Images Of Complications After Orbital Decompression Surgery

(b)

The lamina papyracea is infractured medially and the ethmoidectomy completed, keeping posterior to the posterior lacrimal crest and below the level of the anterior ethmoidal artery; bone excision is continued inferiorly until the medial part of the orbital floor is removed. The periosteum is incised widely, to allow free prolapse of orbital fat into the areas of bone removal, and the anterior periosteal incision and superficial tissues closed in layers.

Extended lateral canthotomy approach

The lateral canthotomy approach (Figure 11.7), with extension of the incision along the lower conjunctival fornix (the "lower

Figure 11.6 Ten millimetre reduction in left proptosis after three-wall orbital decompression performed through an extended lateral canthotomy incision (a). Preoperative views (b,c) and five weeks after surgery (d,e).

Figure 11.6 Ten millimetre reduction in left proptosis after three-wall orbital decompression performed through an extended lateral canthotomy incision (a). Preoperative views (b,c) and five weeks after surgery (d,e).

lid swinging flap"), provides excellent access to the orbital floor, although decompression of the medial wall requires greater dexterity than with the Lynch approach as access is more restricted. A 1-2 cm extension of the canthotomy into the lateral part of the upper eyelid skin crease (Figure 11.8a) eases access to, and decompression of, the lateral wall.

A horizontal canthotomy of 1.5 cm is made and the orbicularis oculi cauterised and divided infero-laterally to the orbital rim; division of this muscle must be continued until there is a clear release of the lateral tethering of the lower eyelid. The conjunctiva is divided at a point 1 mm below the lower border of the lower tarsus and the conjunctival edge attached to the upper eyelid with a

0 Bicoronal flap approach

© Lateral canthotomy approach

@ Lynch external ethmoidectomy approach

Figure 11.7 Incisions for orbital decompression through (a) Lynch external ethmoidectomy approach; (b) lateral canthotomy approach; (c) the bicoronal flap approach.

4/0 nylon suture - this acting to protect the cornea and to keep the lower orbital septum tight during subsequent preparation of a pre-septal skin-muscle flap (Figure 11.8b). The periosteum is opened at the rim, raised widely across the orbital floor and medially up to the level of the ethmoido-frontal suture. The medial part of the orbital floor is fractured with a surgical clip, as much as necessary of the floor and medial wall removed (Figure 11.8c) and the periosteum excised or incised widely over the area of bone removal; it is prudent to preserve the infero-medial bone strut between the maxilla and ethmoid, as this maintains aeration of the maxillary sinus.

If the lateral wall is to be removed, the outer quarter of the upper eyelid skin-crease is divided to reach the level of the superficial temporalis fascia and the periosteum divided 8 mm outside the rim. The periosteum is raised over the rim and into the orbit, the lateral wall removed in part (Figure 11.8d) or whole, and the periosteum below the orbital lobe of the lacrimal gland incised or excised. The periosteal incision may be continued upwards just anterior to the orbital lobe and, when clear of the gland, directed posteriorly along the orbital roof to allow the orbital lobe to fall posteriorly into the defect in the lateral wall (Figure 11.8e) - this repositioning of the gland, together with the marked reduction in proptosis, restoring the depth of the upper eyelid sulcus.

The lateral periosteal strip, to which the intact upper limb of the lateral canthal tendon is still attached, is fixed around the residual bone of the rim and, after placement of a vacuum drain in the intraconal space and sub-temporalis space, the lower fornix incision and canthotomy closed in layers with absorbable sutures.

After instillation of an antibiotic ointment into the conjunctival sac, a 4/0 lower lid traction ("Frost") suture is placed on traction to the forehead and a firm eye dressing applied for 12-18 hours.The vacuum drain and patient are monitored for abnormal haemorrhage.

Subciliary blepharoplasty approach

This approach is similar to the extended lateral canthotomy, except that the preseptal, post-orbicularis plane is reached through a subciliary incision. The technique and view is otherwise identical for the two procedures.

Bicoronal scalp-flap approach

The scalp is shaved 2-3 cm behind the hairline, the operative field prepared and both eyelids closed with tarsorrhaphy sutures. A scalp incision, down to the periosteum, is placed parallel to the hair line (Figure 11.7), compressive haemostatic clips placed, and the flap raised down to the brow ridge. The deep layer of the temporalis fascia is followed down to the level of the zygomatic arch, thereby avoiding branches of the facial nerve.

The pericranium is incised 2 cm above the orbital rim and the periosteal flap raised inferiorly, using (if necessary) an osteotome to

Malleable Osteotome

release the supraorbital neurovascular bundle from its canal. Using malleable retractors in a hand-over-hand technique, the periosteum is raised across the roof and lateral wall of the orbit and, likewise, the temporalis muscle is raised from its fossa. The thinnest part of the lateral wall is shown by transillumination and an osteotome used to breach the wall at this

Figure 11.8 Extended lateral canthotomy approach to orbital decompression: (a) skin incisions for three wall decompression; (b) lower conjunctiva closed over the cornea, with preparation of a lower eyelid swinging flap which provides excellent access to the orbital floor; (c) infraorbital nerve visible after removal of the bone of the orbital floor; (d) the lateral wall has been removed behind an undisturbed orbital rim; (e) the lacrimal gland settles backwards behind the orbital rim, restoring the depth of the upper eyelid sulcus.

Figure 11.8 Extended lateral canthotomy approach to orbital decompression: (a) skin incisions for three wall decompression; (b) lower conjunctiva closed over the cornea, with preparation of a lower eyelid swinging flap which provides excellent access to the orbital floor; (c) infraorbital nerve visible after removal of the bone of the orbital floor; (d) the lateral wall has been removed behind an undisturbed orbital rim; (e) the lacrimal gland settles backwards behind the orbital rim, restoring the depth of the upper eyelid sulcus.

point, the orbital contents being protected at all times; the breach is extended with rongeurs until adequate lateral wall removal has been accomplished. A series of incisions, to the depth of Richter's muscle, are made in the periosteum above the orbital rim, this increasing flap mobility and reducing thyroid "frown". The medial wall and accessible parts of the orbital floor are removed, the periosteum incised to maximise prolapse of orbital fat and the temporalis fascia closed with 3/0 non-absorbable sutures. Vacuum drains are placed across the subgaleal space from each temporalis fossa, the periosteum closed with a 4/0 absorbable suture and the scalp incision closed with surgical staples. A firm scalp dressing is applied and the vacuum drains maintained until dry.

Post operative management and complications

The patient should be nursed half-seated on bed-rest, to minimise post operative swelling, and (where accessible) the pupils checked for a few hours after surgery. If the patient complains of severe or increasing pain, the affected side should be examined for signs of rising intraorbital pressure due to haemorrhage and appropriate measures taken if it is impairing optic nerve function.

Post operative antibiotics and anti-inflammatory drugs (such as prednisolone 80mg daily, tailing over about ten days) should be administered and the patient instructed to avoid nose-blowing and strenuous exercise over this period. Forced ocular ductions are to be encouraged, as this probably encourages clearance of post operative oedema and recovery of normal ocular balance and movements.

With administration of post operative systemic antibiotics, early infection is rare but sinusitis, particularly maxillary, can be a recurrent late complication of decompression and may require middle meatal antrostomy or other corrective procedure. Under- or over-correction of the proptosis may occur (Figure 11.9 a) and, very rarely, the latter (enophthalmos) may be accompanied by hypoglobus.

Loss of vision is extremely rare, but the patient must be made aware of this remote possibility prior to surgery.

Diplopia is almost universal after surgery, will settle within a few weeks in most cases, but presents the greatest practical problems with the activities of daily living. If diplopia is troublesome, it is worthwhile occluding one eye in the early post operative period for those activities (such as descending stairs) where a second image is distracting or dangerous. Where there is no risk with diplopia - as, for example, with watching television - the patient should be encouraged to try and fuse the two images.

Other complications, such as persistent infraorbital neuropraxia, nasolacrimal duct obstruction with epiphora, or secondary lower lid entropion, are uncommon. Likewise, major intraoperative or post operative (Figure 11.9b) haemorrhage, or loss of cerebro-spinal fluid is relatively rare.

Figure 11.9 Complications of orbital decompression: (a) late enophthalmos due to maxillary atelectasis; (b) limited orbital haemorrhage after third-time revisional orbital decompression.

Figure 11.9 Complications of orbital decompression: (a) late enophthalmos due to maxillary atelectasis; (b) limited orbital haemorrhage after third-time revisional orbital decompression.

Further reading

Bartalena L, Marcocci C, Bogazzi F et al. Relation between therapy for hyperthyroidism and the course of Graves' ophthalmopathy. New Engl J Med 1998; 338:73-8.

Burch HB, Wartofsky L. Graves' ophthalmopathy: current concepts regarding pathogenesis and management. Endocrinology Rev 1993; 14:747-93.

Char DH. Thyroid eye disease (3rd ed.) Boston: ButterworthHeinemann, 1997.

Claridge KG, Ghabrial R, Davis G et al. Combined radiotherapy and medical immunosuppression in the management of thyroid eye disease. Eye 1997; 11:717-22.

Consensus of an ad hoc committee. Classification of eye changes of Graves' disease. Thyroid 1992; 2:235-6.

Fatourechi V, Garrity JA, Bartley GB, Bergstralh EJ, DeSanto LW, Gorman CA. Graves' ophthalmopathy. Results of transantral orbital decompression performed primarily for cosmetic indications. Ophthalmology 1994; 101:938-42.

Garrity JA, Fatourechi V, Bergstralh EJ et al. Results of transantral orbital decompression in 428 patients with severe Graves' ophthalmopathy. Am J Ophthalmol 1993; 116:533-47.

Hales JB, Rundle FF. Ocular changes in Graves' disease: a long term follow-up study. QJM 1960; 29:113-9.

Kalmann R, Mourits MP, van der Pol JP, Koornneef L. Coronal approach for rehabilitative orbital decompression in Graves' ophthalmopathy. Br J Ophthalmol 1997; 81:41-5.

Lyons CJ, Rootman J. Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy. Ophthalmology 1994; 101:223-30.

McCord CD Jr. Orbital decompression for Graves' disease; exposure through lateral canthal and inferior fornix incision. Ophthalmology 1981; 88:533-41.

Metson R, Dallow RL, Shore JW. Endoscopic orbital decompression. Laryngoscope 1994; 104:950-7.

Mourits MP, Koornneef L, Wiersinga WM, Prummel MF, Berghout A, van der Gaag R. Clinical criteria for the assessment of disease activity in Graves' ophthalmopathy; a novel approach. Br J Ophthalmol 1989; 73:639-44.

Mourits MP, Koornneef L, Wiersinga WM, Prummel MF, Berghout A, van der Gaag R. Orbital decompression for Graves' ophthalmopathy by inferomedial, by inferomedial plus lateral, and by coronal approach. Ophthalmology 1990; 97:636-41.

Naniaris N, Hurwitz If, Chen JC,Wortzman G. Correlation between computed tomography and magnetic resonance imaging in Graves' orbitopathy. Can J Ophthalmol 1994; 29:9-19.

Olivari, N. Transpalpebral decompression of endocrine ophthalmopathy (Graves' disease) by removal of intraorbital fat: experience with 147 operations over 5 years. Plast Reconstr Surg 1979; 87:627-41.

Perros P, Crombie AL, Kendall-Taylor P. Natural history of thyroid associated ophthalmopathy. Clin Endocrinol Oxf 1995; 42:45-54.

Prummel MF, Wiersinga WM. Medical management of Graves' ophthalmopathy. Thyroid 1995; 5:231-4.

Prummel Mf, Wiersinga WM, Mourits MP et al. Effect of abnormal thyroid function on severity of Graves' ophthalmopathy. Arch Intern Med 1990; 150:1098-101.

Shine B, Fells P, Edwards OM, Weetman OP. Association between Graves' ophthalmopathy and smoking. Lancet 1990; 335:1261-3.

Tagami T, Tanaka K, Sugawa H, et al. High-dose intravenous steroid pulse therapy in thyroid-associated opthalmopathy. Endocr J 1996; 43:689-99.

Trokel S, Kazim M, Moore S. Orbital fat removal. Decompression for Graves' orbitopathy. Ophthalmology 1993; 100:674-82.

Werner SC. Classification of changes in Graves' disease. J Clin Endocrinol Metab 1969; 29:982-9.

Wulc A, Popp JC, Bartlett SP. Lateral wall advancement in orbital decompression. Ophthalmology 1990; 97:1358-69.

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