Periorbital Bone and Fat Decompression Surgery Effectively Reduces Graves Orbitopathy

Deborah Brauser

September 28, 2009

September 29, 2009 (Palm Beach, Florida) — A novel procedure combining endoscopic endonasal bone and transpalpebral fat decompression surgery can decrease proptosis, lid fissure width, and upgaze intraocular pressure without any major adverse effects for patients with severe Graves' orbitopathy, according to a new study.

Results were presented in a poster session here during the American Thyroid Association (ATA) 80th Annual Meeting.

Dr. George Kahaly

"Disfiguring proptosis and dysthyroid optic neuropathy lead to cosmetic impairment and loss of vision for patients with severe [Graves' orbitopathy]," said lead investigator George Kahaly, MD, from the Department of Medicine at Gutenberg University in Mainz, Germany, during his presentation. "Surgical decompression of the crowded orbit offers a valid therapeutic option."

In an interview with Medscape Diabetes & Endocrinology, Dr. Kahaly said that patients with this disease have significant problems with impaired vision, including double vision.

"It is a huge medical problem, but it's also a huge economical problem since these patients are having trouble working and are staying home. The jobless rate of these patients is approximately 40% in Germany."

He reported that although steroid treatment can help, it is just a temporary fix, with several adverse effects, and irradiation is not very effective alone. "We can help them more by correcting the orbital space. For these patients, orbital muscles and fat are increasing, but the orbital space is very narrow. That's why we have to give them more space."

"We are going through the nose to remove the medial lobe of the orbital space, and then the eye and the bulge can go back," Dr. Kahaly explained. In this procedure, they also remove the palpebral adipose tissue (median, 8 mL in the series reported here; range, 3–21 mL).

Marked Improvement

For this study, Dr. Kahaly and his team examined 150 consecutive patients (median age, 54 years; 113 females) with severe Graves' orbitopathy who underwent endonasal bone and transpalpebral fat decompression surgery at a large thyroid eye clinic in Germany.

Surgery indications included cosmetic reasons (73%), dysthyroid optic neuropathy (24%), and corneal ulceration (0.4%).

All study patients received a complete multidisciplinary endocrine and ophthalmic assessment preoperatively and at 3 and 12 months postoperatively.

Results showed that proptosis decreased from 23 mm (range, 13–32) at baseline to 20 mm (range, 10–30) at 3 months postsurgery and to 19 mm (11–30) at 12 months postsurgery (< .001).

In addition, lid fissure width decreased by 2 mm (= .0001) and upgaze intraocular pressure dropped by 4 mm Hg at the 12 month mark (< .001).

The median severity score also declined, from 7 points (range, 2.5–13) at baseline to 4 points (range, 1–11) at 3 months postsurgery and 3.5 points (range, 1–7) at 12 months postsurgery (< .001).

A total of 89% of the patients reported that subjective eye signs significantly decreased, an the satisfaction rate from a quality-of-life questionnaire was more than 90%.

No major adverse effects were reported. Two patients (1.3%) experienced new-onset constant diplopia 3 months after decompression, and 22 patients (15%) reported de novo inconstant or intermittent diplopia. All cases of diplopia were corrected by prisms and/or subsequent squint surgery.

In a comparison of smokers and nonsmokers, both the intraocular pressure and median severity scores decreased less in the 96 patients who smoked than in the 54 who did not (P < .001 for both).

Finally, the decompression procedure successfully treated all 97 of the patients who had preoperative coexistent sinusitis.

Multidisciplinary Team Needed

"The combined endonasal bone and transpalpebral fat orbital decompression is a safe and efficient therapy for severe [Graves' orbitopathy]," said Dr. Kahaly. He noted that after 3 months, many of these patients were able to return to work.

"I think this disease is regarded as very complex and difficult to treat and manage," said Dr. Kahaly. "It's also time-consuming and very costly. So it's important that the general practitioner refer these patients to a specialist. This complex disease needs a multidisciplinary team."

He added that he's looking forward to seeing results from several ongoing studies that are evaluating new biotechnical drugs for treating patients prior to surgery. "For now, the best treatment is to start with steroids to deactivate the inflammation, rendering the disease inactive, and to then do surgery. But for the long term, we hope that we will get new drugs to eventually avoid surgery all together."

Comparisons to Mayo's Approach

"There are limited treatment options for patients with [Graves' orbitopathy]," Rebecca S. Bahn, MD, professor of medicine and consultant in endocrinology at Mayo Clinic School of Medicine in Rochester, Minnesota, and immediate past president of the ATA, said in an interview. Dr. Bahn, who was not involved with this study, reported that 3% to 5% of these patients have very severe disease, which can lead to blindness.

"When they have very severe disease, and especially when it's compressing the optic nerve, then we think about doing surgery that goes in and removes some of the bone around the eye," said Dr. Bahn.

"At the Mayo Clinic, [the surgeons] go into a more posterior part of the orbit and remove more of the bone. We have very good results from that, but it's a fairly major operation. Dr. Kahaly and his group have devised an operation that is less invasive. It goes in not quite as far back, removes some fat right around the eye lids and then removes just 1 part of the bone in the medial area," she explained.

"The question is: Are the results as good? He showed that it did relieve pressure on the optic nerve and patients don't have very much double vision after the surgery. So my impressions of his findings are that they really look very good," said Dr. Bahn.

She added that the procedure needs to be studied further in more patients. "To understand what the best approach is, you'd really have to do a side-by-side study."

"There are several different ways to approach orbital decompressive therapy," observed Gilbert Daniels, MD, professor of medicine at Harvard Medical School, codirector of the Thyroid Clinic and the Endocrine Tumor Genetics Clinic at Massachusetts General Hospital in Boston, and past member of the ATA Board of Directors.

"The Mayo approach seems to be better at decreasing proptosis, but it's so good that the eye often drops down and can cause double-vision, leading to other corrective operations," explained Dr. Daniels. "In Dr. Kahaly's study, the actual decompression is not very impressive. It goes from a median of 23 down to a median of 20, and the Mayo's decompression numbers are more than that. So basically, the more walls you take out, the better your decompression. But the more walls you take out, the more likely you are to get double-vision."

He added: "There aren't a lot of surgeons in the United States that specialize in decompression surgery. You want somebody who is really expert in it. This study showed a different method and it's very nice. But if your surgeon doesn't know how to do it and you tell them to start taking the fat out from above the orbit, that can lead to complications. I would say whichever your surgeon has the most expertise in and the best results in is a great way to do it."

Dr. Kahaly, Dr. Bahn, and Dr. Daniels have disclosed no relevant financial relationships.

American Thyroid Association (ATA) 80th Annual Meeting: Abstract Poster 13. Presented September 24, 2009.

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