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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 32-34

Efficacy of lateral orbital rim decompression in patients with prior rim-sparing, three-wall orbital decompression


1 Department of Ophthalmology, University of Miami, Bascom Palmer Eye Institute, Miami, FL; Oculofacial Plastic Surgery of Hawaii, Honolulu, HI, USA
2 UC San Diego School of Medicine, La Jolla, CA, USA
3 Oculoplastic Service, Chelsea & Westminster Hospital London, SW10 9NH, UK, England, UK
4 Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology; Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, CA, USA

Date of Submission14-Dec-2021
Date of Acceptance17-Dec-2021
Date of Web Publication28-Feb-2022

Correspondence Address:
Dr. Don O Kikkawa
Shiley Eye Institute, 9415 Campus, Point Drive, La Jolla, CA 92093
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjo.tjo_56_21

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  Abstract 


PURPOSE: The purpose was to study the effects of removal of the lateral orbital rim in patients with prior three-wall decompression for thyroid eye disease (TED).
MATERIALS AND METHODS: This was a single-institution retrospective case series of patients presenting with symptoms and signs of residual symptomatic proptosis that had previously undergone three-wall decompression for TED. Data collected included patient age, gender, presenting symptoms, ocular history, proptosis reduction, and complications.
RESULTS: Eleven orbits were identified. The mean preoperative exophthalmometry for the operative eye was 24.0 mm with 2.7 mm of relative proptosis. Removal of the lateral orbital rim resulted in a mean reduction in proptosis of 2.5 mm (range: 0.5–5.0 mm, P < 0.001). There was no significant change in diplopia, lagophthalmos, margin reflex distance (MRD) 1, MRD2, or exposure keratopathy. No canthal deformities were noted. All subjects reported satisfaction with functional and cosmetic outcomes of lateral orbital rim removal, and none reported problems with external contour irregularities of the lateral canthal region.
CONCLUSION: Removal of the lateral orbital rim as part of a maximal orbital bony decompression adds to the decompressive effect of proptosis reduction with minimal side effects.

Keywords: Lateral wall decompression, orbital decompression, orbital rim removal, thyroid eye disease


How to cite this article:
Lee BW, Kim JS, Scawn RL, Korn BS, Kikkawa DO. Efficacy of lateral orbital rim decompression in patients with prior rim-sparing, three-wall orbital decompression. Taiwan J Ophthalmol 2022;12:32-4

How to cite this URL:
Lee BW, Kim JS, Scawn RL, Korn BS, Kikkawa DO. Efficacy of lateral orbital rim decompression in patients with prior rim-sparing, three-wall orbital decompression. Taiwan J Ophthalmol [serial online] 2022 [cited 2022 Jun 26];12:32-4. Available from: https://www.e-tjo.org/text.asp?2022/12/1/32/338538




  Introduction Top


Orbital decompression is the treatment of choice for functionally disfiguring exophthalmos secondary to thyroid eye disease (TED). For patients with severe exophthalmos, a “maximal decompression” typically refers to a lateral rim-sparing, three-wall orbital decompression with fat removal. Incomplete decompression surgery or disease progression can result in residual exophthalmos that may cause persistent symptoms, signs, and disfigurement. In these cases, further decompression may be necessary to achieve improved patient outcomes if medical therapies are unsuccessful.

Many strategies exist for handling the lateral orbital rim during lateral wall decompression surgery. Some surgeons may not remove the lateral orbital rim during orbital decompression surgery due to concerns about functional impairment and cosmetic deformity, whereas others may remove the rim for improved visualization but replace it at the end of the surgery.[1],[2],[3]

Several studies have looked at the functional and esthetic outcomes when removing the lateral orbital rim as part of a primary lateral orbital decompression surgery.[2],[3],[4],[5],[6],[7] These studies used different surgical techniques and showed a fairly wide range of proptosis reduction between studies, and conclusions were mixed. Sagiv et al. studied the issue of replacement versus removal of the orbital rim in patients undergoing two- and three-wall decompressions and supported the idea of removal of the rim without replacement.[3] Meanwhile, Zhang et al. studied rim-sparing versus rim-removal lateral orbital decompression and concluded that rim-sparing was preferable in their study due to better improvement in quality of life.[2]

This study evaluated functional, cosmetic, and patient satisfaction outcomes associated with secondary lateral orbital rim decompression (LORD) in patients who had previously undergone rim-sparing, three-wall orbital decompression with continued symptomatic exophthalmos. In choosing this study population, we aimed to isolate and study the direct effect of LORD based on the authors' surgical technique when prior deep lateral wall decompression had already been performed.


  Materials and Methods Top


This retrospective, interventional case series included 11 subjects with severe TED who had undergone prior rim-sparing, three-wall orbital decompression who subsequently underwent LORD surgery for residual exophthalmos. Institutional review board approval (HRPP #180153) and patient consent were obtained for this study.

Technique

Through an upper eyelid crease incision, the lateral orbital rim was completely removed en bloc from the frontozygomatic suture to the zygomatic arch using an oscillating saw or through direct burring with a diamond burr drill to remove the entire lateral orbital rim while leaving a very thin layer of bone overlying the temporalis muscle.

Primary outcomes included change in exophthalmos, change in relative proptosis, complications, cosmesis of the lateral canthal region, presence or absence of masticatory oscillopsia, development of new strabismus, and patient satisfaction. Secondary outcomes included change in margin reflex distance (MRD) 1, MRD2, and exposure keratopathy. SPSS (IBM, Armonk, New York, USA) was used to perform statistical analysis including calculating t-tests.


  Results Top


Eleven orbits underwent secondary LORD surgery. The mean preoperative exophthalmometry for the operative eye was 24.0 mm with 2.7 mm of relative proptosis. LORD resulted in a mean reduction in proptosis of 2.5 mm (range: 0.5–5.0 mm, P < 0.001) [Table 1]. There was no significant change in lagophthalmos, MRD1, MRD2, or exposure keratopathy.
Table 1: Patient data of study cases

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There were no instances of complications associated with LORD surgery, such as worsened diplopia, decreased vision, pupillary abnormalities, or masticatory oscillopsia. There were no external deformities of the lateral canthal region that were appreciable by either the treating physician or the patient. All subjects reported satisfaction with functional and cosmetic outcomes of LORD, and none reported problems with external contour irregularities of the lateral canthal region.


  Discussion Top


Patients with persistent exophthalmos and symptomatic TED who have already undergone a “maximal decompression” can be clinically challenging. In cases where this is due to reactivation or progression of orbital inflammation, medical therapies such as biologic therapy may be effective in reducing proptosis and orbital inflammation.[8] However, in the setting where there is minimal active orbital inflammation, the surgeon must determine a plan for revisional surgery that can further reduce exophthalmos and treat the symptoms of TED.

In certain cases, a postoperative computed tomography scan can easily reveal areas where a prior three-wall decompression surgery was incompletely performed and where additional volume could be created. Often, the revisional surgery may require removing the residual bone that is closest to the dura, the skull base, the middle cranial fossa, or the infraorbital nerve with the associated risk of injuring these structures. However, once complete internal decompression of all walls is performed, including the deep lateral wall, the surgeon has limited remaining options, such as decompressing the orbital roof (potentially in conjunction with a neurosurgeon) or removing the lateral orbital rim if it was not removed with the primary surgery.

Various studies have examined primary lateral wall decompression surgery that includes rim removal. Some of these studies used a surgical approach through an upper eyelid crease incision (as was done in this study), whereas others used a lateral canthotomy incision or swinging eyelid incision. Unsurprisingly, these studies showed a wide range of proptosis reduction, most likely due to varying amounts of bone removal in the deep lateral wall, as well as varying amounts of fat removal.

We controlled for this potential variability in this study by examining the effect of lateral orbital rim removal in patients who had already had a prior three-wall decompression, including the deep lateral wall. This more closely isolated the effects of rim removal on proptosis reduction and on any adverse effects in function and cosmesis. Using the authors' surgical technique, LORD resulted in additional mean proptosis reduction of 2.5 mm and had an excellent safety profile and a high degree of patient satisfaction. While LORD was successfully performed in this study with either an oscillating saw or a diamond burr drill, our technique has shifted toward using a diamond burr drill in order to preserve a very thin layer of bone overlying the temporalis muscle. This has the benefit of serving as a barrier to prevent potential adhesions between the temporalis and the rectus muscles and also reducing the risk of potential masticatory oscillopsia. It also helps to prevent the collapse of the temporalis muscle into space previously occupied by the lateral orbital wall, which could potentially reduce the decompressive effect and result in subtle temporal hollowing. Men et al. have described a technique for using an implant to further expand the orbit and prevent the collapse of the temporalis muscle into the orbit.[9]

Despite concerns about functional or cosmetic defects to the lateral canthal region, none of these were noted by physicians or patients in this study. Preservation of the soft-tissue architecture in the lateral canthal region likely explains the normal external appearance of the lateral canthal region following removal of the lateral rim. Preservation of the lateral canthal complex by removing the rim through a lid crease incision rather than canthotomy may also contribute to the avoidance of canthal irregularity.


  Conclusion Top


Surgeons performing “maximal” orbital decompression should consider including removal of the lateral orbital rim, either during primary lateral orbital decompression surgery to achieve a greater decompressive effect or in cases where residual exophthalmos persists after traditional three-wall orbital decompression.

Financial support and sponsorship

Generously supported by the Bell Charitable Foundation, Mrs. Toby Wolf, and Research to Prevent Blindness.

Conflicts of interest

The authors declare that there are no conflicts of interests of this paper.



 
  References Top

1.
Mehta P, Durrani OM. Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated orbitopathy: A new technique and results of a case series. Orbit 2011;30:265-8.  Back to cited text no. 1
    
2.
Zhang S, Li Y, Wang Y, Zhong S, Liu X, Huang Y, et al. Comparison of rim-sparing versus rim-removal techniques in deep lateral wall orbital decompression for graves' orbitopathy. Int J Oral Maxillofac Surg 2019;48:461-7.  Back to cited text no. 2
    
3.
Sagiv O, Satchi K, Kinori M, Fabian ID, Rosen N, Ben Simon GJ, et al. Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease. Graefes Arch Clin Exp Ophthalmol 2016;254:791-6.  Back to cited text no. 3
    
4.
Fichter N, Krentz H, Guthoff RF. Functional and esthetic outcome after bony lateral wall decompression with orbital rim removal and additional fat resection in graves' orbitopathy with regard to the configuration of the lateral canthal region. Orbit 2013;32:239-46.  Back to cited text no. 4
    
5.
Fichter N, Guthoff RF. Results after en bloc lateral wall decompression surgery with orbital fat resection in 111 patients with graves' orbitopathy. Int J Endocrinol 2015;2015:860849.  Back to cited text no. 5
    
6.
Schaaf H, Santo G, Gräf M, Howaldt HP. En bloc resection of the lateral orbital rim to reduce exophthalmos in patients with graves' disease. J Craniomaxillofac Surg 2010;38:204-10.  Back to cited text no. 6
    
7.
Horn M, Schittkowski MP. Efficacy and side effects of lateral orbital wall decompression including the orbital rim in patients with graves' orbitopathy. Klin Monbl Augenheilkd 2019;236:17-24.  Back to cited text no. 7
    
8.
Sears CM, Wang Y, Bailey LA, Turbin R, Subramanian PS, Douglas R, et al. Early efficacy of teprotumumab for the treatment of dysthyroid optic neuropathy: A multicenter study. Am J Ophthalmol Case Rep 2021;23:101111.  Back to cited text no. 8
    
9.
Men CJ, Gur Z, Ko AC, Liu CY, Korn BS, Kikkawa DO. Lateral wall implant as an adjunct to lateral wall orbital decompression in severe thyroid eye disease. Ophthalmic Plast Reconstr Surg 2021. [doi: 10.1097/IOP. 0000000000002007]. Online ahead of print.  Back to cited text no. 9
    



 
 
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