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Nahyoung Lee, Benjamin Bleier, Suzanne Freitag; Preservation of the inferomedial strut in endoscopic orbital decompression for thyroid orbitopathy reduces the rate of postoperative diplopia. Invest. Ophthalmol. Vis. Sci. 2013;54(15):747.
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With advances in endoscopic technology, it is becoming safer to perform orbital decompressions of the medial wall and orbital floor through an endonasal approach rather than an open approach. The inferomedial strut that bridges the medial and inferior walls of the orbit is usually preserved through a transconjunctival incision in order to reduce the risk of postoperative diplopia. However, the strut can be removed in severe cases of orbital compartment syndrome that require a more dramatic decompression. It was once thought that preserving the strut in an endonasal approach was not technically feasible. We present our experience in seven patients (14 eyes) that have undergone 3-wall decompression with and without preservation of the strut and the subsequent rates of postoperative diplopia.
Seven patients were examined at the Massachusetts Eye and Ear Infirmary and were deemed to be surgical candidates for 3-wall orbital decompressions. Six out of 7 patients had signs of mild to severe compressive optic neuropathy. All patients underwent endoscopic inferior and medial wall decompressions as well as open lateral wall decompressions, bilaterally. The patients were then followed in clinic for at least 2 months where presence and duration of diplopia were documented.
Among patients who had signs of optic neuropathy prior to decompression surgery, 100% of them had improvement in vision and visual field after surgery. There were no cases of postoperative vision loss. When the strut was preserved, there were no cases of new, post-surgical diplopia. In the 4 patients where the strut was removed, 3 out of 4 had new diplopia or worsened diplopia following surgery despite leaving a sling of periorbita medially to prevent excessive prolapse of orbital contents into the ethmoid sinus.
With increased sophistication in endoscopic techniques, it is possible to perform a localized medial and floor orbital decompression while leaving the intervening strut intact. While it may be necessary to remove the strut for maximal decompression in severe cases of optic nerve compression, there is now a role for balanced, endoscopic decompression with strut preservation for patients with thyroid orbitopathy who desire better cosmesis without the high risk of postoperative diplopia.
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