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Clinical Sciences |

Minimally Invasive Orbital Decompression:  Local Anesthesia and Hand-Carved Bone FREE

Guy J. Ben Simon, MD; Robert M. Schwarcz, MD; Ahmad M. Mansury, BS; Lillian Wang, BS; John D. McCann, MD, PhD; Robert A. Goldberg, MD
[+] Author Affiliations

Author Affiliations: Jules Stein Eye Institute and Department of Ophthalmology, The David Geffen School of Medicine, University of California, Los Angeles.


Arch Ophthalmol. 2005;123(12):1671-1675. doi:10.1001/archopht.123.12.1671.
Text Size: A A A
Published online

Objective  To investigate the safety and efficacy of a conservative orbital decompression using sharp-curette bony decompression and intraconal fat debulking through a transconjunctival incision in patients with thyroid-related orbitopathy and mild to moderate proptosis.

Design  Retrospective, noncomparative, interventional case series.

Participants and Methods  Data from all patients undergoing minimal orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, over a period of 4¼ years were collected and analyzed. Data included visual acuity, exophthalmometry measurements, intraocular pressure, complete slitlamp examination results, ocular ductions, new-onset primary or downgaze diplopia, and patient satisfaction. Conservative decompression was performed through a transconjunctival incision using a manual curette and by removing cortical bone from the zygomatic marrow space on the anterior rim of the inferior orbital fissure; intraconal fat was bluntly dissected and excised or suctioned with a Frasier tip aspirator.

Main Outcome Measures  Patient perception of pressure pain and ocular discomfort, proptosis, visual acuity, intraocular pressure, postoperative complications, and new-onset primary or downgaze diplopia.

Results  Eighty minimally invasive orbital decompression surgeries were performed in 48 patients (6 male, 42 female). Six surgeries (4 patients) were performed for prominent globes with relative proptosis and no thyroid-related orbitopathy (non-Graves proptosis). All patients had improvement in congestive orbitopathy and pressure pain associated with thyroid-related orbitopathy. Exophthalmos decreased by a mean ± SD of 2.4 ± 2.6 mm from 22.7 ± 2.5 mm (range, 17-29 mm) to 20.3 ± 2.3 mm (range, 14-25 mm) (P<.001 [95% confidence interval, 1.8-3.0]). Mean visual acuity improved after surgery (P = .02). One patient (2.1%) developed postoperative primary or downgaze diplopia; he underwent successful eye muscle surgery at a later stage. No complications were associated with orbital decompression.

Conclusions  Minimally invasive orbital decompression surgery with intraconal fat debulking in this group of patients was effective in proptosis reduction; improvement in subjective pressure pain and high patient satisfaction were noticed. Surgery was associated with a low rate (2.1%) of new-onset primary or downgaze diplopia. Proptosis reduction using a graded approach accounting for 4 mm of retrodisplacement was achieved.

Figures in this Article

Thyroid-related orbitopathy (TRO) is the most frequent extrathyroid manifestation of Graves disease.1 It is believed to be an autoimmune disorder, caused by autoreactive CD4 T lymphocytes recognizing a similar antigen to thyroid and orbital tissue, that infiltrates the orbital tissue and the perimysium of extraocular muscles. This immune-mediated inflammation causes increased production of glycosaminoglycans in the orbital tissue, edematous expansion of the extraocular muscles, and increased volume of the orbital tissue. In a later phase, cicatricial formation may occur, leading to irreversible changes in orbital connective tissue and extraocular muscles.16

Most of the patients with Graves disease have mild TRO that tends to improve spontaneously, and only 15% show deterioration of ophthalmopathy.7 Clinical manifestation includes a wide variety of signs and symptoms including subclinical involvement demonstrated only by computed tomographic scans or magnetic resonance images, mild pain or discomfort, eyelid retraction, and mild proptosis (2-4 mm). In its severe form, optic neuropathy, marked proptosis with exposure keratopathy, eyelid edema, chemosis and conjunctival hyperemia, blurred vision, and diplopia from eye muscle involvement can ensue.8 Thus, TRO can be disfiguring and quite an invalidating disease that profoundly impairs the quality of life of the affected individuals.911

Orbital decompression is effective to treat proptosis and congestion associated with TRO.9,10,1216 It is usually performed in the noninflammatory phase of the disease and is reserved for moderate to severe TRO. The goal of surgery is to provide additional space for orbital tissue expansion either by bone or fat removal, thus reducing proptosis. In the past, orbital decompression was associated with high surgical morbidity. This is greatly reduced with modern orbital surgical techniques. Today, up to one third of patients undergo operations for cosmetic indications to decrease disfiguring proptosis.14,15,17

Many of the patients with thyroid orbitopathy often have a diffuse pressure pain and limitation of eye movements, which are related to decreased venous outflow and orbital congestion. These symptoms can be substantially disabling and may respond well to orbital decompression, improving venous outflow and relieving or ameliorating the congestive symptoms.

Orbital decompression is individualized to each patient according to the desired amount of proptosis reduction. Bony decompression includes removing portions of the orbital wall (floor, medial, and lateral walls)15,16,1826; other surgeons perform primarily intraconal fat removal.25,27 We have developed a graded approach to decompression that is customized to the patient. For patients with congestive orbitopathy and mild to moderate proptosis (2-4 mm of anticipated retrodisplacement), we use a minimally invasive approach that involves conservative bone expansion using a sharp curette and removal of intraconal fat using a suction cutting technique through a small conjunctival incision. The surgery can be performed using sedation and local anesthesia on an outpatient basis. The goal of this study was to review in a retrospective fashion the results of a consecutive series of surgeries.

This study is a retrospective, interventional case series. Medical records of all patients who underwent minimally invasive hand-carved bony orbital and fat decompression for TRO at the Jules Stein Eye Institute, Los Angeles, Calif, between January 1, 1999, and December 31, 2003, were reviewed. The study complied with the policies of the local institutional review board. Data regarding visual acuity, exophthalmometry measurements, intraocular pressure (IOP), primary or downgaze strabismus, clinical assessment of ocular motility, and patient satisfaction were recorded and analyzed.

SURGICAL TECHNIQUE

The orbital surface of the zygomatic and maxillary bones was exposed through an eyelid-crease incision or inferior fornix conjunctival incision. Using a sharpened curette (2-4 mm in cup size), cortical bone was removed from the lateral maxillary sinus roof and the zygomatic marrow space on the anterior rim of the inferior orbital fissure (the “basin”19) (Figure 1). The extent of bone removal was individualized according to the degree of proptosis. In all patients, intraconal fat located between the lateral and inferior rectus muscle was bluntly dissected and excised or suctioned using a Frasier tip aspirator; the volume of excised fat removed ranged from 1.5 to 3 mL3.

Place holder to copy figure label and caption
Figure 1.

The diploic space above the inferior orbital fissure typically widens to form a large lake of diploe that can be carved out along the edge of the inferior orbital fissure.

Graphic Jump Location

The suction technique is performed by gently teasing forward the intraconal fat using Stevens tenotomy scissors in a blunt spreading technique. Once the fat is released from the septae of the intraconal space, it flows into the extraconal space. A 10F Frasier tip aspirator is used to suction the fat out of the orbit, using sharp release of residual fibrous attachments with the scissors. The suction technique allows gentle and efficient removal of intraconal fat with decreased need for extensive dissection. The surgeon excises the fat that flows into the extraconal space, hence reducing the risk of nerve or muscle injury. Bipolar cautery is used to obtain hemostasis.

STATISTICAL ANALYSIS

Statistical analysis was performed using a paired-samples t test to evaluate preoperative and postoperative data such as visual acuity, exophthalmometry measurements, IOP, and ocular ductions measurements. Pearson bivariate correlation was used to examine the influence of age, visual acuity, IOP, and extent of exophthalmos on treatment outcome. A nonparametric Wilcoxon Mann-Whitney U 2 independent-samples test was used to compare different variables in patients with TRO and patients with prominent globes and no TRO undergoing minimally invasive orbital decompression.

Eighty minimally invasive orbital decompression surgeries were performed on 48 patients (6 male, 42 female); all surgeries were performed by 1 of us (R.A.G.). Data regarding patient demographics are summarized in Table 1. Seventy-four surgeries were performed on patients with TRO and 6 surgeries (4 patients) on patients with prominent globes with relative proptosis and no TRO.

Table Graphic Jump LocationTable 1. Demographics of Study Population*

After minimally invasive orbital decompression, exophthalmometry measurements decreased a mean ± SD of 2.4 ± 2.6 mm from 22.7 ± 2.5 mm (range, 17-29 mm) preoperatively to 20.3 ± 2.3 mm (range, 14-25 mm) at the end of follow-up (P<.001 [95% confidence interval, 1.8-3.0]).

Postoperative medical record notes indicated that almost all patients reported improvement in pressure pain and ocular discomfort after surgery. Although no specific quality of life questionnaire was used, our anecdotal experience is that patients were happy with surgical results and noticed functional as well as aesthetic improvement after minimally invasive decompression (Figure 2).

Place holder to copy figure label and caption
Figure 2.

A 54-year-old woman preoperatively (A and C) and 6 months postoperatively (B and D) after minimally invasive orbital decompression with correction of upper eyelid retraction.

Graphic Jump Location

Mean visual acuity improved after surgery (P = .02) (Figure 3); IOP decreased a mean ± SD of 0.6 ± 3.1 mm Hg. Older patients had higher preoperative IOP in primary and upgaze diplopia (r = 0.7; P = .006 and r = 0.9; P = .001, respectively, Pearson bivariate correlation).

Place holder to copy figure label and caption
Figure 3.

Scattergram of preoperative and postoperative logMAR (logarithm of the minimal angle of resolution) of visual acuity in 48 patients undergoing minimally invasive orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, in a 4-year period.

Graphic Jump Location

Eleven patients (23%) had preoperative primary or downgaze diplopia. Postoperatively, 7 patients (14.6%) had persistence of double vision and 4 patients (8.3%) had improvement in double vision to the point that single binocular vision was present in primary or downgaze diplopia. Only 1 patient without preoperative primary or downgaze diplopia developed new-onset primary or downgaze diplopia postoperatively (Table 2) (Figure 4). He underwent successful eye muscle surgery at a later stage.

Place holder to copy figure label and caption
Figure 4.

Number of patients with preoperative and postoperative primary or downgaze diplopia.

Graphic Jump Location
Table Graphic Jump LocationTable 2. Preoperative and Postoperative Primary or Downgaze Diplopia

Limitations in ocular ductions in all positions of gaze did not change significantly postoperatively; limitations in upgaze were most common. No correlation was found between degree of exophthalmos correction to change in extraocular motility after surgery. Field of binocular single vision increased postoperatively in upgaze and downgaze diplopia (P<.001, paired-samples t test).

Four patients underwent 6 minimally invasive orbital decompressions for prominent globes with relative proptosis; these patients were not diagnosed with TRO. These patients were older as compared with patients with TRO (mean ± SD, 55 ± 7 years vs 44 ± 11.7 years; P = .01, Wilcoxon Mann-Whitney U test) and showed no extraocular muscle motility disturbances prior to surgery (P = .005, Wilcoxon Mann-Whitney U test). They achieved similar exophthalmos reduction with surgery.

No severe complications of minimally invasive orbital decompression, such as vision loss, occurred.

Minimally invasive orbital decompression with intraconal fat debulking was associated with subjective improvement in pressure pain and congestive orbitopathy in the study group. Moderate reduction in proptosis was achieved and no severe complications occurred; only 1 patient (2.1%) developed new-onset primary or downgaze diplopia postoperatively.

There are many surgical options for orbital decompression. Multiple anatomical surfaces (medial, floor, and lateral wall) could be used with or without intraconal fat debulking.1,15,16,1825,27 These anatomical areas can be approached through various surgical incisions, including endonasal.28 Surgery should always be individualized to the patient’s specific needs, and in cases where there is a choice of surgeries, the least invasive approach should be selected to reduce complications (which can include death, stroke, intracranial injury, vision loss, numbness, and paresthesia.) Variables that affect surgical decision making include the amount of desired proptosis reduction, bony and sinus anatomy, risk factors for surgical complications (including advancing age), and aesthetic goals based on facial configuration.

This series of patients did not have severe proptosis. However, proptosis is not the only problem associated with the orbital soft-tissue volume expansion that characterizes Graves ophthalmopathy. The increased soft-tissue volume leads to congestion of the orbit, producing symptoms such as vague pressure pain around the eye and temple and ocular discomfort even without frank proptosis or exposure keratopathy.11,29 From an aesthetic standpoint, there can be fullness of orbital fat, congestive edema, and increased suborbicularis oculi fat volume.

Although local eye symptoms and ocular discomfort may somewhat improve with topical treatment and with time, many patients experience vague pressure pain and headache that persists even after disease inactivity. The pressure pain is sometimes associated with eye movements or tasks requiring prolonged visual concentration. Patients with congestive orbitopathy, pressure pain, and periocular swelling can be substantially bothered by these symptoms. Many of these patients do not have severe proptosis. In these cases, the goal of surgery is directed toward reduction in orbital congestion and minimal reduction in proptosis (for example, 1-3 mm). Surgery for this group of patients should be designed to open the orbital fat septae and conservatively remove bone and fat to improve the congestive orbitopathy without excessive globe retrodisplacement. The techniques of hand-carved bony removal, combined with intraconal fat decompartmentalization and debulking, can accomplish these goals with a minimally invasive procedure often performed under sedation anesthesia. Interestingly, 4 patients in our study did not have TRO but had mild corneal exposure secondary to relative proptosis; these patients had similar improvement in ocular discomfort and in proptosis reduction.

In cases of severe TRO and optic neuropathy, orbital decompression is found to be an effective treatment. Orbital decompression frequently improves visual function and individual patients are satisfied with the long-term results.30 In mild to moderate disease, patient satisfaction may be more subjective and was found to be associated with young age and with surgeries performed mainly for cosmetic purposes.9 Relatively low mean age (44 years) may have contributed to high patient satisfaction in our study.

However, when surgery is performed primarily for cosmetic reasons, as in all cases of aesthetic surgery, patients may be less tolerant of adverse effects and complications of orbital decompression. Fatourechi et al31 reported a high rate (73%) of postoperative diplopia in patients who underwent transantral decompression for cosmetic purposes. A substantial percentage of the patients in their study underwent eye muscle surgery for symptomatic diplopia and eyelid retraction correction. A possible explanation for the high percentage of postoperative complications could be attributed to transantral decompression as a major orbital surgical undertaking. In addition, patients in the earlier mentioned study had more advanced TRO (proptosis had decreased a mean of 5.2 mm compared with only 2.4 mm in our study). Lyons and Rootman15 reported new-onset diplopia in 18% of patients who underwent orbital decompression for cosmetic indications. The minimally invasive technique presented in the current study achieves less decrease in proptosis (mean, 2.4 mm) and therefore less chance of developing new-onset diplopia.9 Postoperative new-onset symptomatic diplopia may occur in 0% to 70% of cases, depending on surgical approach and the amount of retrodisplacement of the globe.18,2124,26,3133 In a recent study,33 we found that patients who developed new-onset primary or downgaze diplopia after deep lateral-wall decompression achieved a greater decrease in proptosis (6 mm vs 3.1 mm) as compared with patients with no new-onset diplopia.

We recognize that a staged surgical rehabilitation for TRO reduces the total number of procedures needed.34 Some patients in our study underwent eyelid retraction surgery at the time of orbital decompression. Patients are counseled that additional stages of eyelid repositioning may be needed, but during follow-up, none of the patients who underwent concomitant eyelid surgery required additional eyelid repositioning surgery.

The major limitation of our study stems from using subjective measurements for evaluating patient satisfaction. Recently, a Graves ophthalmopathy quality of life questionnaire was developed in the Netherlands and has been proven to be an effective tool in evaluating the clinical importance of different treatment modalities in patients with TRO.11 However, we suggest that minimally invasive decompression was effective in treating pressure pain of congestive orbitopathy, and proptosis reduction of up to 4 mm can be achieved. A prospective study comparing different treatment modalities along with different decompression surgeries and using a more powerful tool, such as the Graves ophthalmopathy quality of life questionnaire,10 is required to accurately estimate the effectiveness of various surgical techniques. Treatment studies should take into account the individualized nature of surgical planning; not all patients with Graves disease are alike, and a “one size fits all” surgical approach should be discouraged.

Correspondence: Guy J. Ben Simon, MD, Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90095-7006 (guybensimon@gmail.com).

Submitted for Publication: September 8, 2004; final revision received December 22, 2004; accepted January 25, 2005.

Financial Disclosure: None.

Bartalena  LPinchera  AMarcocci  C Management of Graves' ophthalmopathy: reality and perspective. Endocr Rev 2000;21168- 199
PubMed
Weetman  ACohen  SLGatter  KCFells  PShine  B Immunohistochemical analysis of the retrobulbar tissues in Graves' ophthalmopathy. Clin Exp Immunol 1989;75222- 227
PubMed
Kubota  SGunji  KAckrell  BAC  et al.  The 64-kilodalton eye muscle protein is the flavoprotein subunit of mitochondrial succinate dehydrogenase: the corresponding serum antibodies are good markers of an immune-mediated damage to the eye muscle in patients with Graves' hyperthyroidism. J Clin Endocrinol Metab 1998;83443- 447
PubMed
McGregor  A Has the target autoantigen for Graves' ophthalmopathy been found? Lancet 1998;352595- 596
PubMed
Grubeck-Loebenstein  BTreib  KSztankay  AHolter  WAnderl  HWick  G Retrobulbar T cells from patients with Graves' ophthalmopathy are CD8+ and specifically recognize autologous fibroblasts. J Clin Invest 1994;932738- 2743
PubMed
Heufelder  AHerterich  SErnst  GBahn  RSHeufelder  AE Analysis of retroorbital T cell antigen receptor variable region gene usage in patients with Graves' ophthalmopathy. Eur J Endocrinol 1995;132266- 277
PubMed
Perros  PCrombie  ALKendall-Taylor  P Natural history of thyroid-associated ophthalmopathy. Clin Endocrinol (Oxf) 1995;4245- 50
PubMed
Bartley  GFatourechi  VKadrmas  EF  et al.  Clinical features of Graves' ophthalmopathy in an incidence cohort. Am J Ophthalmol 1996;121284- 290
PubMed
Fatourechi  VBergstralh  EJGarrity  JA  et al.  Predictors of response to transantral orbital decompression in severe Graves' ophthalmopathy. Mayo Clin Proc 1994;69841- 848
PubMed
Gerding  MTerwee  CBDekker  FWKoornneef  LPrummenl  MFWiesinga  WM Quality of life in patients with Graves' ophthalmopathy is markedly decreased: measurement by the medical outcomes study instrument. Thyroid 1997;7885- 889
PubMed
Terwee  CDekker  FWMouritus  MP  et al.  Interpretation and validity of changes in scores on the Graves' ophthalmopathy quality of life questionnaire (GO-QOL) after different treatments. Clin Endocrinol (Oxf) 2001;54391- 398
PubMed
Baylis  HCall  NBShibata  CS The transantral orbital decompression (Ogura technique) as performed by the ophthalmologist: a series of 24 patients. Ophthalmology 1980;871005- 1012
PubMed
Anderson  RLinberg  JV Transorbital approach to decompression in Graves' disease. Arch Ophthalmol 1981;99120- 124
PubMed
McCord  C Current trends in orbital decompression. Ophthalmology 1985;9221- 33
PubMed
Lyons  CJRootman  J Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy. Ophthalmology 1994;101223- 230
PubMed
Paridaens  DAVerhoeff  KBouwens  Dvan Den Bosch  WA Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno. Br J Ophthalmol 2000;84775- 781
PubMed
Cornblath  W Thyroid eye disease. Curr Treat Options Neurol 2000;2401- 406
PubMed
Eloy  PTrussart  CJouzdani  ECollet  SRombaux  PBertrand  B Transnasal endoscopic orbital decompression and Graves' ophthalmopathy. Acta Otorhinolaryngol Belg 2000;54165- 174
PubMed
Goldberg  RAKim  AJKerivan  KM The lacrimal keyhole, orbital door jamb, and basin of the inferior orbital fissure: three areas of deep bone in the lateral orbit. Arch Ophthalmol 1998;1161618- 1624
PubMed
Graham  SMBrown  CLCarter  KDSong  ANerad  JA Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease. Laryngoscope 2003;1131206- 1209
PubMed
Kalmann  RMouritz  MPvan der Pol  JPKoornneef  L Coronal approach for rehabilitative orbital decompression in Graves' ophthalmopathy. Br J Ophthalmol 1997;8141- 45
PubMed
Linnet  JHegedus  LBjerre  P Results of a neurosurgical two-wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy. Acta Ophthalmol Scand 2001;7949- 52
PubMed
Seiff  SRTovilla  SJCarter  SRChoo  PH Modified orbital decompression for dysthyroid orbitopathy. Ophthal Plast Reconstr Surg 2000;1662- 66
PubMed
Shepard  KGLevin  PSTerris  DJ Balanced orbital decompression for Graves' ophthalmopathy. Laryngoscope 1998;1081648- 1653
PubMed
Unal  MLery  FKonuk  OHasanreisoglu  B Balanced orbital decompression combined with fat removal in Graves ophthalmopathy: do we really need to remove the third wall? Ophthal Plast Reconstr Surg 2003;19112- 118
PubMed
Wright  EDDavidson  JCodere  FDesrosiers  M Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia. J Otolaryngol 1999;28252- 256
PubMed
Trokel  SKazim  MMoore  S Orbital fat removal: decompression for Graves' orbitopathy. Ophthalmology 1993;100674- 682
PubMed
Michel  OOberlander  NNeugebauer  PNeugebauer  ARubmann  W Follow-up of transnasal orbital decompression in severe Graves' ophthalmopathy. Ophthalmology 2001;108400- 404
PubMed
Bartalena  LMarcocci  CPinchera  A Treating severe Graves' ophthalmopathy. Baillieres Clin Endocrinol Metab 1997;11521- 536
PubMed
Soares-Welch  CFatourechi  VBartley  GB  et al.  Optic neuropathy of Graves disease: results of transantral orbital decompression and long-term follow-up in 215 patients. Am J Ophthalmol 2003;136433- 441
PubMed
Fatourechi  VGarrity  JABartley  GBBergstralh  EJDesanto  LWGorman  CA Graves ophthalmopathy: results of transantral orbital decompression performed primarily for cosmetic indications. Ophthalmology 1994;101938- 942
PubMed
Metson  RSamaha  M Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique. Laryngoscope 2002;1121753- 1757
PubMed
Ben Simon  GWang  LMcCann  JDGoldberg  RA Primary-gaze diplopia in thyroid-related orbitopathy patients undergoing deep lateral orbital decompression with intraconal fat debulking. Thyroid 2004;14379- 383
PubMed
Shorr  NSeiff  SR The four stages of surgical rehabilitation of the patient with dysthyroid ophthalmopathy. Ophthalmology 1986;93476- 483
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

The diploic space above the inferior orbital fissure typically widens to form a large lake of diploe that can be carved out along the edge of the inferior orbital fissure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A 54-year-old woman preoperatively (A and C) and 6 months postoperatively (B and D) after minimally invasive orbital decompression with correction of upper eyelid retraction.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Scattergram of preoperative and postoperative logMAR (logarithm of the minimal angle of resolution) of visual acuity in 48 patients undergoing minimally invasive orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, in a 4-year period.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Number of patients with preoperative and postoperative primary or downgaze diplopia.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Demographics of Study Population*
Table Graphic Jump LocationTable 2. Preoperative and Postoperative Primary or Downgaze Diplopia

References

Bartalena  LPinchera  AMarcocci  C Management of Graves' ophthalmopathy: reality and perspective. Endocr Rev 2000;21168- 199
PubMed
Weetman  ACohen  SLGatter  KCFells  PShine  B Immunohistochemical analysis of the retrobulbar tissues in Graves' ophthalmopathy. Clin Exp Immunol 1989;75222- 227
PubMed
Kubota  SGunji  KAckrell  BAC  et al.  The 64-kilodalton eye muscle protein is the flavoprotein subunit of mitochondrial succinate dehydrogenase: the corresponding serum antibodies are good markers of an immune-mediated damage to the eye muscle in patients with Graves' hyperthyroidism. J Clin Endocrinol Metab 1998;83443- 447
PubMed
McGregor  A Has the target autoantigen for Graves' ophthalmopathy been found? Lancet 1998;352595- 596
PubMed
Grubeck-Loebenstein  BTreib  KSztankay  AHolter  WAnderl  HWick  G Retrobulbar T cells from patients with Graves' ophthalmopathy are CD8+ and specifically recognize autologous fibroblasts. J Clin Invest 1994;932738- 2743
PubMed
Heufelder  AHerterich  SErnst  GBahn  RSHeufelder  AE Analysis of retroorbital T cell antigen receptor variable region gene usage in patients with Graves' ophthalmopathy. Eur J Endocrinol 1995;132266- 277
PubMed
Perros  PCrombie  ALKendall-Taylor  P Natural history of thyroid-associated ophthalmopathy. Clin Endocrinol (Oxf) 1995;4245- 50
PubMed
Bartley  GFatourechi  VKadrmas  EF  et al.  Clinical features of Graves' ophthalmopathy in an incidence cohort. Am J Ophthalmol 1996;121284- 290
PubMed
Fatourechi  VBergstralh  EJGarrity  JA  et al.  Predictors of response to transantral orbital decompression in severe Graves' ophthalmopathy. Mayo Clin Proc 1994;69841- 848
PubMed
Gerding  MTerwee  CBDekker  FWKoornneef  LPrummenl  MFWiesinga  WM Quality of life in patients with Graves' ophthalmopathy is markedly decreased: measurement by the medical outcomes study instrument. Thyroid 1997;7885- 889
PubMed
Terwee  CDekker  FWMouritus  MP  et al.  Interpretation and validity of changes in scores on the Graves' ophthalmopathy quality of life questionnaire (GO-QOL) after different treatments. Clin Endocrinol (Oxf) 2001;54391- 398
PubMed
Baylis  HCall  NBShibata  CS The transantral orbital decompression (Ogura technique) as performed by the ophthalmologist: a series of 24 patients. Ophthalmology 1980;871005- 1012
PubMed
Anderson  RLinberg  JV Transorbital approach to decompression in Graves' disease. Arch Ophthalmol 1981;99120- 124
PubMed
McCord  C Current trends in orbital decompression. Ophthalmology 1985;9221- 33
PubMed
Lyons  CJRootman  J Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy. Ophthalmology 1994;101223- 230
PubMed
Paridaens  DAVerhoeff  KBouwens  Dvan Den Bosch  WA Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno. Br J Ophthalmol 2000;84775- 781
PubMed
Cornblath  W Thyroid eye disease. Curr Treat Options Neurol 2000;2401- 406
PubMed
Eloy  PTrussart  CJouzdani  ECollet  SRombaux  PBertrand  B Transnasal endoscopic orbital decompression and Graves' ophthalmopathy. Acta Otorhinolaryngol Belg 2000;54165- 174
PubMed
Goldberg  RAKim  AJKerivan  KM The lacrimal keyhole, orbital door jamb, and basin of the inferior orbital fissure: three areas of deep bone in the lateral orbit. Arch Ophthalmol 1998;1161618- 1624
PubMed
Graham  SMBrown  CLCarter  KDSong  ANerad  JA Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease. Laryngoscope 2003;1131206- 1209
PubMed
Kalmann  RMouritz  MPvan der Pol  JPKoornneef  L Coronal approach for rehabilitative orbital decompression in Graves' ophthalmopathy. Br J Ophthalmol 1997;8141- 45
PubMed
Linnet  JHegedus  LBjerre  P Results of a neurosurgical two-wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy. Acta Ophthalmol Scand 2001;7949- 52
PubMed
Seiff  SRTovilla  SJCarter  SRChoo  PH Modified orbital decompression for dysthyroid orbitopathy. Ophthal Plast Reconstr Surg 2000;1662- 66
PubMed
Shepard  KGLevin  PSTerris  DJ Balanced orbital decompression for Graves' ophthalmopathy. Laryngoscope 1998;1081648- 1653
PubMed
Unal  MLery  FKonuk  OHasanreisoglu  B Balanced orbital decompression combined with fat removal in Graves ophthalmopathy: do we really need to remove the third wall? Ophthal Plast Reconstr Surg 2003;19112- 118
PubMed
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