Research Article| Volume 61, ISSUE 2, P152-157, February 2023

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Effect of the lateral wall valgisation in the treatment of patients with endocrine orbitopathy

Published:December 16, 2022DOI:


      Orbital decompression is an established procedure used to correct exophthalmos that results from excess orbital soft tissue. This study aimed to explore a new minimally-invasive technique that features three-dimensional planning and patient-specific implants for lateral valgisation (LAVA) of the orbital wall. We analysed the outcomes of this procedure in nine endocrine orbitopathy (EO) patients (32–65 years of age with a mean clinical activity score of 4.3) who underwent this procedure between 2021 and 2022, including seven patients diagnosed with dysthyroid optic neuropathy. The impact of LAVA and wall resection on orbital areas, volumes, Hertel values, visual acuity, and new-onset diplopia was determined. Among our results, we found that LAVA and resection of 18 orbital walls resulted in significant enlargement of the orbital volume from a preoperative mean of 30.8 ± 3.5 cm3 to a mean of 37.3 ± 5.8 cm3 postoperatively (mean difference, 6.2 ± 1.8 cm3; p < 0.001); this procedure also resulted in a significant reduction in the mean Hertel value, from 28.7 ± 1.9 mm to 20.0 ± 1.9 mm (mean difference, 8.7 ± 1.9 mm; p < 0.001). The procedure resulted in visual acuity declined in three patients (33.3 %) with reductions from 0.25 to 0.125, 0.8 to 0.125, and 1.2 to 0.7, respectively. No new diplopia occurred postoperatively, however, our study included five patients with preoperative diplopia that did not improve postoperatively and required additional surgical intervention. Similarly, four patients required supplemental eyelid surgery. In conclusion, our study suggests the effects of the LAVA with the partial floor resection seems to be effective, which provides a substantially improved outcome for patients undergoing surgical treatment of EO via the use of double navigation and piezosurgical methods.


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        • Eckstein A.
        • Dekowski D.
        • Fuhrer-Sakel D.
        • et al.
        [Graves' ophthalmopathy].
        Ophthalmologe. 2016; 113 (quiz 465-6): 349-364
        • Ponto K.A.
        • Pitz S.
        • Pfeiffer N.
        • et al.
        Quality of life and occupational disability in endocrine orbitopathy.
        Dtsch Arztebl Int. 2009; 106: 283-289
        • Richter D.F.
        • 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: 109-123
        • Leong S.C.
        • Karkos P.D.
        • Macewen C.J.
        • et al.
        A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy.
        Laryngoscope. 2009; 119: 1106-1115
        • Mourits M.P.
        • Bijl H.
        • Altea M.A.
        • et al.
        Outcome of orbital decompression for disfiguring proptosis in patients with Graves' orbitopathy using various surgical procedures.
        Br J Ophthalmol. 2009; 93: 1518-1523
        • Boboridis K.G.
        • Bunce C.
        Surgical orbital decompression for thyroid eye disease.
        Cochrane Database Syst Rev. 2011; 12 (Cd007630)
        • Boboridis K.G.
        • Uddin J.
        • Mikropoulos D.G.
        • et al.
        Critical Appraisal on Orbital Decompression for Thyroid Eye Disease: A Systematic Review and Literature Search.
        Adv Ther. 2015; 32: 595-611
        • Mishra S.
        • Maurya V.K.
        • Kumar S.
        • et al.
        Clinical Management and Therapeutic Strategies for the Thyroid-Associated Ophthalmopathy: Current and Future Perspectives.
        Curr Eye Res. 2020; 45: 1325-1341
        • Goldberg R.A.
        • Perry J.D.
        • Hortaleza V.
        • et al.
        Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy.
        Ophthal Plast Reconstr Surg. 2000; 16: 271-277
        • McCann J.D.
        • Goldberg R.A.
        • Anderson R.L.
        • et al.
        Medial wall decompression for optic neuropathy but lateral wall decompression with fat removal for non vision-threatening indications.
        Am J Ophthalmol. 2006; 141: 916-917
        • Kim K.W.
        • Byun J.S.
        • Lee J.K.
        Surgical effects of various orbital decompression methods in thyroid-associated orbitopathy: computed tomography-based comparative analysis.
        J Craniomaxillofac Surg. 2014; 42: 1286-1291
        • Jefferis J.M.
        • Jones R.K.
        • Currie Z.I.
        • et al.
        Orbital decompression for thyroid eye disease: methods, outcomes, and complications.
        Eye (Lond). 2018; 32: 626-636
        • Cruz A.A.V.
        • Equiterio B.S.N.
        • Cunha B.S.A.
        • et al.
        Deep lateral orbital decompression for Graves orbitopathy: a systematic review.
        Int Ophthalmol. 2021; 41: 1929-1947
        • Kroenlein R.U.
        Zur Pathologie und operativen Behandlung der Dermoidcysten der Orbita.
        Beitrspklin Chir. 1889; 4: 149-163
        • Dollinger J.
        Die Druckentlastung der Augenhöhle durch Entfernung der äusseren Orbitawand bei hochgradigem Exophthalmus (Morbus basedowii) und konsekutiver Hornhauterkrankung.
        Dtsch Med Wochenschr. 1911; 337: 1888-1890
        • Moran R.E.
        The correction of exophthalmos and levator spasm.
        Plast Reconstr Surg. 1956; 18: 411-426
        • Tavassol F.
        • Kokemüller H.
        • Müller-Tavassol C.
        • et al.
        A quantitative approach to orbital decompression in Graves' disease using computer-assisted surgery: a compilation of different techniques and introduction of the “temporal cage”.
        J Oral Maxillofac Surg. 2012; 70: 1152-1160
        • Spalthoff S.
        • Jehn P.
        • Zimmerer R.
        • et al.
        Modified lateral orbital wall decompression in Graves' orbitopathy using computer-assisted planning.
        Int J Oral Maxillofac Surg. 2018; 47: 167-174
        • Krause M.
        • Kamal M.
        • Kruber D.
        • et al.
        Effect of orbital wall resection areas in the treatment of patients with endocrine orbitopathy.
        Br J Oral Maxillofac Surg. 2021;
        • Krause M.
        • Neuhaus M.T.
        • Sterker I.
        • et al.
        Consideration of specific key points improves outcome of decompression treatment in patients with endocrine orbitopathy: pre-/post-OP comparison and biomechanical simulation.
        Eur J Med Res. 2022; 27: 92
        • Siah W.F.
        • Patel B.C.
        • Malhotra R.
        Surgical management of temple-related problems following lateral wall rim-sparing orbital decompression for thyroid-related orbitopathy.
        Br J Ophthalmol. 2016; 100: 1144-1150
        • Goldberg R.A.
        • Kim A.J.
        • Kerivan K.M.
        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; 116: 1618-1624
        • Baldeschi L.
        Small versus coronal incision orbital decompression in Graves' orbitopathy.
        Orbit. 2010; 29: 177-182
        • Tessier P.
        Expansion chirurgicale de l’orbite. Les orbites trop petites. Exophthalmies Basedowiennes. Exorbitisme des dysostoses cranio-faciales. Atresies orbitaires des jeunes enuclees. Tumeurs orbitaires.
        Ann Chir Plast. 1969; 14: 207-214
        • Wolfe S.A.
        Modified three-wall orbital expansion to correct persistent exophthalmos or exorbitism.
        Plast Reconstr Surg. 1979; 64: 448-455
        • Bengoa-González Á.
        • Galindo-Ferreiro A.
        • Mencía-Gutiérrez E.
        • et al.
        Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy.
        J Ophthalmol. 2019; 2019: 9478512
        • Gladilin E.
        • Hierl T.
        • Sterker I.
        • et al.
        Retrospective cohort study of three-wall orbital resection for treatment of endocrine orbitopathy using 3D tomographic data and biomechanical modeling.
        Clin Biomech (Bristol, Avon). 2020; 71: 86-91
        • Gonzalez-Garcia R.
        • Sastre-Perez J.
        • Rodriguez-Campo F.J.
        • et al.
        C-modified osteotomy for bilateral advancement of the orbital rim in Graves orbitopathy: a technical note.
        Int J Oral Maxillofac Surg. 2008; 37: 853-857
        • Matton G.
        Resection, “en bloc” of the lateral wall and floor for decompression of the orbit in dysthyroid exopthalmos.
        Eur J Plast Surg. 1991; 14: 114-119
        • Horn M.
        • Schittkowski M.P.
        Efficacy and Side Effects of Lateral Orbital Wall Decompression Including the Orbital Rim in Patients with Graves' Orbitopathy.
        Klin Monbl Augenheilkd. 2019; 236: 17-24