(5%) had new-onset diplopia. In 47 patients (56%), some degree of temporal hollowing was reported. Among 64 photographed patients, 38 (59%) had.
Acta Ophthalmologica 2016
Temporal hollowing and other adverse effects after lateral orbital wall decompression Hans Olav Ueland,1 Olav H. Haugen1,2 and Eyvind Rødahl1,2 1
Department of Ophthalmology, Haukeland University Hospital, Bergen, Norway Department of Clinical Medicine, University of Bergen, Bergen, Norway
2
ABSTRACT. Purpose: To evaluate the outcome and late postoperative complications after lateral orbital wall decompression in a series of patients with thyroid eye disease (TED). Methods: One hundred and three patients operated in the period 1999–2013 were invited to participate in the study, and 84 were included after a median (range) follow-up time of 124 (13–188) months. The patients were interviewed, and preoperative and postoperative data were collected from hospital records. Photographs (‘selfies’) were obtained from 64 patients. Wilcoxon signed-rank test was used to evaluate the change in pre- and postoperative data. Results: On average, visual acuity was unchanged with a median value (range) of 1.0 (0.4–1.25) before to 1.0 (0–1.25) after surgery (p = 0.5). Intraocular pressure (IOP) was reduced from a median value (range) of 17 (9–26) to 15 (8–23) mmHg (p < 0.001). Median (range) Hertel values were 23 (15–30) mm preoperatively and 20 (12–26) mm postoperatively (p < 0.001) respectively. Mean (SD) reduction in proptosis was 3.6 (2.1) mm. Oscillopsia was reported in 24 patients (29%), 42 (50%) experienced a change in temporal sensation, and four (5%) had new-onset diplopia. In 47 patients (56%), some degree of temporal hollowing was reported. Among 64 photographed patients, 38 (59%) had noticeable hollowing on examination of postoperative pictures. There was agreement of the patient’s perception of temporal hollowing and the appearance in photographs in 26 of 37 patients (70%). Conclusion: Lateral orbital wall decompression has been considered a safe and effective procedure for treatment of TED. Serious side-effects are infrequent, but in rare circumstances, even blindness may occur. Less serious side-effects are relatively common. Among others, a significant number of the patients developed temporal hollowing after the procedure. The patients must be informed about the possible complications before surgery. Key words: oscillopsia – proptosis – temporal hollowing – thyroid eye disease – visual acuity
Acta Ophthalmol. 2016: 94: 793–797 ª 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
doi: 10.1111/aos.13135
Introduction Thyroid eye disease (TED) develops as a consequence of inflammation of extraocular muscles and orbital fat.
The clinical presentation is characterized by increased volume of fat and extraocular muscles, resulting in forward displacement of the eyes (proptosis), retraction of the eyelids and
impaired ocular motility. Surgical treatment may address several of the manifestations, including the increased volume of the orbital contents, the motility disturbance and different lid changes (Bartalena et al. 2000). Usually, surgical treatment of TED will be carried out in the following order; orbital decompression, strabismus surgery and at last eyelid surgery. Decompression of the orbit can be achieved by removing one or several of the orbital walls or by reducing the amount of fat in the orbit (European Group on Graves’ Orbitopathy et al. 2009). Lateral wall decompression in patients with TED is mainly used in disfiguring exophthalmos with moderate proptosis and ocular discomfort (Kikkawa et al. 2002). Our current practice is to do lateral wall decompression for mild to moderate cases (Hertel values of 23 mm or less) with no optic nerve involvement, endoscopic medial wall decompression for cases with optic neuropathy and combined endoscopic medial and lateral wall decompressions for more severe cases. Decompression of the lateral wall of the orbit is a well-established procedure. Serious complications that may result in damage of the optic nerve, are rare (Goldberg et al. 1998). Infections and new-onset diplopia are also uncommon. The occurrence of minor complications of the procedure, like oscillopsia, reduced or altered sensation in the temporal region and temporal hollowing has only been examined to a limited extent (Fayers et al. 2013). To identify possible adverse effects from lateral orbital wall decompression, we recruited 84
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patients operated between 1999 and 2013 to a follow-up study.
Patients and Methods Patients
In the period between 1999 and 2013, 162 patients underwent orbital decompression that included the lateral wall at the Department of Ophthalmology, Haukeland University Hospital. Of these, 14 individuals had also been operated with medial wall decompression. Exclusion criterion was operation with three-wall decompression with simultaneous removal of the lateral and medial wall and the orbital floor (n = 25). Seven patients were dead, and 27 patients were excluded since insufficient data were available at 6 months postoperatively. A total of 103 patients were eligible for the present study and were invited to participate. Eighty-four patients signed an informed letter of consent. The study was considered a quality improvement study by the Regional Committee for Medical and Health Research Ethics, Western Norway, and approved as such by the Haukeland University Hospital review board (ref. 2014/16674). The study adhered to the tenets of the Declaration of Helsinki. Surgical technique
The surgical procedure has been described previously (Mehta & Durrani 2011; Fayers et al. 2013). It was performed under general anaesthesia in all cases. The skin is incised from the lateral part of eyelid crease to the lateral orbital rim. The lateral orbital rim is exposed from the base of the skull to the floor of the orbit. An oscillating bone saw is used to make
two horizontal full-thickness cuts above the zygomatic arc and above the fronto-zygomatic suture, respectively, followed by a full-thickness cut through the lateral bony wall parallel to the rim and extending between the two horizontal cuts. After removing the cut piece of bone, the bony window is widened posteriorly using a rongeur and a bony drill leaving only a thin shell of bone covering the dura. The periosteum is opened from an incision parallel to the posterior rim of the bony window. Fat tissue and the lacrimal gland are allowed to prolapse into the bony opening. The wound is closed in layers. After surgery, the eye is covered with a dressing pad, and a vacuum drain is left in the orbit overnight. Data collection
Pre- and postoperative data were obtained from hospital records. For the patients who later underwent medial wall decompression, postoperative outcome data with respect to visual acuity, intraocular pressure (IOP) and reduction of proptosis and diplopia were recorded before the medial wall decompression. For those who had the medial wall removed before the lateral wall, preoperative data were obtained after the medial orbital wall decompression. The patients were interviewed by telephone calls and were asked about discomfort after the operation, and specifically if they had noticed oscillopsia, altered sensation in the temporal region, diplopia or temporal hollowing. The patients were requested to take a photograph of the temporal region using their mobile phone, and photographs (‘selfies’) were received from 53 patients. In addition, 11 patients were photographed at follow-up visits
during the time frame of the present study, leaving 64 individuals available for investigating temporal hollowing. The grading of temporal hollowing (grade 1–3) was carried out as outlined in Fig. 1. Patients operated bilaterally were graded according to their worst side. The median (range) follow-up time between surgery and assessment of lateral orbital wall disfigurement was 124 (13–188) months. Statistical analysis
Data were analysed using the Statistical Package for the Social Sciences (SPSS Version 21.0; IBM Corporation, Armonk, NY, USA). Wilcoxon signedrank test was used to evaluate the change in pre- and postoperative data.
Results Patient characteristics
The median (range) age of the 84 patients who participated in the study, was 50 (17–75) years at surgery; 76 were females and eight males. Median (range) time from operation to last routine examination was 26 (6–156) months, and from operation to the telephone interview and photography 124 (13–188) months. Information about smoking habits was recorded for 56 individuals, and 70% of them were smokers. All patients were euthyroid both at the time of decompression and at the re-examination. Treatment of their thyroid disease and antiinflammatory treatment prior to decompression are listed in Table 1. Changes in clinical measures
A total of 144 lateral wall decompressions had been carried out, 60 patients
Fig. 1. Grading of temporal hollowing, as exemplified by photographs. Grade 1 denotes no temporal hollowing, Grade 2 noticeable hollowing and Grade 3 disfiguring temporal hollowing (more than 2 cm2 or hollowing in combination with noticeable scarring).
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Table 1. Treatment of patients before undergoing lateral orbital decompression.* Treatment modality Thyroid disease No treatment Thyreostatic drugs and radioactive iodine Thyreostatic drugs and thyroidectomy Thyreostatic drugs, radioactive iodine and thyroidectomy Thyreostatic drugs Orbitopathy No treatment Corticosteroids Radiotherapy Radiotherapy and corticosteroids
Patients
%
6 36 27 4 11
7 43 32 5 13
48 23 5 8
57 27 6 10
* Eighty-four patients were included. Among these, 93% received thyreostatic treatment and/or underwent thyroidectomy, and 43% were treated for their orbitopathy with corticosteroids and/or radiotherapy.
were operated bilaterally and 24 were operated unilaterally. Pre- and postoperative median best corrected visual acuity was unchanged (Table 2). Intraocular pressure (IOP) above 21 mmHg was present in 11 patients before the operation and in two patients postoperatively. Proptosis of more than 21 mm was seen in 57 individuals (103 eyes) preoperatively and in 13 (23 eyes) at re-examination, with a mean reduction of 3.6 (2.1) mm. The reduction in both median IOP and proptosis was statistically significant (p < 0.001, Table 2). Lagophthalmos was seen preoperatively in 12% and postoperatively in 2%.
Adverse effects
One patient suffered a postoperative haemorrhage on one side that resulted in loss of vision. In this patient, visual function was not tested until the next morning after surgery, and amaurosis was then present. A CT scan was immediately performed (Fig. 2), revealing a haematoma in the lateral part of the orbit. The wound was reopened and the haematoma was removed, but visual function did not recover. There were no patients with recognized cerebrospinal fluid leakage after the procedures. Five of 162 individuals
Table 2. Clinical measures and adverse effects in 84 patients after undergoing lateral orbital wall decompression. Parameter
Before
Clinical measures BCVA 1.0 Hertel value, mm 23 IOP, mmHg 17 Complications at clinical examination Onset of diplopia 29 Onset of strabismus 27 Complications reported by patient Temporal hollowing Change in sensation Reduced sensation Hyperesthesia Pain Numbness Coldness Oscillopsia Skin redness Headache
(0.4–1.25) (15–30) (9–26) (35) (32)
After
p-Value*
1.0 (0–1.25) 20 (12–26) 15 (8–23)
0.5
