Orbital Decompression - Indications, Assessment, and Procedure

Introduction

When the eyes protrude, the eyelids also poorly lubricate the eyes' surface. As a result, dry eye symptoms, including redness, irritation, and blurred vision are prevalent. Eyes can bulge for various causes, the most frequent of which is thyroid eye disease. The tissues around the eyes might expand in some situations, such as Grave's disease.

This might include fat or muscles around the eyes. In certain circumstances, the bulging may induce various adverse eye effects, including discomfort, double vision, eyelid retraction, and even vision loss. The eyes become more exposed to the air and surroundings as they swell. Decompression surgery can be performed to assist the eyes in returning to a more normal position, making them more comfortable and alleviating some of these consequences.

What Is the Orbital Decompression Indications?

• The primary reason for orbital decompression is probable eye or optic nerve injury caused by proptosis or compressive optic neuropathy.

• As previously stated, thyroid eye illness is the most prevalent reason for orbital decompression surgery.

• Congenitally shallow orbits, relative maxillary hypoplasia, orbital tumors, and trauma resulting in orbital hemorrhage have all been treated by orbital decompression. It is, however, rarely used for the latter two aetiologies.

• When noninvasive therapy fails, surgery is frequently required, and when there are significant surgical indications such as optic neuropathy, dramatic ocular surface disease, and globe subluxation, quick orbital decompression should be performed.

• Diplopia, orbital discomfort, proptosis, and ocular pressure as a mechanical outcome of proptosis are non-urgent reasons for orbital decompression.

• It is vital to emphasize that non-urgent orbital decompression should not be performed if thyroid eye disease is present.

• Furthermore, following orbital decompression, strabismus surgery to treat diplopia or misalignment should be performed.

• Although orbital decompression has historically been performed for functional (medical) reasons, interest in aesthetic decompression has grown.

• Because of advancements in technique and associated reductions in postoperative problems, there has been an increase in the number of individuals getting cosmetic surgery.

What Is the Physical Assessment for Orbital Decompression Surgery?

A clinical examination involving the eye, orbit, and surrounding tissues is necessary to determine the etiology, severity, and other contributing factors of proptosis. Visual acuity, extraocular motility, confrontational visual fields, pupillary examination, intraocular pressure (often elevated), evaluation of color vision, anterior segment examination, and dilated fundus examination are all included in a thorough eye exam. The inferior rectus is most frequently affected first in thyroid eye disease.

• It should be noted that the anterior segment exam should pay special attention to the cornea, conjunctiva, and caruncle.

• Examining the eyelids involves determining eyelid posture, eyelid function, and the presence of lid lag or lagophthalmos.

• Examine the orbit, including the bony structures of the orbital rim, the existence of any masses, and the capacity to retropulse the eye.

• Eye symmetry and placement should be evaluated, and aberrant positioning, such as hypoglobus, should be recognized.

• Proptosis should be measured quantitatively with a Hertel Exophthalmometer.

• Erythema, chemosis, caruncular injection or swelling, edema, tumors, or other significant anomalies should be noted on the periorbital skin and tissues.

• Visual field abnormalities, color vision loss, an afferent pupillary defect, and vision loss may arise due to compressive optic neuropathy. A corneal examination may indicate punctate epithelial erosions caused by dry eyes.

• If the erosions are localized in the inferior region of the cornea, this might indicate that the patient has lagophthalmos or the inability to close the eyelids fully.

What Is the Procedure of Orbital Decompression Surgery?

• Orbital decompression surgery is intended primarily to treat bulging eyes.

• Bulging is produced by swelling of the fat and muscle surrounding the eyes in the thyroid eye disease.

• Swelling drives the vision forward, resulting in a bulging eye since the eye is in an inflexible bony eye socket.

• Decompression surgery works by removing parts of the eye socket bone to enlarge the size of the eye socket. This causes the enlarged tissue to collapse into the expanded regions, allowing the eye to return to its natural position.

• Orbital decompression is carefully removing or weakening the orbital walls (including orbital fat) to widen the space in orbit, allowing for the accommodation of abnormally expanded muscles and tissue that exceed the orbit's original volume.

• Decompression can be tailored to the severity of the proptosis, as well as functional and aesthetic requirements.

• In rare situations, increased orbital contents pressure the optic nerve and surrounding vasculature, resulting in exposure keratopathy, optic neuropathy, and other visual problems.

• Thyroid eye disease (TED) affects 25 to 50 percent of Graves' patients and is the most prevalent reason for orbital decompression.

• The choice of surgical procedures and knowledge of underlying etiology influence outcomes.

• Dollinger et al. published the first description of orbital decompression in 1911, using a lateral wall approach to produce minimum decompression into the temporal fossa.

• Since then, several procedures have emerged for eliminating one or more orbital walls and orbital fat. The mechanism used to enter into the orbit also differs.

• Kennedy et al. recently pioneered an endoscopic transnasal method that has gradually displaced previous treatments. However, there are restrictions, like with the other ways.

• Regardless of studies claiming one strategy is preferable, individualization is favored, focusing on unique anatomical and clinical findings to determine the optimal plan.

What Is the Post-operative Experience of Orbital Decompression?

Orbital decompression surgery is done in the operating room while you are entirely unconscious. The procedure is carried out through an incision on the underside of the lower eyelid and into the skin on the outer corner of the eye. The bone under the eye and the central wall of the eye socket are then removed.

Sutures are then used to seal the incision in the outer corner of the eye. If both eyes require surgery, it is usually done on both sides simultaneously. Patients may be kept in the hospital overnight, while some may be discharged after surgery. Following this procedure, patients are incredibly swollen and bruised.

Rest and cold packs are needed. For the first few days, doctors usually give a tiny dose of pain reliever and antibacterial ointment. Patients may also be prescribed oral steroids and antibiotics. Following surgery, the eyesight may be somewhat hazy, and swelling may produce minor double vision. After one week, most of these symptoms have subsided, and patients may resume regular activity.

Conclusion

For specific individuals with proptosis, orbital decompression surgery is a potential therapy option. It has been demonstrated to improve proptosis and successfully treat urgent indications for decompression significantly. It is difficult to establish one superior way due to a lack of standardized outcomes and reporting, comparable studies, and various varied techniques. However, the overall view is that the product is favorable, with a significant potential for lowering proptosis. Finally, orbital decompression can help to reduce proptosis. The aim to achieve the maximum volumetric expansion should differ from the purpose of orbital decompression. Instead, it should aim to develop a personalized and viable surgical approach that delivers optimal decompression with success and minimal problems.