Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

Abstract

To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS: Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS: Exophthalmometry reduction was statistically significant in both groups (po0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24 ± 6.9 and 12 ± 8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (po0.05) and third (po0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (po0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS: IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Postoperative diplopia after medial–inferior orbital wall decompression in patients with thyroid eye disease

“…In the setting of severe exophthalmos or preoperative diplopia in primary gaze, additional studies are needed to validate whether the medial-lateral approach is better for this cohort of patients with TED requiring decompression. 6 Although our series demonstrates low rates of postoperative diplopia, there are limitations and room for future inquiry. Our data was limited by the retrospective nature and lack of a comparison group.…”

“…Nonetheless, in patients without diplopia, the MAI offers a low morbidity option without significantly increasing the rate of postoperative diplopia. In the setting of severe exophthalmos or preoperative diplopia in primary gaze, additional studies are needed to validate whether the medial‐lateral approach is better for this cohort of patients with TED requiring decompression 6 …”

Update on the surgical management of Graves’ orbitopathy

“…Balanced decompression may significantly improve mild-to-moderate proptosis in patients lacking diplopia. The mean proptosis reduction was 3.1 to 5.6 mm ( 45 , 73 – 75 ); this reduction was statistically significant, and the extent of reduction was greater in double-wall groups than in single-wall groups ( 76 ). Proptosis reduction was more evident in patients with higher preoperative Hertel values; significantly lower reductions were apparent in patients with less preoperative proptosis ( 75 ).…”

Unveiling Promising Modalities and Enhancing Patient Outcomes in Graves’ Disease Treatment: A Systematic Review and Meta-Analysis

“…More exophthalmos reduction and a more seamless postoperative recovery are provided by ML-OD. New-onset esotropia is possible in patients with preoperatively enlarged medial rectus muscles on CT, and preoperative esotropia is likely to worsen following OD [ 26 ].…”