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Background: Rhinosinusitis may cause serious complications, such as secondary orbital infections, resulting in expansion and erosion of process through the orbital wall. Aims: The aim is to evaluate long-term outcome of ESS in patients suffered from endocrine ophthalmopathy and orbital complications of rhinosinusitis. Material and methods: Thirteen patients with loss of vision, endocrine ophthalmopathy and orbital complication of rhinosinusitis were treated by ESS. Preoperative and postoperative vision was rated by best-corrected visual acuity (BCVA) testing. Nine (69%) have been reinvestigated after 6 years by ophthalmology examination and 10-point scale for assessment of clinical symptoms. Results: The mean BCVA significantly increased after surgery comparing to results before surgery (0.84, 0.62; respectively) ( p  = .007). The mean values of 10-point scale for subjective assessment of symptoms 6 years after surgery were: headache 2.11, sinonasal pressure 1.72, subjective estimation of vision quality on the affected eye was 7.33 and olfaction 7.66. None of the patients developed impairment of vision loss in postoperative period. Conclusions: Long-term outcome of ESS showed decreased symptoms in patients who had endocrine ophthalmopathy and orbital complication of rhinosinusitis. Significance: ESS has numerous advantages for patients with orbital complication and vision loss comparing to conservative treatment and should be considered even in abscess absence.

Purpose : Thermal injury to the optic nerve is a potential complication of bony decompression of the orbital apex. An animal model was used to compare and contrast temperature change while removing orbital bone with ultrasonic and conventional drills. Methods : Two devices, Sonopet ultrasonic bone curette and TPS CORE Micro drill, were used to remove bone from six unpreserved exenterated porcine orbits at fixed distances from the optic canal while temperature was recorded. Increasing irrigation flow rate and decreasing saline temperature with the ultrasonic bone curette were also investigated. Results : The mean change in temperature at the optic canal using the ultrasonic bone curette with 18 ml/min 24°C irrigation was +7.2 ± 3.3°C (range 3.3-12.7 ° C) at 60 s, and using the rotational drill was +1.7 ± 1.3°C (range 0.1-3.3°C), representing a statistically significant increase above baseline for both drills ( p < 0.01 for each). The difference in temperature change between drills was statistically significant ( p < 0.01). When irrigation fluid was changed from room temperature saline (24°C), rate 18 ml/min to chilled (10°C) irrigation saline, rate 40 ml/min, the magnitude of the mean temperature increase was reduced by 3.1°C, p < 0.05. Conclusions : In this orbital decompression model, both ultrasonic and rotational drills induced a rise in temperature. This increase was significantly greater with the ultrasonic bone curette, measuring up to 13.7°C. Clinicians should be aware of the potential for temperature spikes when decompressing the orbital apex. Increasing irrigation flow rate and using chilled saline may mitigate increases in temperature.

Purpose: We sought to investigate the effects of Graves' orbitopathy (GO) and orbital decompression on lamina cribrosa depth (LCD) using spectral-domain optical coherence tomography., Methods: Forty eyes that underwent orbital decompression to relieve compressive optic neuropathy or correct disfiguring exophthalmos in the context of GO were included. Subjects were imaged with spectral-domain optical coherence tomography before surgery and at 1 and 3 months after surgery, at which the examiner measured the LCD (distance from the anterior surface of the lamina cribrosa to the Bruch membrane opening line) and peripapillary retinal nerve fiber layer thickness. Subjects were divided into two groups-a muscle-dominant group composed of patients who had extraocular muscle enlargement on preoperative orbital computed tomography scan and a fat-dominant group composed of patients who did not show extraocular muscle enlargement on preoperative orbital computed tomography scan-and subgroup analysis was performed. Preoperative and postoperative intraocular pressure, exophthalmos, LCD, and retinal nerve fiber layer thickness were evaluated., Results: At baseline, LCD was remarkably shallower in the muscle-dominant group than in the fat-dominant group (95% confidence interval, p = 0.007). In the muscle-dominant group, LCD showed no definite change after surgery. However, the fat-dominant group showed temporary posterior displacement of the lamina cribrosa at 1-month postoperation that was reversed to baseline at 3 months postoperation (95% confidence interval, p < 0.01)., Conclusions: The lamina cribrosa was anteriorly displaced preoperatively, and its position was nearly unchanged after the surgery, especially in association with extraocular muscle enlargement. An enlarged extraocular muscle could reduce the pressure-relieving effect of orbital decompression around the scleral canal in patients with GO., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2019 The Korean Ophthalmological Society.)

Background : Recession and resection of rectus muscles for correction of strabismus in Thyroid Eye Disease (TED) is relatively unpopular as it is assumed to enhance the restriction of ocular ductions. Therefore, the purpose of this study was to compare ductions of recession only and recess/resect procedures. Methods : We retrospectively reviewed the charts of 119 patients who underwent strabismus surgery for TED from 1991 to 2015, of which 102 were included in the present study. Forty-six interventions were performed on horizontal, 56 on vertical rectus muscles; comprising 41 recess/resect surgeries for horizontal deviations, and 7 in patients with vertical strabismus. Ocular ductions and alignment were evaluated preoperatively and at 3 and 12 months postoperatively. Results : Both recessions as well as recess/resect procedures resulted in improved abduction and elevation, respectively. At the exam 3 months postoperatively, median abduction for the recession only group and the recess/resect group were 27.5° and 35°, respectively. The similar figures for elevation were 25° and 10°, respectively. Neither were statistically significant. No restricted adduction or depression was seen in the recess/resect surgeries groups with lateral or superior rectus resection. None of the patients showed unusual postoperative inflammation or conjunctival scarring. Conclusion : In this retrospective analysis, we found an equal effect on ocular ductions in patients with TED when comparing recess/resect eye muscle surgery to recess only procedures. In TED patients with large horizontal angle deviations and abduction deficit, medial rectus recession and lateral rectus resection surgery can be considered. Muscle resections in TED do not seem to have a clinically relevant risk to increase the restriction of ocular ductions but rather improve ductions in the restricted directions of gaze.

Purpose: To report a case of inadvertent inferior oblique extirpation during orbital decompression, its management, and postoperative result., Methods: A 38-year-old female with thyroid eye disease underwent cosmetic right orbital decompression during whichinferior oblique extirpation was noticed., Result: The muscle was repaired on the same session (illustrated in the article) with no postoperative diplopia at 3-month follow-up., Conclusion: Inferior oblique injury should be considered among the uncommon yet important complications of orbital decompression. It can be easily found and repaired in the same session as demonstrated in this case report.

Purpose: Orbital decompression surgery is performed in patients with Graves' orbitopathy to treat dysthyroid optical neuropathy (DON) and reduce disfiguring proptosis. The intended proptosis reduction can deviate from the postoperative result and changes of motility with consecutive diplopia can occur. We performed a retrospective study to identify anatomical factors in computed tomography (CT), which influence the surgical effect and postoperative ocular motility and diplopia., Methods: Pre- and postoperative CT-scans of 125 eyes of 68 patients, who mainly underwent a balanced orbital decompression for disfiguring proptosis (≥18mm Hertel Index), have been analyzed. Proptosis, ductions, misalignment and diplopia were assessed before and after surgery. Medial and lateral orbital wall length, conus angle, depth of ethmoidal sinus, orbital surface, length of medial and orbital defect, depth of tissue prolapse and horizontal muscle diameters were analyzed in CT scans before and after surgery. With linear regression and multivariate analyses these parameters have been correlated with postoperative proptosis, abduction deficit, deviation and binocular single vision (BSV)., Results: Proptosis could be reduced by 5.3±2mm. Patients with <5mm proptosis reduction had significantly less often new onset of diplopia compared to patients with >5mm reduction (13% vs. 56%, p = 0.02). Multiple linear regression showed a significant correlation between tissue prolapse and depth of the ethmoidal sinus as well as age (p<0.001, r = 0.71). Proptosis reduction could not be predicted by tissue prolapse, defect length or depth of ethmoidal sinus. The abduction deficit correlated significantly with tissue prolapse and orbital surface area (p<0.001, r = 0.37) but not with the horizontal muscle diameter., Conclusion: We were able to show that orbital morphology influences the outcome of balanced orbital decompression surgery in terms of proptosis reduction and motility. However, the rather low coefficients of correlation show that the surgical outcome cannot be predicted with simple CT measurements, although risk factors for postoperative abduction deficit could be found. Therefore, preoperative planning should consider especially the orbital surface area and depth of ethmoidal sinus. Patients should be informed about the higher risk of diplopia with higher proptosis reduction., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To compare injections of hyaluronic acid (HA) and autologous fat (AF) for the treatment of unsightly temporal hollowing after lateral orbital wall decompression in thyroid eye disease., Methods: In this nonblinded prospective comparative interventional study, patients received injections of HA in the right temple and AF in the left temple. Additional injections were given when needed at follow-up after 6, 12, 18, and 24 months. Follow-up included an interview; clinical examination with an evaluation of symmetry, contour, and skin surface; and ultrasound measurements. From photographs, the temporal hollowing was graded 1-3. The main endpoints were grading of temporal hollowing and temporal soft tissue thickness., Results: Seventeen patients were treated bilaterally and 12 unilaterally (five received HA and seven AF). Injection(s) of HA and AF administered at each site were a median (range) of 1 (1-4) and 2 (1-5), respectively. The total combined volume of HA injected per site was 0.9 (0.2-2.0) ml and that of AF was 3.1 (0.5-9.6) ml. At the final examination, a statistically significant difference in mean (SD) grading scores of temporal hollowing due to HA (1.18 (0.26)) compared to those of AF (1.85 (0.44)) was observed (p < 0.001). Six months after administering an injection of HA, the temporal soft tissue thickness was 2.35 (0.24) cm compared to 2.19 (0.28) cm obtained with an injection of AF (p < 0.001). By using a linear mixed-effect model and adjusting for baseline values, age, sex, and refill, the difference in favor of HA persisted at all later follow-ups. Increased fibrosis of the subcutaneous tissue developed at 5/24 sites that received AF., Conclusion: Injection of HA is superior to that of AF for treating temporal hollowing after lateral orbital wall decompression., (Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose : To compare efficacy and safety of mechanical drill and piezoelectric technology in the prevention of infraorbital nerve hypoaesthesia during orbital floor decompression. Methods : Single-centre, non-randomized prospective, interventional case series. We enrolled 24 patients who underwent 3-wall orbital decompression. A total of 13 patients underwent floor decompression using 5-mm diamond dusted Piezoelectric tip (Synthes GmbH, Oberdorf, Germany), whereas 11 patients underwent conventional mechanical decompression of the floor using Stryker Core handpiece with 5-mm diamond dusted tip (Stryker, USA) and a Kerrison's bone ronguer. All surgeries were performed by a single surgeon (MNN) using standard surgical technique. The infraorbital nerve hypoesthesia was measured pre-operatively, and post-operatively on day 1, at 1 week, 6 weeks, 3 months, and final follow-up by an independent observer. Hypoaesthesia was graded on a simple numerical scale: 0 defined as "normal", 1 defined as "minimally reduced", 2 defined as "grossly reduced but perceptible", and 3 defined as "total loss". Results : The average follow-up after surgery was 16 months (range 13-48 months). The average score in the mechanical drilling group at day 1, week 6, week 12 and final follow-up was 1.9, 1.2, 0.7, and 0.6, respectively ( p  < 0.001). For the Piezo group, the average scores were 0.3, 0.2, 0.1, and 0.1, respectively. No procedure related complications were noted, and the average surgical time for floor decompression was comparable ( p  > 0.5). Conclusions : Piezoelectric technology is effective in orbital floor removal by minimizing infraorbital nerve hypoaesthesia.

Aims: To report visual acuity outcomes and potential complications in patients undergoing endoscopic transnasal orbital decompression in the setting of acutely deteriorating sight secondary to dysthyroid optic neuropathy (DON) unresponsive to corticosteroid therapy. No previous reports describe vision outcomes in this specific patient population undergoing urgent endoscopic decompression., Material and Methods: Retrospective case review at a tertiary-care academic hospital. Four patients with DON were identified that underwent urgent endoscopic orbital decompression for acutely deteriorating vision. Three patients underwent a later decompression of the other orbit, yielding seven decompressions in total for acutely deteriorating vision. Operative technique entailed inferior and medial wall decompressions. The posterior limit of medial wall decompression was within the sphenoid, just anterior to the annulus of Zinn to fully decompress the optic nerve. Primary outcome was visual acuity., Results: In all seven decompressions, visual acuity improved substantially. In 5/7 eyes, preoperative vision was severely impaired at 20/150 or worse. Two eyes had mild and moderate impairment at 20/50 and 20/100. Post-operatively, the moderately and severely impaired eyes improved to 20/60 or better. No complications were encountered., Conclusion: Transnasal endoscopic orbital decompression is a safe, effective treatment for acutely worsening visual loss from DON. All cases demonstrated significant objective improvement in visual acuity. Given the need for later contralateral decompression in 3 patients, consideration should be given to performing bilateral orbital decompressions at the time of surgery., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Purpose: Current outcome measures do not adequately address the esthetic aspect of the surgical outcome of anterior blepharotomy for Graves' ophthalmopathy. This study aims to highlight the role of tarsal platform show (TPS) in optimizing the esthetic outcome of graded full-thickness anterior blepharotomy for dysthyroid upper eyelid retraction in an ethnic Chinese population., Methods: The records of patients with Graves' ophthalmopathy who underwent anterior blepharotomy for upper eyelid retraction over a period of 30 months were retrospectively reviewed., Results: Fifty-five patients (77 eyelids) with upper eyelid retraction underwent anterior blepharotomy. A statistically significant decrease in marginal reflex distance (MRD 1 ) and lagophthalmos and significant increase in TPS following anterior blepharotomy was observed. A significantly higher proportion of patients who underwent unilateral anterior blepharotomy had TPS asymmetry post-operatively as compared to the bilateral group (p < 0.001). Using logistic regression, the study found that for every 1-mm change in MRD 1 , there was approximately a 1.045-mm change in TPS. The mean percentage increase in TPS observed in our study was 303.1 ± 191% due to the low pre-operative TPS seen in Asian patients., Conclusions: To achieve the most ideal surgical outcome in graded full-thickness anterior blepharotomy, the surgeon will need to consider not only eyelid height but also the subsequent TPS change. The surgeon needs to be mindful of the relationship between MRD 1 change and TPS change to optimize esthetic outcome as well as symmetry. Special considerations need to be taken in unilateral cases as well as patients with low pre-operative TPS.

Purpose : To measure alterations in orbital blood flow parameters using color Doppler imaging (CDI) before and after orbital decompression in patients with moderate to severe thyroid eye disease (TED). Methods : Resistance index (RI) and maximum and minimum velocity of ophthalmic artery (OA), superior ophthalmic vein (SOV), and central retinal artery (CRA) of 24 eyes (14 patients) with TED were measured before and at least 3 months after cosmetic orbital decompression procedure (single or double walls) using CDI. Complete eye examination was performed to define the severity (EUGOGO classification) and activity (clinical activity score) of TED. Results : Median OA ( p  = 0.003) and CRA ( p  = 0.001) resistance indices were significantly reduced postoperatively. Significant differences were found in maximum ( p  = 0.001) and minimum ( p  = 0.014) velocity of SOV before and after surgery. While a significant decrease in exophthalmometry was observed after the orbital decompression ( p  = 0.031), intraocular pressure changes were not significant ( p  = 0.182). Conclusion : Orbital decompression procedure led to a significant reduction of RI in both CRA and OA in patients with TED.

Graves' orbitopathy (GO) is an extrathyroidal manifestation of Graves' disease (GD). The majority of patients has mild form of the disease, with no need of additional treatment. A few percent of patients can have a severe or very severe course of disease. In severe forms of GO there might occur considerable exophthalmos complicated in some cases with corneal ulceration or pressure on optic nerve leading to neuropathy (DON, dysthyroid optic neuropathy). In therapy of severe forms of GO different types of treatment are used depending on diagnosis and activity of disease. The pharmacological (among the others very high doses of intravenous methylprednisolone) and surgery treatment (orbit decompression) are used. The orbital decompression is a procedure performed in order to decrease the intraorbital pressure by removing part of its bony borders in cases with excessive mass in orbit. For decades many external approaches have been used. With the progress of the endoscopic techniques the endoscopic orbit decompression has become the first line treatment. The lack of facial incisions is connected with many benefits for patients. In our article endoscopic decompression technique in GO was described, as well as available medical literature concerning this technique and its outcomes was performed., (© 2019 MEDPRESS.)

Aim: To describe differences in the deep lateral orbital wall (specifically, trigone) between Chinese, Malay, Indian and Caucasian subjects Methods: Single-centre retrospective Computed Tomogram (CT)-based study; 20 subjects of each ethnicity were used from existing databases, matched for gender, average age and laterality. Subjects below 16 years of age were excluded. DICOM image viewing software CARESTREAM Vue PACS (Carestream Health Inc., USA) and OsiriX version 7.5 (Pixmeo., Switzerland) were used to measure deep lateral wall length, thickness and volume, as well as orbital depth and statistical analyses performed using Statistical Package for Social Sciences version 21 (IBM, USA)., Results: In each group, there were 12 males (60%) and average age was not significantly different (p = 0.682-0.987). Using Chinese subjects as a reference, in Chinese, Malay, Indian and Caucasian subjects, mean trigone thickness was 13.68, 14.02, 11.60 (p < 0.001) and 13.80 mm, curved total wall length 45.23, 42.29 (p = 0.048), 41.91 (p = 0.020) and 45.00 mm, curved trigone length 23.03, 22.61, 17.19 (p = 0.011) and 18.76 mm (p = 0.030) and trigone volume 3120.97, 3221.01, 1613.66 (p < 0.001), 2498.46 mm 3 (p = 0.059) respectively. Similarly, perpendicular orbital depth was 27.54, 24.97, 22.12 (p = 0.001) and 25.93 mm and diagonal orbital depth was 34.19, 33.27, 29.48 (p = 0.01) and 34.63 mm respectively., Conclusions: Indian and, to a lesser extent, Caucasian subjects have smaller trigones compared to their Chinese and Malay counterparts. Indian subjects also have shallower orbits and due care should be taken during decompression surgery.

Purpose: To report a simple, highly effective technique of simultaneous transconjunctival repair of upper and lower eyelid retraction in patients with thyroid eye disease (TED)., Methods: A retrospective interventional case review was conducted on 22 eyes of 19 TED patients. The lower eyelid was recessed with placement of a tarsoconjunctival spacer graft harvested from the upper eyelid. The upper eyelid was then recessed through the conjunctival incision used to harvest the tarsal graft. A temporary tarsorrhaphy was placed for 5-7 days. The postoperative outcome was assessed by measuring the margin reflex distance of the upper eyelid (MRD1), inferior scleral show (ISS), and lagophthalmos., Results: The absolute change in MRD1 ranged from 0 to 5 mm with an average of 1.86 ± 1.34 mm. The absolute change in ISS ranged from 0 to 2 mm with an average of 1.3 ± 0.49 mm. One patient had postoperative lagophthalmos and 17 of 19 had improvement in their ocular surface exposure symptoms. None of the patients' grafts were observed to undergo absorption during the postoperative course., Conclusions: This technique of harvesting a free tarsoconjunctival graft from the upper eyelid as a posterior spacer for the lower while simultaneously recessing the upper eyelid through the same incision is an effective and durable method of correcting eyelid retraction in TED.

The purpose is to evaluate the utility of optical coherence tomography (OCT) angiography in the evaluation of Graves' orbitopathy (GO) and response to orbital decompression in patients with and without dysthyroid optic neuropathy (DON). This was a single-center, prospective case series in a cohort of 12 patients (24 orbits) with GO and ±DON, (6 orbits) who underwent bilateral orbital decompression. All patients underwent pre- and postoperative OCT angiography of the peripapillary area. Vessel density indices were calculated in a 4.5 mm × 4.5 mm ellipsoid centered on the optic disk using split-spectrum amplitude decorrelation angiography algorithm, producing the vessel density measurements. Mean change in vessel density indices was compared between pre- and postoperative sessions and between patients with and without DON. Patient 1, a 34-year-old male with GO and unilateral DON OD, showed a significant reduction in blood vessel density indices oculus dexter (OD) (DON eye) after decompression while a more modest reduction was found oculus sinister (OS) with the greatest change noted intrapapillary. Patient 2, a 50-year-old male with DON OU, showed worsening neuropathy following decompression OD that was confirmed by angiographic density indices. Patient 3, a 55-year-female with DON, showed a reduction in blood vessel density OD and increased density OS. Patients without DON showed overall less impressive changes in indices as compared to those with DON. Using OCT angiography, response to surgical treatment in GO orbits, more so in orbits with DON, can be demonstrated and quantified using vessel density indices with reproducibility.

Purpose: To describe surgical management and outcomes for large-angle esotropia of ≥50 Δ secondary to Graves ophthalmopathy using combined initial nonadjustable medial rectus recessions and lateral rectus resections., Methods: The medical records of consecutive patients undergoing strabismus surgery for large-angle esotropia secondary to Graves ophthalmopathy from 1995 to 2012 by a single surgeon at each of two institutions was performed. Patient characteristics, surgical technique, and pre- and postoperative measurements of ocular alignment were analyzed. A modified Gorman diplopia scale was used to assess outcome., Results: Of 38 patients, 36 had bilateral nonadjustable medial rectus recessions and lateral rectus resections as initial treatment for esotropia, and 6 patients underwent simultaneous vertical muscle surgery. Mean preoperative horizontal deviation was 60 Δ and mean preoperative vertical deviation was 10 Δ . Of the 38 patients, 19 (50%) reached the primary outcome, including 5 of 6 (85%) who had no preoperative vertical strabismus. The indications for reoperation were vertical strabismus in 13 of 21 patients (62%), residual esotropia in 7 of 21 (33%), and consecutive exotropia in 1 of 21 (5%). With a median follow-up of 13.2 months after first surgery, 32 of 38 patients (84%) reached the secondary outcome., Conclusions: Combining nonadjustable medial rectus recessions with lateral rectus resections can be a beneficial primary treatment for large-angle esotropia in patients with Graves ophthalmopathy, especially in those patients with small or no associated vertical strabismus., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine the outcome of the use of donor sclera as spacer material in complicated cases of strabismus surgery., Methods: A retrospective cohort study on patients with complicated thyroid-associated ophthalmopathy (TAO) (n = 42) or congenital strabismus (n = 75). Patients underwent strabismus surgery during 1994-2014. The surgical results were evaluated in terms of the reduction in the angle of deviation, the need for re-operation, complications and patient satisfaction., Results: The majority of the TAO patients underwent surgery for vertical strabismus (n = 25). The vertical angle of deviation in the primary position was significantly reduced from a median of 23 prism dioptres (PD) to 2 PD (n = 35, p < 0.001). The horizontal angle of deviation in primary position for TAO patients with esotropia was significantly reduced, from a median of 35 PD to 2 PD (n = 17, p < 0.001). The majority of the congenital cases had horizontal strabismus (esotropia = 29, exotropia = 27). The angle of deviation in esotropia was reduced from a median of 29 PD to 8 PD (n = 36, p < 0.001) and in exotropia from 30 PD to 10 PD (n = 34, p < 0.001). Most of the patients were satisfied with the outcome of surgery, and only 12% required re-operation within 2 years., Conclusion: This is the first clinical study on the use of donor sclera as spacer material in complicated cases of strabismus surgery. The surgical results were good in terms of the reduction in the angle of deviation, the need for re-operation, complications and patient satisfaction, supporting the use of donor sclera for strabismus surgery., (© 2018 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To test the hypothesis that the orbit expands in the cranial vault after wide dural exposure after minimally invasive extradural transorbital decompression for thyroid eye disease., Methods: A cross-sectional cohort study of 36 patients (60 orbits). Preoperative and postoperative (6 months) orbital CT following extradural transorbital decompression was analyzed. Primary outcome measure was the percentage area of the cranial vault occupied by orbital and brain tissue in a predefined window before and after surgery. Secondary outcome measures were displacement of the anteriormost aspect of the temporal lobe, reduction in clinical proptosis, change in clinical activity score, and change in diplopia., Results: The mean percentage of the selected area of the cranial vault preoperatively was 0% orbital and 44% ± 15% brain tissue, compared with 70% ± 16% orbital and 28% ± 14% brain tissue postoperatively (p < 0.001). Posterior movement of the brain was demonstrated in 59 of 60 orbits, with a mean displacement of 2.0 mm ± 1.3 mm (p < 0.001). Mean proptosis reduction was 11.2 mm ± 3.6 mm (p < 0.001). The proportion of patients with clinical activity score <3 compared with clinical activity score ≥3 was not significantly different after surgery (p = 0.163). Improved diplopia was noted in 5 patients (14%), and worsening diplopia was noted in 3 patients (8%), although these changes were not significant (p = 0.772). Intraoperative dural tear with cerebrospinal fluid leak was reported in 2 orbits (3%), which was successfully managed with fibrin glue, with no sequelae. No other complications were noted, including infection, spontaneous orbital pulsations, postoperative hemorrhage (intracranial or intraorbital), or reactivation of disease., Conclusion: With wide exposure of the middle cranial fossa dura following extradural transorbital decompression, orbital tissue typically expands in the cranial vault.

In this study, we try to explore the effect of orbital decompression treatment on severe dysthyroid optic neuropathy.We retrospectively collected demographic and clinical characteristics of thyroid eye disease patients who performed orbital decompression. Then we analyzed the change of best-corrected visual acuity and exophthalmometry after surgery and the correlations among clinical parameters.A total of 22 cases (30 eyes) were included in the study. After orbital decompression, visual acuities improved in 16 eyes, declined in 8 eyes, and had no change in 5 eyes. Best-corrected visual acuity was significantly improved (0.1 vs 0.4, P = .039) and exophthalmometry was significantly declined (22.0 mm vs 16.5 mm, P = .001) after orbital decompression. Better postoperative best-corrected visual acuity was significantly correlated with better preoperative best-corrected visual acuity (r = 0.718, P < .05), and with normal optic disc (r = 0.568, P < .05), but not with age, exophthalmometry, keratopathy, and clinical activity score.These results showed that orbital decompression is a useful approach to manage dysthyroid optic neuropathy. The optimal time for surgery should be chosen based on clinical parameters, such as visual acuity and degree of crowding of orbital apex.

Background: Graves' orbitopathy is the most common extrathyroidal manifestation of Graves' disease. In the burnt out fibrotic phase exophthalmos, diplopia and lid retraction may remain, which can require multiple rehabilitative surgical interventions. Orbital decompression is an established surgical procedure for the treatment of exophthalmos in Graves' orbitopathy. The aim of the study was to evaluate the efficacy and side effects of the deep lateral orbital wall decompression including the orbital rim., Methods: In this retrospective, non-comparative case series, all patients with Graves' orbitopathy, who underwent lateral orbital wall decompression at the Eye Clinic of the University of Göttingen between 2008 and 2015, were analysed in terms of exophthalmos reduction, diplopia (Gorman score) and complications. The surgical technique involved the removal of the lateral orbital wall including the orbital rim combined with additional orbital fat resection via swinging eyelid approach., Results: 127 patients who underwent 195 orbital decompressions were included. Mean exophthalmos reduction was 4.0 ± 1.2 mm (range 1.5 - 7.5 mm). Preoperatively, 47 patients/77 orbits (37.0/39.5%) presented without diplopia. Postoperatively, 3 patients/3 orbits (6.4/3.9%) showed new-onset diplopia (2.4% of all patients, 1.5% of all orbits). Diplopia in primary gaze was noted in one of the 3 patients (0.8% of all patients, 2.1% of patients without preoperative diplopia), and inconstant diplopia was seen in the other 2 patients. Postoperative improvement of diplopia was noted in 19 patients/19 orbits (15.0% of all patients, 23.8% of patients with preoperative diplopia/9.7% of all 195 interventions), and 16.1% of cases with preexisting diplopia. No severe complications were seen, except for one case of postoperative bleeding, which was successfully managed surgically without any functional deficits. A visible scar formation was noted in 6 cases (3.1%), temporal hollowing in 3 cases (1.5%), oscillopsia when chewing in 3 cases (1.5%) and a de-insertion of the lateral canthal region in 2 cases (1%)., Conclusions: Deep lateral orbital wall decompression, including the orbital rim, is an effective surgical technique to reduce exophthalmos in patients with Graves' orbitopathy with a low risk of functional and aesthetic complications., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

The course and pathogenesis of Graves' disease and Graves' ophthalmopathy are interdependent, influencing each other's therapeutic choices. Multiple factors including geographic location, access to medical services, patient and physician preferences influence the management of these conditions. Graves' disease is classically managed with one of three treatment options - antithyroid drugs, radioactive iodine, and thyroidectomy. In recent years, there has been a shift towards antithyroid drugs, including long term therapy with these agents, given the advantage of avoiding hypothyroidism and the apparent safety of this approach. In addition, new therapies are (slowly) emerging, focusing on immunomodulation. Technological advances are opening doors to non-pharmaceutical interventions that aim to deal with both structural thyroid abnormalities as well as biochemical abnormalities of hyperthyroidism. Graves' ophthalmopathy management is guided by its activity and severity status, with treatment options including smoking cessation, control of hyperthyroidism, local eye measures, glucocorticoids, selenium, orbital radiotherapy, and surgery. In addition to these established treatment choices, new immunotherapy-based approaches are being tested. Some of them (tocilizumab and teprotumumab) are very promising but further evaluation is needed before we can establish their role in clinical care. Agents identified as beneficial in Graves' disease management will likely be tested in Graves' ophthalmopathy as well. In the coming years, our main clinical responsibility will be to find the proper balance between the benefits and potential risks of these incoming therapies, and to identify the subgroups of patients where this ratio is most likely to favor a safe and successful therapeutic outcome., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Lateral orbital surgery is challenging and typically involves the use of multiple traction sutures and retractors. This case series describes a novel technique utilising the Alexis retractor to provide access for lateral orbital surgery. Thirteen cases were included and the surgical technique has been described and illustrated. There were no post-operative infections or complications and the Alexis retractor provided excellent exposure whilst reducing the need for further surgical retractors.

Purpose: To evaluate the improvement in quality of life of patients operated within 6 months for strabismus in Graves' disease using a questionnaire., Materials and Methods: A retrospective study was based on a cohort of patients undergoing strabismus surgery for Graves' disease at the Nancy university medical center between June 2015 and January 2017. A quality-of-life questionnaire composed of the functional GO QOL questionnaire plus 10 additional questions was given to patients. The questionnaires were completed by patients in consultation before surgery and then at six months postoperatively. A subgroup analysis was conducted to identify potential risk factors such as smoking, orbital decompression, duration of disease progression, number of surgeries, previous treatments or gender influences on the progression of the postoperative score., Results: Thirty-three patients (15 men/18 women) underwent surgery, with mean age 56 years; 16 (48 %) were smokers, 24 (70 %) were operated for the first time for strabismus. 8 patients (24 %) had a history of surgical orbital decompression. The mean preoperative GO QOLf was 30 (±23.8), which increased to 72 (±29.6) postoperatively (P=0.004). All the answers to the questions proposed were improved by surgery. The most improved items were difficulty in extreme gaze+6.82 points (P=0.001) and going down stairs +6.81 (P=0.002). Smokers had a lower preoperative GO QOLf than non-smokers (25±22.84 vs. 34±24.55); the same was true for their postoperative improvement (35±34.5 points vs. 50±18.8, P=0.002). History of orbital decompression did not appear to influence quality of life (21±25.39 vs. 65±33.98); the same was true for previous corticosteroid or immunosuppressant treatment (28±23.52 vs. 67±28.24), respectively P=0.42; P=0.73. Gender did not appear to influence the results P=0.17. First-time strabismus surgery patients showed a tendency which was not significant toward better improvement after 2 or 3 surgeries (respectively 45 vs. 39 vs. 33) P=0.056. There was no correlation between the duration of the disease and the change in the GO QOLf (R=0.04)., Conclusion: This study confirms that strabismus surgery significantly improves the quality of life of patients with Graves' ophthalmopathy. The GO QOLf demonstrates its effectiveness in highlighting this progression. Our ten additional questions proved to be very good tools for assessing this condition., (Copyright © 2018. Published by Elsevier Masson SAS.)

Purpose: To report on 2 cases of late bony regrowth with clinically apparent proptosis after deep lateral orbital decompression for thyroid orbitopathy., Methods: A retrospective review of 2 cases identified by the authors as having late bony regrowth. The authors review the clinical, historical, radiologic, and anatomical findings and discuss the significance thereof., Results: Bony regrowth with bowing toward the middle cranial fossa is observed at postoperative month 8 in the first case. Cortical bone and marrow was observed to regrow at 2 years postoperatively in the second case. Both patients underwent successful repeat deep lateral orbital decompression with resolution of proptosis and clinical symptoms., Conclusions: Late bony regrowth should be considered as a possible cause of recurrent proptosis after orbital decompression in thyroid eye disease.

Purpose: Surgical management of ophthalmic Graves' disease traditionally involves, in order, orbital decompression, followed by strabismus surgery and eyelid surgery. Nunery et al. previously described two distinct sub-types of patients with ophthalmic Graves' disease; Type I patients exhibit no restrictive myopathy (no diplopia) as opposed to Type II patients who do exhibit restrictive myopathy (diplopia) and are far more likely to develop new-onset worsening diplopia following medial wall and floor decompression. Strabismus surgery involving extra-ocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with Type II patients who have already undergone medial wall and floor decompression and strabismus surgery found, when additional decompression is necessary, deep lateral wall decompression (DLWD) appears to have a low rate of post-operative primary-gaze diplopia., Methods: A case series of four Type II ophthalmic Graves' disease patients, all of whom had already undergone decompression and strabismus surgery, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with DLWD. Institutional Review Board approval was granted by the University of Kansas., Results: None of the four patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following DLWD., Conclusions: While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Graves' disease, for proptosis following consecutive strabismus surgery, DLWD appears to be effective with a low rate of recurrent primary-gaze diplopia.

Purpose: To determine the influence of anatomical changes after orbital decompression to nasal function., Methods: We examined postoperative nasal function after orbital decompression in patients with GO in a prospective study. 25 patients were enrolled between 2014 and 2016. Sense of smell (Sniffin' Test) and nasal airflow (anterior rhinomanometry) were tested pre- and 6 weeks postoperatively. In addition, postoperative incidence of sinus infections, persistent pressure pain, and infraorbital hypoesthesia were assessed by means of a questionnaire., Results: The olfactory performance showed a significant increase (p < 0.05) after surgery, while the nasal airflow significantly decreased (p < 0.05). Acute sinus infection occurred in three, infraorbital sensibility disorders in eight cases within the first 6 weeks after surgery. No persistent pain was recorded., Conclusion: We demonstrate that decompression of the medial orbital wall leads to a decrease in nasal airflow, whereof patients should be informed before the procedure. This is most likely due to a medialization of the medial turbinate and the prolapse of orbital content into the nasal cavity. The increase of the olfactory performance is, in our opinion, more likely due to variation within the standard deviation than to anatomical changes.

Introduction: Thyroid-related immune orbitopathy often results in a restrictive strabismus. We report our experience of surgical management in these cases., Patients and Methods: We present a retrospective case series conducted on 32 patients, operated between 2008 and 2017. Strabismus surgery was proposed in the postinflammatory stage with stable clinical findings for at least 6 months. It was performed under general anesthesia by recessions of restrictive muscles using a fixed suture technique. Outcomes were graded as excellent, good or poor, according to the presence or absence of diplopia in primary or reading positions, and according to whether prism prescription was necessary., Results: The study included 32 patients (21 women, 11 men) with a mean age of 53 years. Average follow-up was 9.6 months. Eight patients developed diplopia after orbital decompression. Fifteen patients had vertical surgery, 8 horizontal surgery, 9 mixed surgery. A mean of 1.31 surgeries (range 1-3) were performed. After all surgeries, 28 patients (87.5 %) had an excellent outcome, 4 (12.5 %) had a good outcome, and none had a poor outcome. There was a significant improvement in stereoscopic acuity (P<0.01), but not motility. Among the 8 patients who developed diplopia after orbital decompression, a clinically acceptable final outcome was achieved after only one surgery., Conclusion: Strabismus surgery using conventional non-adjustable sutures provides excellent ocular alignment and relief from diplopia in the majority of patients with dysthyroid strabismus. The reoperation rate is similar to other techniques, such adjustable suture and intraoperative relaxed muscle technique., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Intravenous (i.v.) glucocorticosteroids (GCs) constitute the first-line treatment for active and moderate-to-severe Graves' orbitopathy (GO). In cases of persistent disease, rituximab, a monoclonal anti-CD20 antibody, may be used, although studies have yielded conflicting results. In case 1, a 50-year-old female heavy smoker presented with severe bilateral disfiguring eyelid edema of four months, bilateral exophthalmos and a clinical activity score (CAS) of 5/7. Laboratory investigation showed thyrotoxicosis and high thyroid-stimulating immunoglobulin (TSI) levels [32 IU/L (normal <1.75]. After minor improvement by i.v. methylprednisolone and standard retrobulbar radiotherapy (20 Gy), her visual acuity progressively declined to "hand motion". Rituximab was administered (two pulses of 500 mg, two weeks apart), with significant response. At 3 1/2 years of follow-up, CAS is 0/7 and CD20+ lymphocytes remain at the lower normal range. In case 2, a 78-year-old non-smoker male was referred for management of severe active GO, one month after total thyroidectomy for Graves' thyrotoxicosis (TSI: 6.74 IU/L). Over the preceding two-three months, severe GO manifested with chemosis, constant diplopia, loss of color vision and acuity of 1/10 bilaterally (CAS: 7/7). Following partial response to i.v. methylprednisolone and concomitant radiotherapy, rituximab (two pulses of 500 mg each, two weeks apart), was administered. Vision partially recovered and GO remains in remission one year later, even after 131 I (100 mCi) administration for papillary thyroid carcinoma (TSI: 0.9 IU/L and CD20+ count at the lower normal range). In conclusion, rituximab may be an effective second-line therapy in GO patients, providing long-lasting remission.

Purpose: Orbital decompression (OD) is a consolidated procedure for the treatment of exophthalmos in Graves' orbitopathy (GO). The efficacy of the various procedures remains unclear due to the variability of the techniques used. To address this issue, we performed a randomized clinical trial to compare the efficacy of two surgical techniques. The primary endpoint was the reduction in proptosis. Secondary aims were the risk of post-operative diplopia (POD) in primary gaze and other surgical complications., Patients: 38 patients (76 orbits) affected with GO were enrolled and randomized into single lateral decompression (LD) (n = 19) or balanced medial plus lateral wall decompression (MLD) (n = 19). Following surgery, patients were seen for a follow-up ophthalmological evaluation at 6 months. Pre-operative diplopia in secondary gaze was present in 13/38 patients (34.2%, 8/19 treated with LD and 5/19 treated with MLD)., Results: The reduction of exophthalmos was greater in patients treated with MLD (5.1 ± 1.5 mm, range 2-8 mm) than in those treated with LD (3.5 ± 1.3 mm, range 1-6.5 mm) (p = 0.01). The overall incidence of POD in primary gaze was 5/38 (13.2%) and all of these patients had pre-operative diplopia in secondary gaze (5/13, 38.5%, vs patients with no pre-operative diplopia p = 0.005). Two of 19 patients (10.5%) treated with LD and 3/19 (15.8%) treated with MLD, developed POD in primary gaze, with no statistical difference between the two techniques., Conclusion: MLD provides a better result in terms of proptosis reduction compared to LD. The two techniques used here appear to have a similar safety profile in terms of POD. Pre-operative diplopia in the secondary gaze remains a major risk factor for development of POD.

A broad understanding of the different imaging modalities used to assess the physiologic changes seen in Graves' orbitopathy complement clinical examination. Subtle applications of radiographic imaging techniques allow for a better understanding of the overall physiology of the orbit, quantify progression of disease, and differentiate it from orbital diseases with overlapping features. A nuanced approach to interpreting imaging features may allow us to delineate inactive from active thyroid eye disease, and advances within this field may arm clinicians with the ability to better predict and prevent dysthyroid optic neuropathy., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the postoperative vertical drift in patients with thyroid eye disease (TED) with hypotropia who underwent vertical rectus recession alone versus vertical rectus recession combined with horizontal rectus recession., Methods: The medical records of patients with TED who underwent strabismus surgery for hypotropia between 2006 and 2015 were reviewed retrospectively. Patients were divided into two groups: group 1 underwent vertical rectus recession only; group 2 underwent vertical rectus recession plus horizontal rectus recession. Data collection included pre- and postoperative deviation measurements and amount of surgical recession performed. The amount of postoperative vertical drift between groups was compared., Results: Of 67 patients who underwent surgery during the study period, 18 met inclusion criteria, 9 in each group. Mean postoperative hypotropia was 24.2 Δ in group 1 and 24.5 Δ in group 2 (P = 0.82). Mean vertical deviations were 0.3 Δ and -2.2 Δ (P = 0.134) on postoperative day 1; -0.9 Δ and -8.0 Δ (P = 0.043) at final follow-up for groups 1 and 2. Mean postoperative vertical drift toward hypertropia was 1.2 Δ in group 1 and 6.8 Δ in group 2 (P = 0.048). The surgical success rate for group 1 was superior to that for group 2 (89% vs 67% [P = 0.024])., Conclusions: There was a significantly larger postoperative vertical drift in TED patients with hypotropia who had combined vertical rectus and horizontal rectus recessions compared with those who underwent vertical rectus recession alone., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

External orbital decompression, including medial wall, inferior wall, lateral wall and orbital fat decompression alone or in combination, has long been considered to be the standard treatment for thyroid related eye diseases. Deep lateral wall orbital decompression has better effect in the balance of eye position, correction of serious exophthalmos and severe oppression optic neuropathy. Recently, however, endoscopic orbital decompression is becoming increasingly popular with the development of endoscopic surgery technique in naso-orbit related diseases. Endoscopic orbital decompression has the advantages of avoiding an external incision scar. Nevertheless, the new method also has some disadvantages, for example, application limited to medial and inferior orbital wall orbital decompression, high incidence of esotropia, need for external lateral wall decompression and expensive cost for equipment. Both surgical approaches have advantages and disadvantages respectively for medial wall and inferior wall decompression. The operative result depends on the individualized surgical design and the experience of the surgeon rather than the choice of the surgical approach. As a result, the choice of the surgical approaches should be specifically based on the patient's conditions, patient's acceptance of the operation, experience of the surgeon and available resources. (Chin J Ophthalmol, 2018, 54: 484-487) .

Dysthyroid optic neuropathy (DON) is the most common cause of visual loss in thyroid associated ophthalmopathy, for which steroid pulse therapy and orbital decompression are the common treatments currently. While steroid pulse therapy was recommended as the first-choice for DON, orbital decompression remained as an indispensable therapy although controversies on such treatment still exist. The mechanism, approaches and outcomes of orbital decompression, as well as its advantages and disadvantages over steroid pulse therapy were retrospectively reviewed, and it was suggested that the combination therapy of steroid pulse therapy and surgical decompression might be the better choice for the treatment of DON. (Chin J Ophthalmol, 2018, 54: 488-490) .

Purpose: Dysthyroid optic neuropathy (DON) is a serious complication of Graves orbitopathy that can result in irreversible and profound visual loss. Controversy exists regarding the pathogenesis and management of the disease. The authors provide an overview of the current understanding of DON and present a therapeutic guideline., Methods: A review of the literature., Results: The mechanism of DON appears to be multifactorial: direct compression of the optic nerve by enlarged extraocular muscles, stretching of the optic nerve by proptosis, orbital pressure, vascular insufficiency, and inflammation. Some or all of these factors may be involved in an individual patient. There has only been one controlled trial comparing high-dose intravenous methylprednisolone to bony orbital decompression for DON. Both 2-wall and 3-wall decompression techniques successfully improve visual functions of patients with DON. There are few case reports/case series that suggest biologic agents may improve visual function in DON., Conclusions: DON is a serious complication of Graves orbitopathy, the diagnosis and management of which is complex and requires a multidisciplinary approach. There is little evidence regarding the optimum management strategy. Based on the current literature, the first line of treatment is intravenous methylprednisolone, with the exact timing and indication of bony orbital decompression still to be determined. In addition, there may be a role for the use of biologic agents that will require a systematic program to determine efficacy.

Purpose: Diagnosing thyroid eye disease-compressive optic neuropathy (TED-CON) is challenging, particularly in cases lacking a relative afferent pupillary defect. Large case series of TED-CON patients and accessible diagnostic tools are lacking in the current literature. This study aims to create a mathematical formula that accurately predicts the presence or absence of CON based on the most salient clinical measures of optic neuropathy., Methods: A retrospective case series compares 108 patients (216 orbits) with either unilateral or bilateral TED-CON and 41 age-matched patients (82 orbits) with noncompressive TED. Utilizing clinical variables assessing optic nerve function and/or risk of compressive disease, and with the aid of generalized linear regression modeling, the authors create a mathematical formula that weighs the relative contribution of each clinical variable in the overall prediction of CON., Results: Data from 213 orbits in 110 patients derived the formula: y = -0.69 + 2.58 × (afferent pupillary defect) - 0.31 × (summed limitation of ductions) - 0.2 × (mean deviation on Humphrey visual field testing) - 0.02 × (% color plates). This accurately predicted the presence of CON (y > 0) versus non-CON (y < 0) in 82% of cases with 83% sensitivity and 81% specificity. When there was no relative afferent pupillary defect, which was the case in 63% of CON orbits, the formula correctly predicted CON in 78% of orbits with 73% sensitivity and 83% specificity., Conclusions: The authors developed a mathematical formula, the Columbia TED-CON Diagnostic Formula (CTD Formula), that can help guide clinicians in accurately diagnosing TED-CON, particularly in the presence of bilateral disease and when no relative afferent pupillary defect is present.

Purpose: To describe historical and modern surgical approaches to orbital decompression in patients with thyroid-related orbitopathy in the quiescent phase., Methods: A literature review of published techniques using the National Institutes of Health PubMed database., Results: Historically, orbital decompression has been accomplished via transantral, transcranial, transnasal, and orbital approaches. Current techniques use predominately periocular incisions to achieve effective decompression and proptosis reduction. Based on exophthalmometry and desired proptosis reduction, the authors propose a graded surgical approach to decompression for thyroid orbitopathy beginning with fat reduction, followed by deep lateral orbit via a superior eyelid crease incision, then medial wall by retro-caruncular approach, then posterior medial orbital floor either via transconjunctival or swinging eyelid approach, and finally with lateral orbital rim removal by superior eyelid crease incision as needed. These approaches can result in a range of proptosis reduction of up to 10 mm., Conclusions: A structured approach to orbital decompression results in predictable and effective outcomes in proptosis reduction.

Purpose: To evaluate the improvement in primary and eccentric gaze ocular alignment in thyroid eye disease (TED) patients undergoing horizontal strabismus surgery with Tenon's recession., Methods: This is an Institutional Review Board-approved retrospective analysis of TED patients undergoing horizontal strabismus surgery for esotropia. The study included all patients from 2007 to 2016 operated on by a single surgeon at Columbia University Medical Center. Surgical success was defined as the ability to fuse at both near and distance either without prismatic correction or with less than 10 prism diopters (PD) of correction. Measurements of ocular alignment were also made in eccentric fields of gaze. This study was Health Insurance Portability and Accountability Act compliant with protection of individually identifiable information., Results: Thirty-eight patients with TED and restrictive horizontal strabismus underwent unilateral or bilateral medial rectus recession to relieve diplopia. All patients underwent Tenon's recession with dissection of Tenon's from the overlying conjunctiva permitting it to retract into the orbit. Overall the success rate was 87% with a reoperation rate of 7.9%. The improvement in horizontal deviation in both primary and eccentric gaze was statistically significant (p < 0.001). The change in vertical deviation in the 5 cardinal positions of gaze was not statistically significant. The postoperative change in vertical deviation was not proportional to the preoperative horizontal deviation or the amount of horizontal recession., Conclusions: Due to the preoperative incomitance of ocular deviations in TED patients, persistent postoperative eccentric misalignment is expected. The addition of Tenon's recession to TED-horizontal strabismus surgery led to statistically significant improvement in ocular alignment in both primary and eccentric gaze. This is the first study of TED-strabismus surgery to analyze the postoperative results in positions outside of primary and reading gaze. The authors postulate that the release of scar tissue by the addition of Tenon's recession contributes to these improvements.

Purpose: Despite the paucity of supporting data, it has generally been held that proptosis in thyroid eye disease (TED) may provide relative protection from compressive optic neuropathy (CON) by producing spontaneous decompression. The objective of this study was to investigate this phenomenon in patients with bilateral TED-CON., Methods: We retrospectively reviewed the charts of 67 patients (134 orbits) with bilateral TED-CON at Columbia-Presbyterian Medical Center. Significant asymmetric proptosis (Hertel) was defined as ≥ 2 mm. Significant asymmetric CON was defined first, as the presence of an relative afferent pupillary defect. Those without an relative afferent pupillary defect were evaluated according to the TED-CON formula y = -0.69 - 0.31 × (motility) - 0.2 × (mean deviation) - 0.02 × (color vision) as previously established for the diagnosis of TED-CON. A difference in the formula result ≥ 1.0 between eyes was considered significant. Patients were then divided into 4 groups., Results: Forty-one of 67 patients demonstrated asymmetric CON (29 by relative afferent pupillary defect, 12 by formula). Twenty-one of 67 patients demonstrated asymmetric proptosis. Only 5 of 12 (41.6%) of the patients who had both asymmetric proptosis and asymmetric CON (group 1) showed greater proptosis in the eye with less CON. Twenty-nine patients (group 2) showed that asymmetric CON occurred despite symmetrical proptosis. Seventeen patients (group 3), showed the inverse, that asymmetric differences in proptosis occurred with symmetrical CON., Conclusion: Despite commonly held assumptions, our results suggest that greater proptosis is not associated with improved TED-CON. Combining groups 1 to 3-all of which demonstrated asymmetry of either proptosis, CON, or both-91.4% of patients did not show a relationship between greater proptosis and improved CON.

Purpose: To review the clinical presentation, disease severity, and surgical interventions of children with thyroid eye disease (TED) at a single institution over a 7-year period., Methods: Retrospective cohort study of children 0 to 18 years of age with a diagnosis of TED, seen at the Children's Hospital of Philadelphia from 2009 to 2016. Ophthalmic examination findings, neuroimaging study results, and ophthalmological management were recorded. t-Tests were used to test for statistical significance. Institutional Review Board approval was obtained for the study., Results: Sixty-seven subjects with pediatric TED were studied: 59 female and 8 male. The mean age at diagnosis was 11.6 years (SD 4.2, range 2.3-17.9). All subjects had proptosis (67, 100%). Other clinical findings were eyelid retraction in 46 (69%), chemosis in 7 (10%), punctate epithelial erosions in 8 (12%), and strabismus in 1 (1.5%). No subjects had evidence of optic neuropathy. Five subjects with static-phase TED received orbital decompression surgery for exposure keratopathy and disfigurement. All had significant cosmetic improvement and resolution of exposure keratopathy., Discussion: In this series, children with TED generally exhibit mild ocular signs, which is in agreement with past studies. Our study presented a high incidence of proptosis compared with other studies; however, this may represent a referral bias to our quaternary care center., Conclusion: Pediatric TED patients exhibit mild symptoms, such as proptosis and eyelid retraction without strabismus, vision loss, or optic neuropathy. Some children with TED have severe disfigurement and corneal exposure due to the disease and benefit from orbital decompression.

Purpose: To review the authors' current understanding of motility dysfunction in patients with thyroid eye disease and to summarize appropriate evaluation and available management options., Methods: Data were retrieved from a systematic search of the literature., Results: Diplopia is one of the most disabling symptoms for Graves orbitopathy patients. It occurs in moderate-to-severe Graves orbitopathy stages and does not respond well to available anti-inflammatory treatment. Inflammation of extraocular muscles induces relatively rapid fibrotic and degenerative changes, which lead to scarring and loss of elasticity with preserved contractility. Inferior and medial rectus muscles are most often involved, which results in horizontal or vertical misalignment or both, and sometimes cyclotorsion. Impaired motility can also be caused by entrapment after orbital decompression. The aim of surgical correction is to restore/enlarge the field of binocular single vision and alleviate abnormal head posture. The basis for successful treatment is dependent on the identification of the involved muscles combined with the correct assessment of motility, misalignment, and binocular single vision., Conclusions: Due to increased muscle tightness, recessions are the first choice of surgical procedures. Dosing is the most difficult part of the surgery. Several techniques are described: deviation-correction with preoperative determination of the dose, duction-correction either by active or passive intraoperative evaluation of ductions, and the application of adjustable sutures. Achievable success rates are comparable among these techniques but are dependent on the surgeon's experience. Cyclotorsion and misalignment after decompression and combined horizontal and vertical misalignments are more challenging to correct. Those types of deviations need special solutions like surgery on the oblique muscles and the usage of implants. The field of binocular single vision is the main outcome criteria for success, and the quantification may differ for research questions, study designs, and clinical purposes.

Introduction: Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED., Aim: We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery., Results: Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring., Discussion: Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.

Purpose: To investigate quantitative changes in eyelid parameters after orbital decompression surgery in thyroid-associated orbitopathy using the PC-based program, Eyelid Analysis Software (EAS)., Methods: This study included 202 eyes of 109 thyroid-associated orbitopathy patients. Digital photographs of the patients in primary gaze were taken just before and after orbital decompression surgery, and exophthalmos degree was measured by Hertel exophthalmometry (Hertel Exophthalmometer SKU:52400; Oculus, Arlington, VA, USA). The custom-made PC-based software EAS (Biomedical Research Institute, Seoul, Korea) was used to analyze eyelid parameters. The 11 parameters included pupil to inferior eyebrow distance (PBD), margin reflex distance 1 (MRD1), margin reflex distance 2 (MRD2), palpebral fissure (PF), total lid length, upper and lower lid length, area, medial area, center area, and lateral area., Results: Univariate linear regression analysis showed a significant positive association between amount of exophthalmos reduction and the following parameters: area (p = 0.007); MRD2 (p = 0.043); upper lid length (p = 0.045); lower lid length (p = 0.006); medial area (p = 0.045); and lateral area (p = 0.005). Multivariate linear regression analysis showed only two parameters, lower lid length (p = 0.022) and lateral area (p = 0.019) were associated with exophthalmos reduction., Conclusions: A reduction in the inferior lateral part of the eyelid (lateral area + lower lid length) occurred after orbital decompression surgery in patients with thyroid-associated orbitopathy.

Background/aims: We performed a retrospective analysis to examine clinical results, establish a dose-effect coefficient and analyze the long-term efficacy of tendon elongation with bovine pericardium (Tutopatch®) for surgical correction of severe esotropia, occurring after three-wall orbital decompression for dysthyroid optic neuropathy in patients with Graves' orbitopathy (GO)., Methods: Tendon elongation of the medial rectus muscle (MR) was performed in our institution using an interponate of bovine pericardium in 60 patients (27 underwent unilateral and 33 bilateral surgery). Success-rate (total horizontal deviation of 10 prism-diopters (PD) or less and evidence of binocular single vision with or without prism glasses) and horizontal motility were examined 3 months, 1 and >4 years after surgery. A dose-effect coefficient for deviation reduction (PD) per recession distance (mm) was established., Results: Horizontal deviations between 28-80 Δ were corrected. Diplopia in primary-gaze disappeared in 65% of the patients after 3 months and in 83% after one year (including 12 patients who underwent subsequent surgery after 3-month follow-up). Patients with deviations ≤40 Δ after unilateral and ≤50 Δ after bilateral tendon elongation showed higher primary success-rates after 3 months (78% and 72%). Vertical deviations (≤10 Δ ) were corrected by the procedure in 28% without need of recession of the inferior rectus (IR). Only 3 patients showed overcorrection after one year. One of these underwent revision surgery, in which the interponate was no longer discernible from surrounding fibrotic scar tissue. At >4-year follow-up (4.3-15years) effects were stable and 95% of patients showed fusion in primary gaze. Median dose-effect coefficient was lower after tendon elongation (1.8 Δ /mm) compared to conventional medial rectus recession in patients with GO. Horizontal motility was slightly decreased, but much more symmetric around primary gaze., Conclusion: Tendon elongation with a bovine pericardium implant is a safe surgical method, suitable to correct severe esotropia after decompression surgery. A lower dose-effect has to be taken into account. Patients with esotropia ≥42 Δ should not be treated with unilateral, but bilateral tendon elongation, to avoid undercorrections. In patients with deviations ≥52 Δ it has to be further investigated if the application of even higher elongation distances is viable or if another approach-the recession of more than one rectus muscle has to be performed simultaneously to handle the severe restriction. Generally, a step-by-step approach is advisable, since small vertical deviations could also be corrected in a third of patients with the procedure and the dose-effect was more variable as in medial recessions without tendon elongation.