Bilateral simultaneous orbital decompression for Graves' orbitopathy with a combined endoscopic and Caldwell-Luc approach

Abstract

Graves' orbitopathy can lead to cosmetic deformity, orbital pain, and visual impairment. Surgical intervention can improve proptosis, cosmetic appearance of the eyelids, vision, and orbital pain with minimal morbidity. Ten patients with dysthyroid orbito-pathy underwent concurrent bilateral orbital decompressions. Of these, 9 underwent simultaneous bilateral endoscopic and transantral decompressions, and 1 had only bilateral endoscopic decompressions. Medical management of keratopathy was attempted before surgery. All patients were previously treated with radioiodine and high-dose corticosteroids, and 2 patients had prior low-dose orbital irradiation. Preoperative and postoperative visual acuity, color vision testing, and measurement of proptosis were recorded for all patients. In addition, photographs and CT scans of the orbit and sinuses were done. After surgery, visual acuity improved in 8 patients and remained unchanged in 2 patients. Diplopia in the primary and downward gaze improved in 1 patient and remained unchanged in the 3 others who had it before surgery. Color vision deficits in the blue/yellow range were present in 8 patients before surgery and all reversed within 2 weeks after surgery. Proptosis decreased by an average of 4.83 mm (range 4–7 mm) in patients undergoing the combined decompression and decreased by 4 mm in the 1 patient who had the endoscopic decompression only. Ethmoid sinusitis developed in 1 patient but resolved with oral antibiotics, and another patient had an asymmetric result requiring additional unilateral surgery, which corrected the asymmetry. Overall, this approach avoids external incisions and allows excellent visualization in the regions of the orbital apex and ethmoid roof, facilitating maximal decompression without the increased risk of bleeding or visual disturbances.