Preoperative Assessment and Orbital Decompression Surgery in Patients with Graves’ Ophthalmopathy

  • James A. Garrity


Many of the signs and symptoms of Graves’ ophthalmopathy result from a discrepancy between the increased volume of the swollen orbital contents and the fixed volume of the bony orbit. While the natural history of the disease includes spontaneous improvement for most and for those patients who require some form of treatment, therapeutic efforts to address this imbalance exist. One can attempt to “shrink” the swollen tissues with corticosteroids, radiation therapy, or immunosuppression. Alternatively the volume of the bony orbit can be expanded by surgically decompressing various walls of the orbit. The amount of proptosis reduction varies according to the number of orbital walls decompressed. There are many different techniques of surgical orbital decompression and the choice of procedure is often surgeon/institution specific. This chapter reviews some of the differential diagnostic considerations encountered in the preoperative evaluation of patients with Graves’ ophthalmopathy along with a discussion of the various types of orbital decompression.


Graves’ orbitopathy Graves’ ophthalmopathy Thyroid eye disease Orbit Orbital decompression Thyroid 


  1. 1.
    Bartley GB, Gorman CA. Diagnostic criteria for Graves' ophthalmopathy. Am J Ophthalmol. 1995;119:792–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Castillo F, Garrity JA, Kravitz DJ. Intractable graves ophthalmopathy? JAMA Ophthalmol. 2013;131:269–70.CrossRefPubMedGoogle Scholar
  3. 3.
    Perros P, Kendall-Taylor P. Natural history of thyroid eye disease. Thyroid. 1998;8:423–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Bartley GB, Fatourechi V, Kadrmas EF, Jacobsen SJ, Ilstrup DM, Garrity JA, et al. The treatment of Graves' ophthalmopathy in an incidence cohort. Am J Ophthalmol. 1996;121:200–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Stanley RJ, McCaffrey TV, Offord KP, DeSanto LW. Superior and transantral orbital decompression procedures. Arch Otolaryngol Head Neck Surg. 1989;115:369–73.CrossRefPubMedGoogle Scholar
  6. 6.
    Kennerdell JS, Maroon JC, Buerger GF. Comprehensive surgical management of proptosis dysthyroid orbitopathy. Orbit. 1987;6:153–79.CrossRefGoogle Scholar
  7. 7.
    Fatourechi V, Bartley GB, Garrity JA, Bergstralh EJ, Ebersold MJ, Gorman CA. Transfrontal orbital decompression after failure of transantral decompression in optic neuropathy of Graves' disease. Mayo Clin Proc. 1993;68:552–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Garrity JA, Fatourechi V, Bergstralh EJ, Bartley GB, Beatty CW, DeSanto LW, et al. Results of transantral orbital decompression in 428 patients with severe Graves' ophthalmopathy. Am J Ophthalmol. 1993;116:533–47.CrossRefPubMedGoogle Scholar
  9. 9.
    Carter KD, Frueh BR, Hessburg TP, Musch DC. Long-term efficacy of orbital decompression for compressive optic neuropathy of Graves' eye disease. Ophthalmology. 1991;98:1435–42.CrossRefPubMedGoogle Scholar
  10. 10.
    Soares-Welch CV, Fatourechi V, Bartley GB, Beatty CW, Gorman CA, Bahn RS, et al. Optic neuropathy of Graves' disease: Results of transantral orbital decompression and long-term follow-up in 215 patients. Am J Ophthalmol. 2003;136:433–41.CrossRefPubMedGoogle Scholar
  11. 11.
    Mourits MP, Prummel MF, Wiersinga WM, Koornneef L. Clinical activity score as a guide in the management of patients with Graves' ophthalmopathy. Clin Endocrinol. 1997;47:9–14.CrossRefGoogle Scholar
  12. 12.
    Naffziger HC. Progressive exophthalmos following thyroidectomy; its pathology and treatment. Ann Surg. 1931;94:582–6.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    MacCarty CS, Kenefick TP, McConahey WM, Kearns TP. Ophthalmopathy of Graves' disease treated by removal of roof, lateral walls, and lateral sphenoid ridge: review of 46 cases. Mayo Clin Proc. 1970;45:488–93.PubMedGoogle Scholar
  14. 14.
    Liao SL, Huang SW. Correlation of retrobulbar volume change with resected orbital fat volume and proptosis reduction after fatty decompression for Graves ophthalmopathy. Am J Ophthalmol. 2011;151:465–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Koornneef L. Orbital septa: anatomy and function. Ophthalmology. 1979;86:876–80.CrossRefPubMedGoogle Scholar
  16. 16.
    Richter DF, Stoff A, Olivari N. Transpalpebral decompression of endocrine ophthalmopathy by intraorbital fat removal (Olivari technique): Experience and progression after more than 3000 operations over 20 years. Plast Reconstr Surg. 2007;120:109–23.CrossRefPubMedGoogle Scholar
  17. 17.
    Kazim M, Trokel SL, Acaroglu G, Elliott A. Reversal of dysthyroid optic neuropathy following orbital fat decompression. Br J Ophthalmol. 2000;84:600–5.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Garrity JA. Orbital lipectomy (fat decompression) for thyroid eye disease: an operation for everyone? Am J Ophthalmol. 2011;151:399–400.CrossRefPubMedGoogle Scholar
  19. 19.
    Ben Simon GJ, Wang L, McCann JD, Goldberg RA. Primary-gaze diplopia in patients with thyroid-related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome. Thyroid. 2004;14(5):379–83.CrossRefPubMedGoogle Scholar
  20. 20.
    Wiersinga WM. Quality of life in Graves' orbitopathy. Best Pract Res Clin Endocrinol Metab. 2012;26(3):359–70.CrossRefPubMedGoogle Scholar
  21. 21.
    Trokel S, Kazim M, Moore S. Orbital fat removal. Decompression for Graves orbitopathy. Ophthalmology. 1993;100:674–82.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of OphthalmologyMayo ClinicRochesterUSA

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