Thyroid Eye Disease (Orbit Surgery)

Orbital Decompression Surgery

Once the “active” inflammatory phase of thyroid eye disease has subsided, an individual may be left with structural changes, such as eye protrusion (proptosis or exophthalmos), eyelid retraction, in some cases, double vision (diplopia). Fortunately, corrective surgical procedures exist to improve these problems.In most people with Thyroid Eye Disease, the expansion of tissue and swelling behind the eye is not severe enough to damage the optic nerve, but it may cause striking proptosis. This is a distressing situation, not only from the standpoint of exposure of the eye, but also because of the disfigurement that is produces. Orbital decompression surgery can often improve proptosis by enlarging the eye socket (orbit) to accommodate the swollen fat and muscle tissues behind the eye. This allows the eye to settle back into a more comfortable position. The consistency and amount of fat varies from case to case and will impact the degree of decompression achieved by surgery. Individuals with thicker, stiff fat may not experience as much decompression effect as those with large amounts of softer, more 'fluid-like' fat tissue.

Anatomy

Around the orbit (the bone socket in which the eyeball sits) there are a number of sinus (air) cavities that can be used to surgically expand the orbit. The sinus below the eye is called the maxillary sinus and the sinus toward the nose is called the ethmoidal sinus. Maxillary-ethmoidal bone decompression is a frequently used combined procedure for accommodating the extra tissues behind the eye. Most people only require a two wall, maxillary-ethmoidal decompression; less frequently, the outside (lateral) wall of the orbit may also be removed.

Surgical Techniques

The method utilized by Dr. Klapper to remove the bone of the orbital floor (underneath the eye) involves an incision on the inside of the eyelid and a very small skin incision near the outer corner of the eye. This skin incision heals nicely within the normal laugh lines around the eye. Using eyeglasses with magnification, Dr. Klapper will meticulously remove the bone of the orbital floor to allow communication with the maxillary sinus air cavity. There is a nerve that runs through this bone to provide sensation to the cheek, lip, and upper teeth. Great care is taken to meticulously nibble the bone away from this nerve so that the nerve is preserved. Despite extreme caution, and the use of microsurgical techniques, some numbness almost always occurs. However, in more than 90% of cases, this numbness lasts less than six months.To remove the medial orbital wall bone, Dr. Klapper may use a very small conjunctival incision near the inside corner of the eye.  Alternatively, Dr. Klapper may work closely with an otolaryngologist (Ear Nose and Throat or ENT surgeon) who performs an endoscopic ethmoidectomy which is a procedure in the nose which permits access to the same area. After the bones of the orbit/sinuses are removed, the tissues which have built up behind the eye (fatty tissue and/or swollen extraocular muscles) are able to expand into the maxillary and ethmoid sinus cavities.

Results

In most cases, if the orbital tissues are soft, improvement will be noted with the settling of the eye into a more acceptable position within several weeks or months. In some cases, the full decompressive effect of surgery may not be evident for 1-2 years.

Postoperative Care

Orbital decompression surgery is performed under general anesthesia. Patients may have the option to stay overnight in the surgical facility (ambulatory surgery center or outpatient hospital) as a 23 hour observation. This is still generally considered outpatient surgery. The overnight stay may be recommended to receive intravenous antibiotics, corticosteroids, pain medication, and nausea medication. Once at home, patients will require assistance during the initial 2-4 days (sometimes more). Oral antibiotics, prednisone, and pain medications are prescribed for one week. Ice packs and rest is recommended during the first week. Patients are asked to avoid nose blowing, heavy lifting, or strenuous activity during the first two to four weeks after surgery. Absorbable sutures are frequently used and do not require removal. Detailed postoperative instructions will be given to you immediately following your surgery. You will need to see Dr. Klapper in his office 1-3 days after surgery and often again at 7-10 days. Further postoperative visits are adjusted on an individual basis.

Expectations and Potential Risks of Surgery

Double Vision

Some patients who undergo decompression already have some double vision. In most patients, orbital decompression does not adversely alter the pattern of double vision. However, in some people the double vision is helped and in other individuals the double vision is worse after surgery. Dr. Klapper utilizes a bone strut preserving technique that greatly reduces the risk of worsened double vision. Patients with severe muscle involvement are at greater risk of worsened double vision after surgery. Treatment of double vision, should it occur, may require prisms in your glasses, further orbital surgery or eye muscle (strabismus) surgery. Patients with double vision will often have their care coordinated with a strabismus surgeons. Dr. Klapper works with several excellent strabismologists in central Indiana.

Minimal Surgical Effect

Other than the amount of bone removal, the main factor that affects the settling of the eye in orbital decompression is how “stiff” the tissue is which has built up behind the eye. Many people have very soft, fatty tissue that will readily expand into the surrounding sinus cavities allowing good retroplacement of the eye. In some thyroid patients, however, the tissue is very stiff and fibrotic (scarred). In these individuals, even though the surgery is performed correctly, the tissue simply will not expand into the newly created spaces. In these situations, the effect of the decompression may be less than expected or desired. It is often difficult to predict before surgery what the consistency of the orbital tissue will be. In general, people who have good eye movement will have softer, more pliable tissue behind the eye.

Asymmetry

Most patients with thyroid-related eye disease have some asymmetry in eye position (protrusion or proptosis) before surgery. If there is significant asymmetry remaining after surgery, it can usually be compensated for with surgical adjustments of upper or lower eyelid positions (Eyelid Retraction Surgery). Rarely, further orbital surgery is helpful. 
It is important to remember that many factors contribute to the overall results of surgery. The way that our tissues heal differs from patient to patient and sometimes from one side to the other side.

Numbness of the Lips and Gums

The sensory nerve, contained within the floor of the orbit, is responsible for feeling in upper lip and gum as well as the cheek. Numbness of these areas frequently occurs after orbital floor surgery. This is not a visible finding, but it can be somewhat of a nuisance. It frequently resolves completely in 3-6 months.

Severe Bruising and Swelling

This operation takes place in an area that is very vascular with a large number of blood vessels, and it is imperative that a person undergoing orbital decompression surgery not take any medication that wound hinder normal blood clotting. Following clearance by the patient's primary care physician or cardiologist, drugs containing aspirin or aspirin-like medications (most arthritis medications) should be held for 10-14 days prior to surgery. Many over-the-counter medications contain aspirin-derivatives. Please check with a physician about all of your medications, including over-the-counter cold remedies and decongestants as well as all herbal medications. Individuals with hypertension should have their blood pressure adequately controlled before undergoing surgery. Even with adequate precautions, some patients may experience significant swelling, particularly if marked proptosis was present preoperatively. Swelling of the conjunctiva (mucosal covering of the outside of eye) may result in a 'blistered or bubbled' appearance of the eye. This typically resolves with frequent ocular lubrication (eye drops and lubricating ointment) over several weeks. Severe bruising and swelling can impair a successful result and cause additional scar tissue to form. Excessive bleeding and swelling, if very severe, could conceivably result in vision loss.

Loss of Vision

Anytime surgery is performed around the eye, especially in the orbit behind the eye, there is a risk of partial or severe vision loss (blindness). Even in the best of surgical hands, bleeding, injury to a critical blood vessel or nerve may cause unexpected vision loss.

Sinus Blockage

Orbital decompression is an operation that essentially borrows part of the sinus cavity to allow the eye to settle into a more normal position. Sinus decongestants are recommended before and after surgery to minimize sinus swelling and optimize sinus drainage. Patients who already have a tendency to develop sinus blockage may experience sinus obstruction after orbital decompression. It is important for these patients to inform Dr. Klapper of their sinus difficulties. In most cases, a surgical drainage procedure of the sinus can be performed at the time of orbital decompression. Dr. Klapper works closely with otolaryngology (ENT surgeons) colleagues in orbital decompression surgery and in the management of patients with sinus disease.

Need for Additional Eyelid or Eye Muscle Surgery

After a patient has entered the “inactive” phase of their thyroid eye disease, surgical reconstructive procedures can be considered. Orbital decompression, if necessary, should always be performed first. Changing the position of the eye may alter the functions of the eye muscles and change the relative positions of the eyelids. In patients with double vision, eye muscle surgery should be performed after orbital rearrangement, but before any eyelid corrections. After orbital decompression surgery, the eye tends to settle backward and slightly downward. This shift combined with the lateral canthoplasty (surgery in the outer corner of the eye) performed at the time of decompression usually result in improvement in the lower eyelid position. The upper eyelids, however, in most cases, continue to “hang up” and require repair to achieve an improved position. Eyelid surgery is typically performed as an out-patient under local-IV sedation anesthesia.

Summary

Thyroid eye disease and its treatments are very complicated so it is important for patients to understand as much as they can about their disease. We recommend that patients review all of the information provided on our website, discuss their disease with their primary care physician and endocrinologist, and seek additional resources to review regarding their specific problem or concern. The more informed patients are regarding their eyelid and orbital disease, the more they will be able to make important informed decisions about their care, and the better they may feel about their disease and the variety of available treatment options.

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Dr. Klapper treats disorders, injuries, and other abnormalities of the eyelids, eyebrow, tear duct system, eye socket, and adjacent areas of the mid and upper face.

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