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Orbital Decompression

Orbital decompression is a specialized orbital surgery that involves either bony or soft-tissue surgery to allow for the eyes to be set back to a more normal position. Proptosis from thyroid eye disease (also referred to as Graves disease, Graves ophthalmopathy, or thyroid ophthalmopathy) is a common reason patients undergo orbital decompression. Proptosis is also referred to as exophthalmos which is a condition where one or both eyes bulge out. Proptosis can lead to both cosmetic deformity and functional problems. Patients can have significant exposure of the eye and cornea, resulting in irritation, eye redness, corneal problems (keratopathy), tearing problems, potential ocular infections, and even vision loss from optic neuropathy (pressure onto the optic nerve).

Why Patients Choose Dr. Zoumalan for Their Orbital Decompression Surgery

Dr. Zoumalan trained with internationally recognized orbital surgeons in New York, using the latest innovations in orbital decompression. Depending on each patient, either soft-tissue decompression (also termed orbital fat decompression), bony decompression, or both are necessary in producing the desired results.

The Orbital Decompression Procedure

Orbital fat decompression allows for an adequate reduction in mild to moderate proptosis (2-4mm of reduction). However, if the patient needs to undergo more reduction in proptosis (moderate to severe cases), bony decompression is necessary. The goal of orbital decompressive surgery is to restore the normal volume relationship between the orbital soft tissues and the surrounding orbital bone volume. Orbital decompression reduces proptosis and intraorbital pressure. It subsequently improves orbital congestion, allows for improvement in corneal exposure, and can also address compressive optic neuropathy. Various methods of orbital decompression have been described, such as removal of orbital fat (orbital fat decompression) and one or more of the four orbital walls, with or without the use of endoscopic visualization.

Causes of Orbital Socket Problems

Thyroid eye disease (TED) is associated with Graves disease (GD) in over 80% of cases, and is an autoimmune disorder characterized by inflammation and expansion of the orbital fat and extraocular muscles. Although it has been identified in all age groups, it primarily affects adults in their thirties and forties. TED can profoundly impair a patient’s ability to work and perform activities of daily living. The pathophysiology of TED is not completely understood; but TED has both an active phase and an inactive, or chronic, phase. The active phase generally persists for six months to three years, and is typically longer in smokers and those with prolonged hypothyroidism. Nevertheless, the duration and severity of disease varies within each individual and can often be unpredictable. After the inflammatory process ends, fibrosis and the associated disabling symptoms persist in the stable, inactive phase. Typically, orbital decompression surgery is performed in the stable, inactive phase in order to get the optimal resuts while reducing the risk of reactivation of TED. However, if there is vision loss from optic neuropathy during the active phase, orbital decompression may have to be performed immediately.

Who is a Candidate for Orbital Decompression Surgery?

The type of decompression applied depends on the needs of the patient, the degree of proptosis, and the technical skills of the surgeon. The selection of a surgical procedure varies based on a complete clinical examination, CT or MRI interpretation, and the patient’s facial photographs from years prior to the onset of TED. The clinical examination includes Hertel exophthalmometry (objective measurement of the amount of proptosis), upper and lower lid retraction, lagophthalmos (do the eyelids completely shut during sleep or not?), evidence of double vision, and corneal exposure. Patients with pre-existing double vision from TED are at risk for having this worsen after orbital decompressive surgery.

In general, the number of bones to be decompressed are based on the desired decompressive effect. Usually, Dr. Zoumalan performs a lateral wall decompression in combination with an endoscopically mediated medial wall decompression. If further decompression is required, the orbital floor of the orbit is also decompressed.

Common Question and Answers
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    Preoperative Diagnosis: Bilateral thyroid eye disease resulting in proptosis, lagophthalmos, and lower lid retraction.

    Procedure Performed: Bilateral orbital fat decompression and left orbital bony decompression (Stage 1) and lower lid retraction repair using hard palate grafts and lateral canthoplasties (Stage 2).

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    Preoperative Diagnosis: Bilateral thyroid eye disease resulting in proptosis, lagophthalmos, and lower lid retraction.

    Procedure Performed: Bilateral orbital fat decompression and left orbital bony decompression (Stage 1) and lower lid retraction repair using hard palate grafts and lateral canthoplasties (Stage 2).

  • image

    Preoperative Diagnosis: Bilateral thyroid eye disease resulting in proptosis, lagophthalmos, and lower lid retraction.

    Procedure Performed: Bilateral orbital fat decompression and left orbital bony decompression (Stage 1) and lower lid retraction repair using hard palate grafts and lateral canthoplasties (Stage 2).

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    Preoperative Diagnosis: Bilateral thyroid eye disease resulting in proptosis, lagophthalmos, and lower lid retraction.

    Procedure Performed: Bilateral orbital fat decompression and left orbital bony decompression. This allowed for an improvement in up to 3.5-4mmin proptosis reduction and better closure of eyelids. The lower lid position is improved as well.