Effektivität und Risiken der tiefen lateralen knöchernen Orbitadekompression mit Entfernung der Orbitakante bei endokriner Orbitopathie

Zusammenfassung

Hintergrund Die endokrine Orbitopathie ist die häufigste extrathyroidale Manifestation einer Autoimmunthyreopathie. In der ausgebrannten fibrotischen Phase können ein Exophthalmus, Doppelbilder und eine Lidretraktion zurückbleiben, die ggf. mehrere rehabilitative chirurgische Eingriffe erfordern. Die orbitale Dekompression ist ein etabliertes Verfahren in der operativen Therapie der endokrinen Orbitopathie, um einen Exophthalmus zu reduzieren. Ziel der Arbeit war, die Technik der tiefen lateralen knöchernen Orbitadekompression mit Entfernung der Orbitakante in Hinblick auf Effektivität und Komplikationen zu evaluieren.

Patienten und Methoden In einer retrospektiven Fallserie wurden alle zwischen 2008 und 2015 in der Augenklinik der Universitätsmedizin Göttingen durchgeführten Dekompressionsoperationen in Hinblick auf Exophthalmusreduktion, Diplopie (Gorman Score) sowie Komplikationen analysiert. Die OP-Technik umfasste die Entfernung der lateralen Orbitawand (Ausmaß und Tiefe individuell angepasst) sowie (partiell) des extrakonalen Fettgewebes über einen Hautschnitt im lateralen Lidwinkel („swinging eyelid approach“).

Ergebnisse 195 Dekompressionsoperationen an 127 Patienten wurden eingeschlossen. Die mittlere Exophthalmusreduktion betrug 4,0 ± 1,2 mm (Min. 1,5; Max. 7,5 mm). Bei 47 Patienten (37,0%)/77 Operationen (39,5%) bestand präoperativ keine Diplopie. Postoperativ wurde bei 3 dieser Patienten/3 Orbitae (6,4/3,9%) eine „new-onset“-Diplopie dokumentiert (2,4% aller Patienten, 1,5% aller Operationen). Einer der 3 Patienten hatte Doppelbilder in Primärposition (0,8% aller Patienten, 2,1% der Patienten ohne präoperative Diplopie), die 2 weiteren Patienten gaben blickrichtungsabhängige Doppelbilder an. Eine postoperative Verbesserung der Doppelbilder zeigte sich bei 19 Patienten (15,0% aller Patienten, 23,8% der Patienten mit präoperativen Doppelbildern) bzw. nach 19 Operationen (9,7% aller 195 Eingriffe, 16,1% der Fälle mit präoperativer Diplopie). Bis auf eine starke postoperative Blutung in einem Fall, die chirurgisch erfolgreich und folgenlos saniert werden konnte, traten keine schwerwiegenden Komplikationen auf. Dokumentiert wurden eine sichtbare Narbenbildung in 6 Fällen (3,1%), eine temporale Einziehung in 3 Fällen (1,5%), Oszillopsien beim Kauen in 3 Fällen (1,5%) und eine Desinsertion der lateralen Kanthusregion in 2 Fällen (1%).

Schlussfolgerung Die tiefe laterale knöcherne Orbitadekompression unter Einschluss des vorderen Orbitarandes stellt eine sichere und effektive Methode zur Reduktion des Exophthalmus bei endokriner Orbitopathie dar.

Abstract

Background Gravesʼ orbitopathy is the most common extrathyroidal manifestation of Gravesʼ disease. In the burnt out fibrotic phase exophthalmos, diplopia and lid retraction may remain, which can require multiple rehabilitative surgical interventions. Orbital decompression is an established surgical procedure for the treatment of exophthalmos in Gravesʼ orbitopathy. The aim of the study was to evaluate the efficacy and side effects of the deep lateral orbital wall decompression including the orbital rim.

Methods In this retrospective, non-comparative case series, all patients with Gravesʼ orbitopathy, who underwent lateral orbital wall decompression at the Eye Clinic of the University of Göttingen between 2008 and 2015, were analysed in terms of exophthalmos reduction, diplopia (Gorman score) and complications. The surgical technique involved the removal of the lateral orbital wall including the orbital rim combined with additional orbital fat resection via swinging eyelid approach.

Results 127 patients who underwent 195 orbital decompressions were included. Mean exophthalmos reduction was 4.0 ± 1.2 mm (range 1.5 – 7.5 mm). Preoperatively, 47 patients/77 orbits (37.0/39.5%) presented without diplopia. Postoperatively, 3 patients/3 orbits (6.4/3.9%) showed new-onset diplopia (2.4% of all patients, 1.5% of all orbits). Diplopia in primary gaze was noted in one of the 3 patients (0.8% of all patients, 2.1% of patients without preoperative diplopia), and inconstant diplopia was seen in the other 2 patients. Postoperative improvement of diplopia was noted in 19 patients/19 orbits (15.0% of all patients, 23.8% of patients with preoperative diplopia/9.7% of all 195 interventions), and 16.1% of cases with preexisting diplopia. No severe complications were seen, except for one case of postoperative bleeding, which was successfully managed surgically without any functional deficits. A visible scar formation was noted in 6 cases (3.1%), temporal hollowing in 3 cases (1.5%), oscillopsia when chewing in 3 cases (1.5%) and a de-insertion of the lateral canthal region in 2 cases (1%).

Conclusions Deep lateral orbital wall decompression, including the orbital rim, is an effective surgical technique to reduce exophthalmos in patients with Gravesʼ orbitopathy with a low risk of functional and aesthetic complications.

Schlüsselwörter

endokrine Orbitopathie - Orbitadekompression - Exophthalmusreduktion - Diplopie - Komplikationen

Key words

Gravesʼ orbitopathy - orbital decompression - exophthalmos reduction - diplopia - complications

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