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Alan Hromas, Jason Sokol, Thomas Whittaker; Deep lateral wall orbital decompression following strabismus surgery in patients with type II Graves orbitopathy. Invest. Ophthalmol. Vis. Sci. 2014;55(13):4078.
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Surgical management of thyroid eye disease traditionally involves, in order, orbital decompression, followed by strabismus surgery, followed by eyelid surgery. Nunery et al previously described two distinct subtypes of patients with ophthalmic Graves’ disease; type I patients exhibit no restrictive myopathy, as opposed to type II patients, who do exhibit myopathy and are far more likely to develop diplopia following medial wall and floor decompression. Strabismus surgery involving extraocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with type II patients who have already undergone medial wall and floor decompression and strabismus surgery has found that, when additional decompression is necessary, deep lateral wall decompression appears to have a low rate of post-operative primary-gaze diplopia.
We present a case series of five type II ophthalmic Grave’s disease patients, all of whom had already undergone decompression and strabismus surgery, or strabismus surgery alone, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with deep lateral wall decompression. Approval for a retrospective review was granted by the Institutional Review Board of the University of Kansas.
None of the five patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following deep lateral wall decompression.
While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Grave’s disease, deep lateral wall decompression for those patients who develop worsening proptosis or optic nerve compression following consecutive strabismus surgery appears to be effective with a low rate of recurrent primary-gaze diplopia.
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