that there are two types of orbitopathy, one with more significant muscle involvement and the other dominated by expansion of the orbital fat (said to be more common amongst Asians). Generally, patients with significant expansion of orbital fat respond very well to decompressive techniques and offer a greater opportunity for fat resection. Evaluation of the orbital apex allows for determination of the roles of lateral, medial, and floor structures in potential decompression; evaluation of the sinus configuration and presence=absence of sinus disease may help in determining site and timing of decompression or need for adjunctive surgery. Some patients may have a particularly shallow orbit on imaging, implying the need to advance orbital bones or utilize an onlay technique. The bony structure, particularly the size of the marrow space and greater wing of sphenoid, may help in determining the potential for decompressive effect.

I have already mentioned that surgery on active disease may be associated with more complications and continued progression of disease, thus requiring vigilant postsurgical follow-up, continued medical care, and potentially repeat imaging. It is also worthy to note that inactive disease may reactivate following decompression and although this is a relatively rare event, we have seen it in a not insignificant number of patients (12). It should also be remembered that psychosocial factors may play an important role in determining the timing and nature of surgery for patients with Graves’ orbitopathy.

Preferred Decompression Techniques

There are multiple and variable technical options for decompression, which are listed in Table 1 (13). With regard to our own preferences, we tend toward minimal incision approaches using the medial caruncular incision with or without a lateral canthal incision. If, however, we are considering fat resection, we may utilize a swinging eyelid approach, which accesses the lower lid fat as well as the inferolateral orbit. This also can be augmented by a medial fat resection through the lid crease superomedially as well as a medial caruncular approach for

Table 1 Technical Options in Decompression

A.Floor and medial wall

1.Anterior Caruncular Medial skin

Medial upper eyelid

2.Sinus approach Ogura

Transnasal endoscopic

B.Lateral wall floor roof augmentation or bony advancement

1.Canthotomy

2.Swinging eyelid approach

3.Lateral upper eyelid approach

4.Burke–Kronlein þ medial approach

5.Burke–Kronlein þ Ogura or transnasal endoscopic

6.Coronal approach

C.Soft tissue

1.Orbital fat excision

2.Blepharoplasty

External

Internal

Modified with permission from Ref. 2 (p. 199).

decompression (14). Earlier, I noted that there are instances where we might combine mu¨ llerectomy or upper lid lengthening at the beginning of a decompressive surgery. This would be under local anesthetic and would be followed by the decompression under general anesthetic. The addition of blepharoplasty is also an option. We also favor a more minimal approach laterally by simply exposing the lateral wall through a canthal incision that does not involve incising the lateral canthal tendon.

EYE MUSCLE SURGERY

In our opinion, the sine qua non of eye muscle surgery is the use of adjustable sutures to achieve the best outcomes (15). In principle, we prefer to use recessions vs. resections, since this is a cicatricial disease. The intraoperative rule of thumb is

that one can achieve 2.5 diopters per mm of recession; however, the fewer the muscles involved, the more one can achieve per mm.

It is important to be aware of the potential for consecutive deviations in surgical management of strabismus related to Graves’ orbitopathy. These tend to occur when the surgeon fails to recognize ipsilateral agonist involvement, leading to an overcorrection. This can be avoided by careful forced duction test as a primary aspect of corrective strabismus surgery.

LID PROCEDURES

The three major procedures for managing lid malpositions are mu¨ llerectomy, lower lid elevation, and blepharoplasty. As mentioned earlier, these are infrequently combined with decompressive surgery but usually are done subsequent to either decompression or strabismus surgery.

Mu¨ llerectomy can be achieved either through an internal conjunctival or an anterior approach (16–18). In both instances, relaxing both Mu¨ller’s muscle and the levator aponeurosis is necessary. This is best achieved under local anesthetic, allowing for evaluation intraoperatively of lid position. Lower lid elevation is best achieved by placing a spacer between the lower lid retractors and the tarsal plate. Our general rule of thumb is that the choice of spacer should be increasingly rigid with increasing degrees of lower lid retraction. Finally, the principles we observe in blepharoplasty are aggressive fat resection and moderate skin resection to avoid tense lids. We will often add to the blepharoplasty, some resection of periorbital fat in the upper lid, particularly temporally overlying the bone, since this fat may have increased as a result of the orbitopathy.

The key issue in managing the surgical paradigm for thyroid orbitopathy is to recognize that this may be complex and must be individualized based on the activity and severity of disease. I have included a table describing the range of choices with regard to decompressive surgery in Graves’ orbitopathy (Table 1).

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