Long‐term follow‐up of patients with thyroid eye disease treated with endoscopic orbital decompression

Abstract

ABSTRACT.Purpose: To evaluate the outcome of endoscopic decompression in a series of patients with thyroid eye disease. Methods: All 46 patients operated at our institution in the period 2001 to 2011 were invited for re-examination. Thirty-seven patients were included in the study and underwent a general otorhinolaryngological and ophthalmological examination. Nasal endoscopy, autoperimetry and a CT scan of the orbits and paranasal sinuses were performed. Preoperative and early postoperative data were obtained from hospital records. Re-examination was performed from 12 months to 9 years postoperatively. Paired t-test was used to evaluate the change in pre-and postoperative data. Image-guided surgery was used in two patients. Results: Visual acuity improved from a median value (range) of 0.8 (0.05-1.25) to 1.0 (0.4-1.25) (p = 0.006). Intra-ocular pressure (IOP) was reduced from a median value (range) of 18 mmHg (10-27 mmHg) to 14 mmHg (8-24 mmHg) (p < 0.001). Median (range) Hertel values were 22.5 mm (14-29 mm) preoperatively and 19 mm (11-26 mm) postoperatively (p < 0.001). Mean reduction in proptosis was 4.0 mm. At follow-up, visual fields were normal in 16/37 patients (43%) and with small defects in 12/37 patients (32%). Seventeen patients (46%) had diplopia preoperatively in one or more directions of gaze while 9 (24%) suffered from constant diplopia. After endoscopic decompression, new onset diplopia was seen in seven (19%) individuals, while worsening of diplopia occurred in eight (22%). Impaired motility in abduction and/or elevation was seen in 20 (54%) individuals before decompression and in 23 (62%) after. Strabismus surgery was performed in 22 patients. On final examination 85% of the study population were totally free of diplopia or experienced diplopia only in the peripheral field of gaze. Three patients developed sinusitis. Of these, endoscopic sinus surgery was performed in two patients, and one patient was conservatively treated. Symptoms resolved in all three patients. Conclusion: Endoscopic medial orbital decompression including removal of the medial floor of the orbit is a safe and effective procedure for treatment of thyroid eye disease. Navigation can be of valuable help to ensure complete resection of the bony walls. However, the majority of patients will need subsequent strabismus surgery, mainly due to significant increase of esotropia.

Current trends in the management of thyroid eye disease

“…Although studies show normalization of visual acuity and optic nerve head edema after decompression surgery, almost half of patients have persistent visual field defects [51]. This finding underscores that signs of optic nerve involvement may persist despite adequate decompression and anti-inflammatory treatment.…”

Update on thyroid-associated Ophthalmopathy with a special emphasis on the ocular surface

“…Endoscopic techniques may allow decompression with less morbidity, accessing areas with good visibility and less exposure. Purely endoscopic procedures and intraoperative surgical tailoring with personalized boney decompression have resulted in good outcomes [90]. These procedures can reduce intraocular tension and provide pain relief, improve strabismus and correct postural visual obscuration in patients with orbital and optic nerve microvasculopathy [90].…”

“…Purely endoscopic procedures and intraoperative surgical tailoring with personalized boney decompression have resulted in good outcomes [90]. These procedures can reduce intraocular tension and provide pain relief, improve strabismus and correct postural visual obscuration in patients with orbital and optic nerve microvasculopathy [90]. The most common surgical complications include de novo onset or worsening of preexisting strabismus and globe dystopia [89, 91].…”

“…The most common surgical complications include de novo onset or worsening of preexisting strabismus and globe dystopia [89, 91]. Despite normalization of visual acuity and resolution of optic nerve head edema, almost half of patients with substantial nerve damage will manifest persistent visual field defects following adequate decompression [90]. On the other hand, improvement in severe vision loss as late as 3-month after onset has been reported following decompression, suggesting that the procedure may be effective in reversing DON in patients with NLP vision [92].…”

Long-term outcomes of orbital fat decompression in Graves’ orbitopathy

“…These results were consistent with previous studies in which proptosis reduction ranged from 3 to 5.9 mm at 12,12 16,19 2217 and 3620 months follow-up. The amount of proptosis reduction for solely fat decompression in this study was also comparative with those of bony decompression with21 or without22 the endoscopic approach that reported 4 and 4.45 mm, respectively, in the long-term follow-up.…”