Korean J Ophthalmol.  2014 Feb;28(1):1-11. 10.3341/kjo.2014.28.1.1.

Graded Decompression of Orbital Fat and Wall in Patients with Graves' Orbitopathy

• Lee KH
• Jang SY
• Lee SY
• Yoon JS

• KMID: 1792088
• DOI: http://doi.org/10.3341/kjo.2014.28.1.1

Abstract

PURPOSE
To investigate the results of graded decompression of orbital fat and walls in Graves' orbitopathy (GO) considering the degree of proptosis reduction at surgery and preoperative computed tomography (CT) findings.
METHODS
This is a retrospective interventional case series. Graded orbital fat and wall decompression was performed in 90 orbits of 55 patients. In patients with enlarged extraocular muscles and minimal orbital fat proliferation in preoperative CT scans, one- or two-wall decompression of posterior orbit was performed with minimal fat excision. In other cases, the maximal amount of fat tissue was removed from the post-septal area to the apex. If the proptosis was not satisfactorily symmetrically reduced at surgery, one- or two-wall decompression was performed successively. Symmetric reduction of proptosis was consistently confirmed intraoperatively to assure that a desired amount of exophthalmos reduction was achieved.
RESULTS
Four types of decompression were performed: fat only (group 1), fat and one-wall (group 2), fat and two-wall (group 3), and two-wall and minimal fat decompression (group 4). The mean preoperative Hertel value (20.6 +/- 2.8 mm) was reduced significantly at six months postoperatively (16.1 +/- 2.3 mm). Proptosis significantly decreased with a mean of 4.3 +/- 1.7 mm, and the reduction was greatest (5.1 +/- 2.1 mm) in group 3. In group 1, a significant correlation between Hertel change and the volume of resected orbital fat was found (r = 0.479). Diplopia was newly developed or aggravated postoperatively in eight patients, and six of these patients were in group 3. With the exception of one patient, visual acuity improved to nearly normal postoperatively in all patients with optic neuropathy.
CONCLUSIONS
Graded orbital decompression of orbital fat and bony walls, as assessed by the degree of proptosis reduction during surgery, was effective and predictable with minimal complications in GO patients with vision-threatening or cosmetically disfiguring proptosis.

Keyword

Decompression; Exophthalmos; Graves ophthalmopathy; Orbit

MeSH Terms

Adipose Tissue/*surgery
Adult
Aged
Decompression, Surgical/*methods
Female
Follow-Up Studies
Graves Ophthalmopathy/diagnosis/*surgery
Humans
Male
Middle Aged
Orbit/*surgery
Retrospective Studies
Tomography, X-Ray Computed
Treatment Outcome
Young Adult

Figure

• 

  Fig. 1 Algorithm of the surgical approach for orbital fat and/or bony decompression according to preoperative computed tomography (CT) scans in patients with Graves' orbitopathy. When preoperative CT scans showed significant extraocular muscle (EOM) enlargement with minimal fat proliferation, posterior one-wall (ethmoid) or two-wall (combined with orbital floor, including the posterior strut) decompression was performed without fat removal or with minimal fat removal (less than 1 mL). However, if increased orbital fat volume was primarily observed, rather than EOM enlargement shown in CT scans, the maximal amount of extraconal fat tissue was removed from the inferotemporal area, towards the medial orbit, with conservative removal of intraconal fat tissues. If proptosis was not sufficiently and symmetrically reduced during surgery, a one-wall or two-wall decompression was added successively until sufficient reduction of proptosis was achieved.

• 

  Fig. 2 Intraoperative photographs showing fat removal method. After removal of the post-septal medial, central, and lateral fat pads, maximal amounts of caruncular (A), inferolateral and inferomedial fat tissues (B) were removed through transcaruncle and canthofornix incision after careful dissection of intermuscular septa without damaging the medial, inferior rectus muscle (IR) and inferior oblique (IO) muscle. (C,D) Fat was removed until the surface of the IO muscle, and inferior and medial rectus muscle (MR) were clearly visible, and was further resected immediately proximal to the anterior end of the inferior ophthalmic fissure. Superomedial fat was additionally removed by incising the intermuscular septum above the MR, and for further decompression, the deep and posterior loose intraconal fat was carefully removed until satisfactory reduction of proptosis was achieved using forceps and scissors conservatively. Severe exophthalmos (E) was significantly reduced (F) by the removal of orbital fat. The level of corneal apex became lower than the eyelids. *Deep posterior intraconal fat.

• 

  Fig. 3 Intraoperative photographs showing adjustment of the decompression method according to intraoperative assessment of proptosis reduction (A) By Hertel exophthalmometry, 22.5 and 24 mm of exophthalmos in the right and left eyes, respectively were measured before surgery. (B) After the removal of the maximal amount of fat (right, 4.8 mL OD; left, 3.8 mL OS) in both eyes, satisfactory reduction of proptosis was achieved in the right eye through fat-only decompression. However, a posterior two-wall decompression was further performed in the left eye to achieve a sufficient proptosis reduction. Finally, the level of cornea apex became lower as much as desired amount of decompression with symmetry. (C) Preoperative computed tomography (CT) scans (axial, coronal, and sagittal views) shows significant increases in fat volume without extraocular muscle involvement. (D) Postoperative CT scans (axial, coronal, and sagittal views) show significantly decreased volumes of extraconal and intraconal fat tissues, especially at the inferior orbit in both eyes.

• 

  Fig. 4 Preoperative and postoperative photographs and computed tomography (CT) scans in a 70-year-old female patient with compressive optic neuropathy, proptosis, restrictive myopathy, and congestion due to Graves' orbitopathy, who underwent orbital fat and posterior two-wall decompression. (A) Preoperative photographs and CT scans. Red dotted line indicates the outline of fat removal. (B) Postoperative photographs and CT scans at 6 months after surgery. Congestive symptoms and signs including chemosis, conjunctival injection, caruncular swelling, and lid erythema and swelling all resolved after surgery. Compressive optic neuropathy was also completely resolved.

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