Eyes wide shut: necessity and effect of adjunctive procedures after decompression surgery in patients with endocrine orbitopathy

Background Orbital decompression surgery is frequently the last therapeutic measure in the surgical treatment of endocrine orbitopathy (EO). Additional rehabilitative and corrective surgical treatments are often used to improve the resulting eyelid stigmata, such as an increased lid aperture and scleral show. The aim of the study was to evaluate the effect of adjunctive surgical procedures after orbital decompression surgery in patients with EO. Methods A total of 120 orbitae from 65 patients with EO from 2010 to 2020 at a tertiary care center in Germany were retrospectively evaluated. Ocular surface area (OSA) and vertical palpebral fissures were three-dimensionally analyzed at the following stages: presurgical decompression, postsurgical decompression, and post-adjunctive surgical procedures. For the analysis of vertical palpebral fissures, predefined vertical line distances were measured on the upper and lower lids in the central, medial, and lateral pupillary regions. Results The initial OSA was 2,98 ± 0.85 cm2, and it decreased significantly after decompression surgery to 2.52 ± 0.62 cm2. After adjunct surgical procedures, OSA further decreased to 2,31 ± 0,55 cm2. Furthermore, a statistically significant reduction in all pupillary parameters was noted after each treatment step. More lid-lengthening procedures were performed on the lower lid than on the upper lid. Canthoplasty (n = 13) was the most frequently performed procedure during rehabilitation. Conclusion Surgical decompression surgery improves OSA and leads to a significant reduction in lid aperture. Adjunctive surgical procedures, addressing the upper and lower lid, have a significant influence on the ongoing clinical course and contribute to a reduction in OSA.

Endocrine Obitopathy: a Personalized Approach to Patient Сare

Background. This article highlights the main approaches to the treatment of patients with endocrine orbitopathy (EO) and current opportunities for planning and conducting personalized orbital decompression, including the use of Computer-Aided Design (CAD) / Computer-Aided Manufacturing (CAM) technologies. Optimization of treatment of this pathology which can lead to changes in appearance, inability to perform usual work, social isolation, and in the most difficult cases to vision loss is a topical issue of ophthalmology and maxillofacial surgery. The aim. To analyze current information on basic approaches to the treatment of patients with endocrine orbitopathy and the possibility of using computer technologies for planning and performing personalized orbital decompression. Results. The use of corticosteroids, radiation therapy, surgical treatment are the key methods used to manage patients with EO. The use of CAD/CAM technologies allows to plan surgery according to the morphological features of the orbit of each patient. This can potentially affect the outcome of decompression and reduction of exophthalmos, as well as intraoperative complications. When using standard approaches, the results of decompression may vary significantly due to the differences in morphological parameters of the orbits. This dictates the need for a personalized approach to the management of patients with EO. Due to the significant variability of morphological parameters of the orbits in the case of standard approaches, the results in different patients can differ significantly, which dictates the need for a personalized approach to the management of patients with EA. Conclusions. EUGOGO 2016 recommends a multidisciplinary step-by-step approach to the management of patients with EO, depending on its activity and severity and the impact on the patient’s quality of life. A personalized approach using computer simulations and the development of surgical navigation templates for surgical decompression of the orbit will ensure optimal functional and aesthetic treatment results. Keywords: endocrine orbitopathy, treatment, orbital decompression, ComputerAided Design (CAD) / Computer-Aided Manufacturing (CAM) technologies, personalized approach.

Short-Term Outcomes of Surgery for Graves’ Disease in Germany

Background: Surgical treatment of Graves’ disease (GD) has a potentially increased incidence of postoperative hypoparathyroidism, recurrent laryngeal nerve palsy (RLNP) and bleeding. The aim of this study was to evaluate the current extent of surgery for the treatment of GD and its safety as a short-term outcome. Methods: Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patient data were retrospectively analyzed regarding demographics, surgical procedures and perioperative outcomes. Statistics were performed with Student’s t-test or Fisher’s exact test and multivariate Cox regression analysis. The level of statistical significance was set at p < 0.05. Results: A total of 1808 patients with GD with a median age of 44 (range 14–85) years were enrolled in a 25-month period by 78 departments, of which 35.7% (n = 645) had an endocrine orbitopathy and 0.1% (n = 6) had thyrotoxic crisis. Conventional open surgery was used in 98.6% of cases and minimally invasive or remote-access approaches were used in 1.4%. Total thyroidectomy was performed in 93.4% of cases (n = 1688). Intraoperative neuromonitoring (IONM) was used in 98.9% (n = 1789) of procedures. In 98.3% (n = 1777) at least one parathyroid gland was visualized and in 20.7% (n = 375) parathyroids were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n = 134/3429 nerves at risk) and 0.1% (n = 4/3429 NAR). The rates of transient RLNP tended to be higher when intermittent IONM was used compared to continuous IONM (4.1% vs. 3.4%, p < 0.059). The rate of transient postoperative hypoparathyroidism was overall 29% (n = 525/1808). Multivariate analysis revealed fewer than 300 thyroid resections and fewer than 15 thyroid resections for GD per year, male sex, BMI > 30, autotransplantation of parathyroid glands and previous bilateral thyroid surgery as independent risk factors for postoperative temporary hypoparathyroidism. Reoperations for bleeding (1.3%) were rare. Conclusion: Total thyroidectomy with IONM is safe and currently the most common surgical therapy for GD in Germany. Postoperative hypoparathyroidism is the major complication which should be focused on.