Non-surgical facial rejuvenation Cosmetic procedures Eyelid surgery Tear drainage surgery Eye socket/orbit surgery Cataract surgery
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 normal position.
The indications for orbital decompression include:

  • Compressive optic neuropathy
  • Exposure keratopathy
  • Spontaneous globe prolapse
  • Disfigurement
  • Discomfort due to orbital pressure/pain
  • Orbital congestion

Preoperative assessment

Imaging
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 be performed).

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


Surgical Planning
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 has occurred.
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:

  • Bruising
  • Infection (no nose blowing for one week following surgery)
  • Scar formation
  • Swelling
  • 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
  • Rarely
    • temporary cerebrospinal fluid leak (leakage of fluid of the brain)
    • 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 discomfort
  • Improve corneal exposure and reduce the risk of corneal infection
  • 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.

Post-operative care
Patients typically stay one night in the hospital unless there are other medical problems.

  • 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 fluid intake.
  • Do not take aspirin or clopidogrel for 48 hours after surgery.
  • 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.

INCISION CARE

  • 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.

ACTIVITIES

  • 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 (narcotics).
  • 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.

APPEARANCE

  • Bruising and swelling of the eyelids may last up to 3-4 weeks.
  • 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 are removed.

FOLLOW-UP CARE

  • You will be reviewed after one week and sutures will usually be removed
  • Additional rehabilitative surgery for double vision, lid problems will be planned for 3-6 months after the decompression surgery

Images
2 patients preop & post op