopia are changing. Recent studies focused on the development of imaging measurements in order to objectively evaluate the surgical results and QOL questionnaires are gaining increasing importance. KEY WORDS: nasal endoscopy, orbital decompression, thyroid eye disease, compressive optic neuropathy RIASSUNTO La chirurgia endoscopica orbitaria rappresenta un ambito multidisciplinare in costante evoluzione grazie allo sviluppo delle tecniche sia in ambito oftalmologico che otorinolaringoiatrico. Tali progressi hanno esteso le applicazioni cliniche della decompressione orbitar...

Interdisziplinäre Therapie der Erkrankungen der Orbita

“…1) Die knöcherne Dekompression ist im Hinblick auf einen postoperativen Visusgewinn und Rückgang des Exophthalmus der reinen Fettgewebsresektion überlegen 2) Die Dekompression sollte immer bis in die Orbitaspitze durchgeführt werden, da sich hier der größte hydrostatische Druck auf den N. opticus findet. Es gibt einige Evidenz in der Literatur, dass eine balancierte Dekompression mit oder ohne Fettresektion die effektivste Methode mit relativ wenig Komplikationen ist [202,218,236,241].…”

“…Operative Maßnahmen stellen eine Zweitlinienbehandlung dar. Es bestehen im Wesentlichen in Abhängigkeit von dem Aktivitätsgrad der Erkrankung 3 Indikationen für die OD bei EO 217 218 :…”

Optimization of the treatment of moderate to severe and active thyroid orbitopathy considering the recommendations of the European Group on Graves’ Orbitopathy (EUGOGO) [Optymalizacja leczenia umiarkowanej do ciężkiej i aktywnej orbitopatii tarczycowej z uwzględnieniem zaleceń European Group on Graves’ Orbitopathy (EUGOGO)]

“…Additional ophthalmologic procedures, i.e. strabismus surgery and lowering of the upper eyelid position, are necessary to restore normal eye function and appearance [119,120]. Topical treatment (lubricating drops, vitamin A eye ointments, moist chambers, tarsorrhaphy) can be used in active TO as an emergency treatment to shield the cornea in the case of corneal surface damage, thus reducing the risk of corneal perforation [121].…”

“…Trójścienną dekompresję wybiera się w przypadku dużego stopnia proptozy, ale obarczona jest ona większą częstością powikłań, a zwłaszcza dwojenia pooperacyjnego. W celu przywrócenia prawidłowej funkcji wzroku i wyglądu konieczne są dodatkowe operacje okulistyczne, czyli operacja zeza w celu usunięcia diplopii i obniżenia położenia powieki górnej [119,120]. Leczenie miejscowe (krople nawilżające, maści oczne z witaminą A, komory wilgotne, tarsorafia) mogą być stosowane w aktywnej OT jako leczenie doraźne, służące osłonie rogówki w przypadku uszkodzeń jej powierzchni, zmniejszając w ten sposób ryzyko jej perforacji [121].…”

Treatment of moderate to severe and active thyroid orbitopathy during SARS-CoV-2 pandemic.

“…In the active phase of OT, decompression surgery is indicated in patients with severe exposure keratopathy and, as second-line treatment, in patients with DON unresponsive to i.v. glucocorticosteroids [20,73].…”