Transcranial Orbital Decompression as a Salvage Procedure for Graves' Ophthalmopathy: A 26-Year Experience

Background Effective treatment for exophthalmos and optic neuropathy of Graves' ophthalmopathy is a very challenging problem. When patients present to neurosurgeons, they have typically already failed multiple medical and surgical interventions. In this study, we evaluated a cohort of patients with refractory or recurrent Graves' ophthalmopathy who had salvage surgery after failed previous procedural intervention.

Methods A retrospective review was performed of patients with persistent Graves' ophthalmopathy following previous surgical intervention treated between 1990 and 2016 at a single, large academic institution. All patients received an extensive transcranial decompression, including removal of the medial sphenoid wing, roof, and lateral walls of the orbit, as well as skeletonizing of the meningo-orbital band. Bone removal continued medial to the level of the ethmoid, and inferiorly down to the floor of the orbit. Various patient and treatment characteristics were collected and analyzed.

Results A total of 22 patients and 39 orbits were included in the analysis. The median age was 58.5 years (range: 29–72 years). All patients had ophthalmopathy that was inadequately controlled by other surgical approaches including transantral decompression, lateral wall and fat decompression, and endoscopic medial wall decompression. 19 patients underwent bilateral transcranial decompressions. No major complications were noted; however, one case required a revision due to hardware failure, and one case required surgery for a wound dehiscence. Average length of time from surgery and postoperative ophthalmologic measurements was 70.6 days. Paired t-tests were used for statistical analysis. Mean preoperative visual acuity was 20/74 and mean postoperative visual acuity was 20/41 (p < 0.01). Mean preoperative exophthalmometry was 24.0 mm and mean postoperative exophthalmometry was 20.8 mm (p < 0.01).

Conclusion Patients with Graves' ophthalmopathy can present to neurosurgeons when disease is inadequately controlled by other surgical approaches. Our series found that transcranial orbital decompression is a safe and effective treatment. We conclude that in Grave's ophthalmopathy, a thorough transcranial orbital decompression is an acceptable and beneficial salvage operation after failure of previous surgical intervention.