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

Abstract

Purpose Despite the number of publications on orbital decompression surgery for thyroid eye disease (TED), there are few comparative studies and most studies are underpowered. The goal of our study is to use multivariable analysis to identify independent patient and disease-related predictors of response to decompression surgery and of need for secondary decompressions. Methods We retrospectively reviewed all patients who underwent transorbital thyroid-related orbital decompression surgery at the Kellogg Eye Center of the University of Michigan between 1999 and 2014. Demographic, medical, and surgical covariates were collected. Decompression techniques included medial, lateral, and balanced decompressions, with or without orbital fat removal. Main outcomes included proptosis reduction and secondary decompressions, both analyzed at the orbital level. Univariate and multivariable analyses (with adjustment for inter-orbit correlation) were conducted to determine predictors of our outcomes of interest. Results Mean proptosis reduction was 3.8 ± 2.4 mm (mean ± standard deviation, N = 420 orbits). The secondary decompression rate was 13.8% (82/594). On multivariable mixed linear regression, larger preoperative proptosis (P < 0.0001), balanced decompression (P = 0.0002), TED duration < 4 years (P = 0.0093), and history of orbital radiation (P = 0.0111) were all predictive of greater proptosis reduction. On multivariable survival modeling, factors associated with increased hazard for secondary decompression include younger age (P = 0.0434), larger preoperative proptosis (P = 0.0001), unilateral decompression (P = 0.0272), preoperative steroid treatment (P = 0.0200), and normal thyroid function (P = 0.0148). Factors associated with decreased hazard include adjunctive fat decompression (P = 0.0004), balanced decompression (vs lateral, P = 0.0039), and African-American ethnicity (P = 0.0076). Conclusions Despite a diverse study cohort, we have identified factors associated with clinically relevant outcomes of decompression surgery for TED, including proptosis reduction and incidence of secondary decompression. Randomized controlled trials of different treatment algorithms for thyroid eye disease are needed to devise optimized guidelines for individualizing surgical care.

Teprotumumab, an insulin-like growth factor-1 receptor antagonist antibody, in the treatment of active thyroid eye disease: a focus on proptosis

“…The level of proptosis reduction produced by teprotumumab is comparable with the −3.8 mm reported in a recently published retrospective trial of 169 patients with TED (319 eyes) undergoing orbital decompression [22]. Similarly, in another recently published retrospective study of 263 patients (420 orbits) who had decompression for TED at one institution, the mean reduction in proptosis was also −3.8 mm [23]. The proptosis reduction achieved with teprotumumab (mean −3.14 [range −1.0 to −6.0] mm) at week 24 compares favorably with the proptosis reduction achieved with surgery.…”

Teprotumumab: The Dawn of Therapies in Moderate-to-Severe Thyroid-Associated Ophthalmopathy

“…In addition, QoL and visual function of TMB group were prominently improved at all assessment time points, which was higher than that of placebo. The remarkable reduction of proptosis was similar to the report after decompression surgery [25,90]. However, orbital surgery may lead to the recurrence of ophthalmopathy and may cause or aggravate diplopia [25,57,91].…”

“…A variety of procedures for surgical decompression include balanced decompression, medial and floor decompression, lateral wall decompression, and orbital fat decompression. Orbital surgery may cause recurrence of ophthalmopathy and may cause or aggravate diplopia [25]. Garrity at al.…”

Balancing orbital volume reduction and redistribution for a tailored surgical treatment in Graves’ ophthalmopathy

“…Ultimately, the goal of decompression surgery is to increase the patient's quality of life by improving the aesthetics and functionality, while decreasing subjective complaints. Most of the existing studies describe a decrease in orbital discomfort following orbital decompression surgery [26,27]. In our study, all the included patients described a reduction in local pain and retro-ocular pressure feeling.…”