Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy

Abstract

Purpose: To describe the results of thyroid-related orbitopathy (TRO) treated by ultrasonic deep lateral wall bony decompression with partial rim sparing (DLW-PRS).

Methods: A review was carried out, from January 2015 to September 2017, of all patients treated with ultrasonic DLW-PRS decompression using a SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator, using a lateral, small triangle flap incision for access. The primary outcome was the change in proptosis (measured by the difference in Hertel exophthalmometry measurements). Other secondary outcomes were changes in visual acuity (VA) (using Snellen scale, decimal fraction), presence of lagophthalmos, eyelid retraction (measured by upper eyelid margin distance to the corneal reflex (MRD1) and lower eyelid margin distance to the corneal reflex (MRD2), and presence of exposure keratopathy).

Results: A total of 58 orbital decompressions in 35 patients were reviewed, with 23 patients (65.7%) having bilateral decompressions. There was a female preponderance with 26 patients (74.2%), and the mean age ± standard deviation was 52.6 ± 13.9 years. Mean proptosis was 24.51 ± 1.76 mm preoperatively, reduced to 19.61 ± 1.27 mm in final follow-up. The mean reduction was 4.9 ± 1.54 mm. VA improved from 0.8 ± 0.14 to 0.9 ± 0.12, p=0.039. 5 of 13 patients (38.4%) with preoperative diplopia reported improvement or complete resolution after surgery. MRD1 was reduced from 5.25 ± 0.88 mm to 4.49 ± 0.7 mm. MRD2 was also reduced from 6.3 ± 0.88 mm to 5.0 ± 0.17 mm. Presence of lagophthalmos was reduced from 35 eyes (60.3%) to five (8.6%); the presence of epiphora was also reduced from 20 patients (57.1%) to 3 (8.5%) following decompression. Complications of the surgery included zygomatic hypoaesthesia in 14 (40%) patients in the early postoperative period and chewing alterations in 10 (28.5%) of the patients. All of these complications were resolved at the 6-month follow-up visit. We noted no surgical complications such as ocular or soft tissue damage, infection, inflammation, or visual loss.

Conclusions: The SONOPET® ultrasonic bone curette can be used safely and effectively for DLW orbital decompression surgery. The main benefits were good visualization and handling of tissues and speed and ease of use of the equipment. This trial is registered with ClinicalTrials.gov identifier: NCT04025034.

Conflict of interest statement

The authors received financial support for this study but have no financial or proprietary interest in the materials presented in this study. The authors have no commercial associations that might be perceived as a conflict of interest in connection with the article.

Copyright © 2019 Álvaro Bengoa-González et al.

Figures

Figure 1

The triangular incision along the eyelid crease (a) allows excellent exposure of the orbital rim (b). The exposed lateral wall (c). The serrated aggressive knife used for osteotomies (d). The plastic irrigation sleeve on the ultrasonic tip prevents thermal damage to the skin and soft tissues. Full-thickness osteotomy made 5 mm posterior and parallel to the lateral orbital rim with the aggressive serrated knife tip, extending from the level of the orbital roof to the floor and a second full-thickness back-cut placed above the zygomatic arch (e).

Figure 2

(a) Superlong Payner 360° used for trigone removal. (b) The deep lateral wall to the trigone is removed. The image shows the intact orbital rim and bony window following osteotomy. (c) Prolapse of the lacrimal gland and orbital fat in the newly opened 623 bony spaces. (d) The incision is closed in layers and vacuum drain inserted. (e) 1 year after surgery, the scar is almost invisible.

Figure 3

(a) Patient before surgery and (b) following decompression showing a reduction of proptosis and palpebral fissure. (c) Orbital computed tomography (CT) before surgery. The arrows show the extent of the lateral wall which will be removed to create a full-thickness bony window. (d) Postsurgery orbital CT showing a reduction of exophthalmos. It also illustrates the preservation of the orbital rim, removal of the lateral wall and sphenoidal trigone (arrow), and the soft tissue prolapse into the newly created spaces (e) and postoperative three-dimensional CT reconstruction (f).