Orbital Decompression Surgery for
Thyroid Eye Disease
The primary goal of an orbital decompression surgery is to create
more space in the orbit to allow the eye to return to a more
The indications for orbital decompression include:
Compressive optic neuropathy
Spontaneous globe prolapse
Discomfort due to orbital pressure/pain
Patients being considered for orbital decompression have a
high resolution CT scan in the axial and coronal planes.
Several factors are examined including presence of sinus
disease, size of extraocular muscles, thickness of bony walls
(particularly the deep lateral wall) and the position/angle
of the cribriform plate in relation to the medial orbital
wall (this is important if medial wall decompression is to
A full ophthalmic and orbit work-up including exophthamometry
are carried out. External photographs are taken, including
full face and profile views, and a view from above and below
showing the amount of globe protrusion.
All patients undergo a standard preoperative medical clearance
that includes full blood count, ESR, U&E, thyroid function
test (TSH, free T3 & T4) and an ECG
A thorough discussion of risks, benefits, and alternatives
to the planned surgery is undertaken.
Orbital decompression can be categorized into three types:
Removal of bone from one or more walls of the orbit
Removal of orbital fat, including intraconal fat
A combination of bony and fat removal
In our experience, the indications for fat decompression only
are few. Most of the orbital decompressions we perform involve
removal of bone and occasionally fat.
The most important factor that determines our technique is
the amount of proptosis. Traditionally, the orbital floor and
medial orbital wall
were the first walls removed. Recently, a trend toward deep
lateral wall decompression as the first choice in bony removal
The benefits of lateral wall removal include up to 4mm reduction
in proptosis and less induction of strabismus and infra-orbital
nerve damage. If further
decompression is required, then the medial wall is removed
in a balanced fashion to symmetrically retro-place the orbital
tissues from each side, thereby in theory also reducing the
induced strabismus by balancing the muscle pull.
If further proptosis reduction is necessary, then we remove
orbital fat. The orbital floor is only removed if the proptosis
is greater than 7mm . This is because orbital floor removal
is associated with complications like globe ptosis, worsening
hypotropia, and infraorbital hypesthesia and we reserve it
as the last wall to be removed.
What are the risks:
The risks of this surgery include, but are not limited to:
Infection (no nose blowing for one week following surgery)
Suture related inflammations
Asymmetry of eye position
New-onset double vision following surgery (may be permanent,
especially in extreme peripheral gaze)
Numbness of cheeks and lip
Loss of vision that may be permanent
Additional surgery in the future
temporary cerebrospinal fluid leak (leakage of fluid of
fatal brain hemorrhage
In addition to the risks specific to the individual procedure,
there are also general risks, such as blood loss, infection,
cardiac arrest, airway problems and blood clots, which are
associated with any surgical procedure. As the operation is
carried out under general anaesthesia, the anaesthetist will
discuss this with you.
Although we have discussed with you the purpose and likely
outcome of the proposed procedure it is not possible to guarantee
a successful outcome in every case. Those treating you will
do their best to ensure success but unfortunately complications
can and do occur. You should only agree to surgery if you fully
understand the risks.
What are the benefits?
Improve position of eye back into orbit (bony socket),
Improve corneal exposure and reduce the risk of corneal
Possibly improve raised intraocular pressures (especially
when looking up).
Are there any alternatives to surgery?
In some patients, this surgery is necessary in order to preserve sight and
without it there is a risk of permanent visual loss. If it is performed for
other reasons and you decide not to proceed, the appearance of the eyes and
symptoms are unlikely to improve spontaneously. They may stabilize or worsen
over time, although this is unlikely to have any permanent detrimental effect
to your vision or general health.
If you have any specific concerns, you should discuss them with your surgeon
before the operation.
Patients typically stay one night in the hospital unless there are other medical
post-operative course of corticosteroids and antibiotics
are prescribed to minimize swelling and prevent infection.
Have someone drive you home after surgery and help you
at home for 1-2 days.
Decreased activity may promote constipation, so you may
want to add more raw fruit to your diet, and be sure to increase
Do not take aspirin or clopidogrel for 48 hours after
Do not drink alcohol when taking pain medications.
Even when not taking pain medications, no alcohol for
3 weeks as it causes fluid retention.
If you are taking vitamins or other dietary supplements,
resume these as tolerated.
Do not smoke, as smoking delays healing and increases
the risk of complications.
Instill drops and apply ointment as advised
Use ice packs every 2-3 hours for the first 2 days for
comfort and to reduce swelling and bruising.
You may shower 48 hours after removal of the dressing.
Keep incisions clean with soap and water and inspect daily
for signs of infection.
Keep your head elevated for several days; sleep with your
head on 2 pillows at least 1 week.
Generally, your hair can be shampooed anytime after surgery.
Wait at least 3 weeks before wearing contact lenses.
You will have sensitivity to sunlight, wind and other
irritants for several weeks, so wear sunglasses.
Start walking as soon as possible, as this helps to reduce
swelling and lowers the chance of blood clots.
Do not drive until you are no longer taking any pain medications
Avoid strenuous activities for 10-14 days.
Return to work 10- 14 days after surgery
WHAT TO EXPECT
The eyes are bandaged for the first night.
Maximum discomfort should occur in the first few days,
improving each day thereafter.
Expect temporary swelling of the eyelids, tightness of
lids, bruising, dryness, burning, and itching of eyes.
You may have gummy eyes for approximately 1 week.
For the first few weeks, you may experience excessive
tearing, sensitivity to light, and double or blurred vision.
Bruising and swelling of the eyelids may last up to 3-4
Healing is a gradual process and your scars may remain
slightly pink for 6 months or more.
Tiny whiteheads may appear after stitches are taken out;
can be easily removed by surgeon.
Facial makeup can cover up bruising after the sutures
You will be reviewed after one week and sutures will usually
Additional rehabilitative surgery for double vision, lid
problems will be planned for 3-6 months after the decompression