How Effective is Superolateral Orbital Decompression in Cases of Drug-Resistant Graves’ Ophthalmopathy

Abstract

Introduction: Graves’ ophthalmopathy (GO) is the most common and difficult-to-treat extrathyroidal symptom of Graves’ disease. Though retraction of the upper eyelid is the most common clinical feature of GO, it can have a much more severe clinical manifesta-tion with symptoms such as conjunctival chemosis, keratopathy, extraocular muscle dysfunction, proptosis of the bulb and dysthyroid optic neuropathy. Treatment methods include control of the thyroid function, corticosteroid and immunosuppressive therapy as well as radiotherapy. These approaches are ineffective in one-third of cases, with patients being refractory to all aforementioned therapeutic modalities. In these cases, surgical decompression of the orbit is in order.The spectrum of surgical techniques is wide and varies from decompression of the lateral wall of the orbit to decompression via removal of all four orbital walls. The aim of the current study was to evaluate the results of superolateral orbital decompression. Patients and methods: The study is retrospective and covers the period from January 2009 to January 2019. During that period eight patients with Graves’ ophthalmopathy underwent surgery and were followed up in the Department of Neurosurgery in the Mili-tary Medical Academy, Sofia. The mean age of the patients was 57 years, with the youngest being 30 years old and the oldest – 74 years old. The gender distribution was 1.6/1 with predominance in females (5 women and 3 men). The surgical approach we used is a com-bination of lateral and upper orbitotomy and was described in detail by Al-Mefty. All of patients underwent ophthalmic examinations in the pre- and postoperative period, with special attention to their visual acuity, the condition of the eyelid and the width of the ocular slit. Exophthalmometry was obtained via Hertel’s method. The participants in this study are followed for a period of six months after the operation. Results: All eight patients underwent superolateral orbitotomy. There were a total of ten orbital decompressions. Improvement of visual acuity and reduction of the proptosis were reported in all other surgically treated patients. The mean reported improvement of visual acuity (measured via Snellen’s method) was 0.27±0.17. The mean reported a reduction of proptosis was 7.53±2.58 mm. Conclusions: Although the surgical techniques for orbital decompression we used have significant disadvantages, they remain the only alternative in order to avoid the complication of severe GO.