The Four Stages of Surgical Rehabilitation of the Patient with Dysthyroid Ophthalmopathy NORMAN SHO~R, MD,* STUART R. SEIFF, MDt

Abstract: A logical and comprehensive program for the total ophthalmic re­habilitation of the dysthyroid patient is described. Surgical rehabilitation is always considered in four stages: (1) orbital decompression, (2) extraocular muscle surgery, (3) eyelid margin repositioning, and (4) blepharoplasty. Each stage must be considered in order. By observance of this protocol, repeat surgical procedures can be minimized. [Key words: blepharoplasty, compressive optic neuropathy, dysthyroid ophthalmopathy, Graves' disease, lid retraction, orbital decompression, strabismus.] Ophthalmology 93:476-483, 1986

Multiple techniques have been described over the years for the management of various structural abnormalities encountered in patients with dysthyroid ophthalmopathy. However, a systematic approach to these techniques has not been previously described. We have formulated a protocol which describes four basic stages of the surgical rehabilitation of the patient with dysthyroid ophthalmop­athy. Stage one is orbital decompression to replace the eyes to a more protected and posterior position within the orbit. Stage two is extraocular muscle surgery to correct diplopia. Stage three is eyelid malposition correction, and stage four is removal of excess eyelid skin and fat which has formed as a result of the disease process. Each stage must be considered in order. Any unnecessary stage may be skipped. Surgical rehabilitation performed in this order provides better results and keeps the number of procedures to a minimum.

From the Departments of Ophthalmology, University of California. Los Angeles' and University of Califomia, San Francisco.t

Presented at an Annual Meeting of the American Acade~y of Ophthal­mology.

Reprint requests to Norman Shorr, MD, 435 North Roxbury Drive, Suite 104, Beverly Hills, CA 90210.

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MATERIALS AND METHODS

The protocol study consisted of 80 consecutive patients with dysthyroid ophthalmopathy. Each patient underwent a complete ophthalmologic evaluation. A diagnosis of dysthyroid ophthalmopathy was made in the presence of a combination of the following findings: (1) proptosis without a discrete orbital mass and computed tomography (CT) and/or ultrasound evidence of enlarged extraocular muscles; (2) restrictive noncomitant strabismus, often with diplopia; (3) eyelid malpositionssuch as upper and lower eyelid retraction, lateral canthal thyroidmongoloid slant, medial mechanical entropion of the lower eyelid by an orbital mass effect, and lagophthalmos; (4) excess skin and fat of the eyelids as a result of the disease process; (5) conjunctival inflammation and chemosis; (6) compressive optic neuropathy; and (7) demonstration of thyroid en­docrine abnormalities.

Once the diagnosis was made, the four stages of reha­bilitation were explained to the patient as previously de­scri~d. They were entered into the protocol if they de­sired. In general, no surgical intervention was undertaken until the endocrine abnormality was medically controlled and the ophthalmic findings had been stable for six months.

SHORR AND SEIFF • DYSTHYROID OPHTHALMOPATHY REHAB

During the acute phase, several supportive measures were recommended. These included elevation ofthe head off the bed and artificial tear drops to the eyes. In addition to corneal exposure from proptosis and eyelid retraction, many of these patients have decreased tear production. Thyroid gland abnormalities are important to the general health of the patient and should be controlled, but no correlation between such control and the progression of the orbitopathy has been noted. Occasionally, diuretics may prove useful. Prednisone is occasionally of use to patients with severe inflammatory reactions, but should not be used on a regular basis and should not be used for longer than several weeks.

During the acute phase, the patient was examined reg­ularly by an ophthalmologist for evidence of dysthyroid compressive optic neuropathy. Compressive optIc neu­ropathy was diagnosed by evaluating the best corrected visual acuity, defects in color vision/saturation, afferent pupil defects, and visual fields. In the absence of other causes in a patient with findings of dysthyroid ophthal­mopathy, such abnormalities were considered evidence of compressive optic neuropathy. This is most likely caused by the enlarging extraocular muscles compressing the optic nerve at the orbital apex. It is interesting to note that patients with minimal proptosis may have extensive posterior muscle enlargement and develop optic neurop­athy. When optic neuropathy was detected, a trial of cor­ticosteroid therapy was instituted for several weeks. Oral prednisone may minimize orbital apex edema and allow the patient to pass through this phase of the orbitopathy without surgery or radiation. If optic neuropathy persisted on a regimen of 100 mg of prednisone daily for several weeks, surgical orbital decompression was performed. Careful attention was given to depression of the orbital apex. It is only after failure of corticosteroids and surgical decompression to relieve the optic neuropathy that we advised radiation therapy. It is believed that radiation causes extreme fibrosis of the orbital contents and in­creased difficulty with the patient's future rehabilitation. It was therefore avoided whenever possible.

STAGE ONE-ORBITAL DECOMPRESSION

The indications for orbital decompression include re­duction of corneal exposure, restoration of the globes to their normal anatomic position, severe proptosis caus­ing eyelid entrapment, and compressive optic neurop­athy.1-4 As soon as the clinical situation dictated, surgery was undertaken for compressive optic neuropathy. For indications other than optic neuropathy, all supportive measures were used in an attempt to allow the malady to run its course and stabilize before considering surgical intervention. Prior to orbital decompression, the patient was cautioned regarding the possibility of inducing or worsening diplopia.5 Two approaches were used, the transantral and transconjunctival methods. The transan­tral approach was preferred when large amounts of prop­tosis were present or when there was evidence of optic nerve compression.6

Technique for the transantral approach. USing general intubational anesthesia, the ethmoid sinuses, anterior maxillary wall, and unattached gihgivae are infiltrated with a solution of 1 % lidocaine with 1: 100,000 epinephrine with Wydase. The incision is made as for the Caldwell­Luc operation. This exposes the face of the maxilla. The periosteum is elevated superiorly until the infraorbital nerve exiting the foramen is identified. Using an osteo­tome and mallet, the anterior wall of the maxillary antrum is entered and the wall is extensively removed with a ron­geur. The antrostomy is carried superiorly to the level of the infraorbital foramen and this bony structure wili be chipped away later in the procedure. Once the antrostomy is completed, the mucosa is removed, especially supero­medially. Using Takahashi forceps and a suction tip, a radical ethmoidectomy is preformed, preserving the me­dial wall of the orbit and the cribiform plate. Oilce the ethmoidectomy has been completed, the bony buttress at the junction of the medial wall and floor of the orbit is removed, using a rongeur. The thin medial wall of the orbit is then removed with a Takahashi forcep, taking care not to damage the periorbita. Exposure of the perior­bita then extends alorig the orbital floor to the infraorbital nerve. At this point, the infraorbital nerve is disencased and allowed to hang like a hammock. Using ribbon re­tractors and a no. 12 Bard-Parker blade, periorbital strip­ping begins superomedially. It then proceeds inferome­dially and then to the orbital floor. The decompression effect appears to be directly related to the amount that the periorbita is opened. When optic nerve compression is present, it is imperative to relieve the compression at the orbital apex inferiorly and medially. This should be done prior to the extensive opening of the anterior per­iorbita, as prolapsing fat will interfere with visualization of the orbital apex. After the decompression is complete and hemostasis is assured, a nasal antral window is placed below the inferior turbinate along the floor of the nose. A no. 16 French Foley catheter is placed through the nasal antral window and the balloon is inflated in the maxillary sinus. This is removed from two to four days postopera­tively.

Technique for the transconjunctival approach. The transeonjunctival approach is used when there is moderate proptosis and no evidence of optic nerve compression. The transconjunctival incision is employed as it minimizes shortening of the anterior lainella of the lower eyelid and reduces the risk of lower eyelid retraction and ectropion. In this procedure, using general intubational anesthesia, the lower eyelid, floor of the orbit, and ethmoidal sinuses are infiltrated with 1 % lidocaine with i: 100,000 epineph­rine with Wydase. A lateral canthotomy is performed and the inferior limb of the lateral canthal tendon is lysed. This frees the lower eyelid. An infratarsal incision is made from the conjunctival surface to just anterior to the orbital septum. This effectively recesses the retractors of the lower eyelid. The dissection is then carried inferiorly between septum and orbicularis to the level of the inferior orbital rim. Dissection in this plane minimizes prolapsing orbital fat and maximizes visualization. Once the inferior orbital

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OPHTHALMOLOGY • APRIL 1986 • VOLUME 93 • NUMBER 4

rim is located, periosteum is elevated and the periorbita of the orbital floor is reflected off the floor and medial wall. The dissection is carried superiorly and posteriorly along the medial wall of the orbit. An osteotome is used to open the bony floor of the orbit and then rongeurs are used to create a bony opening into the maxillary antrum. Care is taken to preserve the infraorbital nerve but remove as much of its bony casing as possible. Using the Taka­hashi forceps and the suction tip, the medial wall of the orbit is opened and an ethmoidectomy is performed. Once the sinuses are opened, the medial and inferior periorbita are stripped, using Westcott-type scissors. Orbital fat is allowed to prolapse. No nasal antral windows are generally placed during this procedure. The periorbita is closed with absorbable sutures to the periosteum at the arcus margin­aliso Next, the conjunctiva is closed with interrupted 6-0 plain gut sutures. The lateral canthal tendon is recon­structed to periosteum and then the canthotomy is closed.

STAGE TWO-EXTRAOCULAR MUSCLE SURGERY

Generally, approximately six weeks is allowed to elapse between stage one and stage two. If the patient has been on corticosteroids, these are ideally discontinued prior to muscle surgery. Prism measurements are taken several times during the preoperative period and stability must be achieved prior to deciding on a surgical plan. It must be remembered that dysthyroid ophthalmopathy repre­sents a restrictive cicatricial myopathy and that we are dealing with a noncomitant strabismus. Therefore, it is virtually impossible to assure the patient of binocular vi­sion without diplopia in all fields of gaze postoperatively. The goal is to achieve a "tunnel" of single vision in the primary and reading positions. With time, patients enlarge this tunnel due to increasing vergences to include virtually all useful fields of gaze.

The plan generally includes recessions, as these are more effective than resections in a cicatricial disease. Most pa­tients have restriction of the inferior rectus muscles and benefit from some degree of bilateral inferior rectus reces­sions. Adjustable sutures are used almost without excep­tion for each muscle pair. A conjunctival restriction is present in most cases. Therefore, a conjunctival recession and bare sclera closure are used even where adjustable sutures are not employed. The sutures are adjusted in standard fashion on the first postoperative day. The pa­tient is then encourged to keep both eyes unpatched and practice achieving single vision with a distant target such as television.

STAGE THREE-EYELID MALPOSITION

Multiple eyelid malpositionings have been described in dysthyroid ophthalmopathy. These include upper and lower eyelid retraction, lateral canthal thyroidmongoloid slant, lagophthalmos, and a medial mechanical entropion. The most common malposition is upper and lower eyelid retraction which results in the typical thyroid stare. The upper eyelid is usually lowered using either an anterior

478

or posterior levator recession.7,8 If this is not successful,

"spacers" may be used to further lower the eyelids. These spacers may include eye bank sclera, nasal septum, and temporalis fascia. For the lower eyelid, a recession of the lower eyelid retractors may be performed as a first pro­cedure. This is often unsuccessful and a spacer must be placed to raise the lower lid margin. The most commonly used are eye bank sclera and ear cartilage.

Lateral canthal resuspensions may be employed to cor­rect lateral canthal malpositioning.

It has been noted that with proptosis or a shift in the muscle cone, a medial mechanical entropion may develop. This likely occurs when the muscle cone is moved infero­medially with a relative medial shortening of the posterior lamella of the lower eyelid. It has been noted in patients with a mass effect due to enlarged extraocular musck or an orbital tumor. Additionally, it is commonly seen after orbital decompression where there is a shift of the muscle cone. This may be corrected by standard entropion pro­cedures.

STAGE FOUR-BLEPHAROPLASTY

Dysthyroid ophthalmopathy causes accurimlation of excess fatty tissue about the eyelids and redundant skin becomes prominent. Stage four deals with the removal of this excess tissue, as in standard blepharoplasty and re­stores a more normal appearance to the patient. The stan­dard rules and considerations in blepharoplasty certainly apply in these cases. The eyebrow position must be ex­amined in order to prevent "sewing the eyelashes to the eyebrows" in cases of eyebrow ptosis. When eyebrow pto­sis exists, eyebrow elevating procedures should be consid­ered, such as a coronal forehead and eyebrow elevation, mid forehead lift, or direct eyebrow lift. If eyebrow surgery is not done, then minimal skin should be removed. The authors employ the open sky blepharoplasty technique, in which the orbital septum is opened along its entire length and fat is removed in a graded fashion.9 This is extremely useful in cases of dysthyroid ophthalmopathy where the fat often has a woody consistency and does not prolapse well through buttonholes in the orbital septum, as classicly described. to Further, special attention must be paid to the avoidance of postoperative lagophthalmos since many of these patients have preexisting dry eyes and cannot tolerate any additional corneal insult (exposure).

The goals oflower eyelid blepharoplasty are extremely important in patients with dysthyroid ophthalmopathy. These goals are: (1) to remove excess fat; (2) to not induce lower eyelid retraction; and (3) to excise minimal excess skin. The last thing that a patient with dysthyroid ophthalmopathy needs is surgically induced lower eyelid retraction.

RESULTS

There were 80 patients with dysthyroid ophthalmo­pathy included in the protocol study. Seventeen (22%)

SHORR AND SEIFF • DYSTHYROID OPHTHALMOPATHY REHAB

Fig 1. Top left. prior to transantral orbital decompression. Top righl. post-transantral orbital decompression. Bot/om left. prior to transantral orbital decompression. Bot/om righl. post-transantral orbital decompression.

were men and 63 (78%) were women. The average age for the men was 49 years (range, 27-68 years) and 52 years (range, 23-80 years) for women.

One hundred twenty-three eyes in 63 patients under­went orbital decompression in stage one. Forty-six were for corneal exposure, 49 were for restoration of the globes to the normal anatomic position, and 28 were for com­pressive optic neuropathy. Forty-two patients underwent 84 transantral orbital decompressions and 17 patients un­derwent 33 transconjunctival orbital decompressions. Four patients underwent six transantral-ethmoidal-lateral wall and floor (3 wall) decompressions.

Those undergoing transantral orbital decompression generally received a mean of 4.81 ± 1.75 mm of proptosis reduction (Fig 1), while those undergoing transconjunc­tival decompression achieved approximately 4.27 ± 1.92 mm of proptosis reduction (Fig 2).

Twenty-eight patients identified as having dysthyroid compressive optic neuropathy underwent transantral or­bital decompressions. All improved. Three patients with visual acuity of 20/200 or worse regained vision to 20/25 or 20/20. Three patients having visual acuity from 20/ 100-20/80 improved approximately 6 lines of Snellen acuity to 20/30 or better. Ten patients (visual acuity 20/

50-20/40) improved a mean of 2.5 (range, 1-3) lines of Snellen acuity. There were 12 patients with visual acuity between 20/30 and 20/20. These patients all had abnor­malities of color desaturation, afferent pupil defects, visual field defects, or disc edema which improved after de­compression. A few had slight improvements in Snellen acuity. No patient in the series lost visual acuity due to decompression. One patient's visual acuity decreased sev­eral weeks after initial post-decompression improvement. She was steroid intolerant and received radiation to her orbit with restoration of her vision to 20/25. She was the only patient in the entire series who received radiation (Table 1).

Motility abnormalities remained the most common problem arising after orbital decompression. Of the 42 patients who underwent transantral orbital decompres­sion, 27 (64%) had diplopia before surgery that persisted after surgery; one (2%) had diplopia preoperatively that resolved after orbital decompression. Interestingly, this patient was exotropic preoperatively. Fourteen (34%) of the patients had no diplopia or intermittent diplopia in lateral fields of gaze prior to decompression. All four of the patients with intermittent diplopia developed diplopia in primary gaze postoperatively. One half of the ten pa-

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OPHTHALMOLOGY • APRIL 1986 • VOLUME 93 • NUMBER 4

Fig 2. Top leli, prior to transconjunctival orbital decompression. Top right, post-transconjunctival orbital decompression. Bottom leli, prior to transconjunctival orbital decompression. Bottom right, post-transconjunctival orbital decompression.

tients with no diplopia preoperatively developed double vision in primary gaze after surgery (Table 2).

Of 17 patients undergoing transconjunctival orbital decompression, five (29%) had diplopia before surgery. One patient, again exotropic with diplopia preoperatively, was orthophoric without diplopia postoperatively. Sev­enty-one percent of these patients had single vision or only intermittent diplopia in lateral fields of gaze preop­eratively. Of these patients, 12% developed diplopia in primary gaze. Again, those with intermittent diplopia lat­erally were most at risk. Ten of 17 patients (59%) had no diplopia after transconjunctival decompression (Table 3).

Three patients underwent 3 wall orbital decompres­sions. All patients had diplopia before and after surgery except one patient who was exotropic preoperatively and was without diplopia after surgery (Table 4).

Other complications from transantral orbital de­compressions include two CSF leaks, three oral antral fis­tulae, one antral hematoma, one antral mucocele, and one patient with thyroid storm immediately postopera­tively.

Fourteen eyes developed lacrimal outflow obstructions. Ten underwent DCRs, two required lacrimal intubation, and two were untreated.

480

Complications encountered in the transconjunctival decompression cases were one antral mucocele, which needed evacuation five months postoperatively and one cerebrospinal fluid leak, which closed spontaneously.

Virtually all the patients entered in the protocol with motility abnormalities were esotropic with inferior re­striction. In general, this esotropia increased, with some decrease in vertical restriction after decompression, espe­cially via the transantral approach. Three exotropic pa­tients benefited from post-decompression shift of the muscle cone toward esotropia, resulting in an improve­ment in their diplopia.

The results of the stage two operations were very en­couraging. After transantral decompression, 19 of 36 (53%) achieved single vision after one operation. An ad­ditional25% (9 patients) were without diplopia in primary gaze after a second procedure. Only three patients (8%) required a third operation and one (3%) a fourth. These were all cases with severe restrictive disease. Four patients chose not to have stage two surgery.

All patients with diplopia after transconjunctival or 3 wall decompression achieved single vision in primary gaze after one operation (except for one transconjunctival de­compression patient who refused surgery).

SHORR AND SEIFF • DYSTHYROID OPHTHALMOPATHY REHAB

Table 1. Dysthyroid Compressive Optic Neuropathy

Visual Acuity Patient Snellen Lines

No. Preop Postop Improved

1 20/400 20/25 9 2 20/200 20/25 8 3 20/200 20/20 9 4 20/100 20/30 6 5 20/80 20/25 6 6 20/80 20/25 6 7 20/50 20/30 2 8t 20/50 20/25 3 9 20/50 20/25 3

10 20/40 20/30 1 11 20/40 20/30 1 12 20/40 20/25 2 13 20/40 20/25 2 14 20/40 20/20 3 15 20/40 20/20 3 16 20/40 20/20 3 17 20/30 20/30 * 18 20/30 20/30 * 19 20/30 20/25 1 20 20/30 20/20 2 21 20/25 20/25 * 22 20/25 20/25 * 23 20/25 20/20 24 20/20 20/20 * 25 20/20 20/20 * 26 20/20 20/20 * 27 20/20 20/20 * 28 20/20 20/20 *

* Improvement in visual parameter other than acuity. tSteroid intolerant, required radiation.

Table 2. Motility Abnormalities after Transantral Orbital Decompression

No. Patients operated

Preoperative diplopia in primary gaze Diplopia persisted Diplopia resolved (XT)

Preoperative single vision or intermittent diplopia in lateral fields of gaze

Diplopia postoperatively Intermittent diplopia No diplopia

No diplopia postoperatively

42 (100%)

28 (66%) 27 (64%) 1 (2%)

14 (34%) 9 (22%)

4/4 (100%) 5/10 (50%)

5 (12%)

After muscle surgery, proptosis was noted to occasion­ally increase slightly due to relaxation of the restriction in the muscle cone. This was not a significant problem.

Many procedures were used in stage three to correct the eyelid malpositionings. In general, only one procedure for each eyelid was necessary (Fig 3). Six entropion pro­cedures were performed on lower eyelids and none were repeated. Upper eyelid retraction was corrected most commonly by an anterior approach levator recession as the first operation. Of these, 16% required a second pro-

Table 3. Motility Abnormalities after Transconjunctival Orbital Decompression

No. patients operated

Preoperative diplopia in primary gaze Diplopia persisted Diplopia resolved (XT)

Preoperative single vision or intermittent diplopia in lateral fields of gaze

Diplopia postoperatively Intermittent diplopia No diplopia

No diplopia postoperatively

17 (100%)

5 (29%) 4 (24%) 1 (5%)

12 (71%) 2 (12%)

1/1 (100%) 1/11 (9%)

10 (59%)

Table 4. Motility Abnormalities after 3 Wall Orbital Decompression

No. patients operated

Preoperative diplopia in primary gaze Diplopia perSisted Diplopia resolved (XT)

3 (100%)

3 (100%) 2 (67%) 1 (33%)

cedure. Of the posterior levator recessions, 18% required a second procedure. A nasal septum cartilage graft was used in two upper eyelids and both were successful as primary procedures. Temporalis fascia was used as a spacer in the upper eyelids in three cases and two had to be supplemented with eye bank sclera. Sclera was used once primarily and was adequate (Table 5).

Upper eyelid ptosis was a presenting problem in 4 pa­tients of the 80 entered in the protocol. This represents an incidence of 2.5% (4 of 160) in this population. They were generally of the levator aponeurosis dehiscence type (Table 5).

For lower eyelid retraction, eye bank sclera was used in 16 cases and has not been revised. Ear cartilage grafts were used 15 times in this series and were replaced 13% ofthe time (2 cases). Lower eyelid retractor recession was performed as a primary procedure six times in mild cases and was repeated once (Table 5).

Entropion and lateral canthal procedures were generally successful using standard techniques. Only one lateral canthal suspension has been revised (Table 5).

In stage four, five patients underwent coronal eyebrow and forehead lifts for eyebrow ptosis preparatory for blepharoplasty. Forty-five upper and eleven lower eyelid blepharoplasties were performed without significant complications (Fig 4). One patient underwent a face lift and one patient has undergone blepharopigmentation.

DISCUSSION

There is nothing unique about the procedures described here. They are all described eloquently elsewhere. The goal of this paper is to give a rational, systematic approach to the surgical rehabilitation ofthe patient with dysthyroid

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OPHTHALMOLOGY • APRIL 1986 • VOLUME 93 • NUMBER 4

Fig 3. Eyelid mal positions. Left. prior to eyelid positioning. Right. after eyelid repositioning procedures to each eyelid.

ophthalmopathy. This protocol does not advocate more procedures, only that they be considered in a given order. It is hoped that this approach will minimize the number of procedures which need to be repeated during the entire course of treatment. For example, if strabismus is cor­rected prior to orbital decompression, after decompres­sion, the muscle cone shifts and diplopia would recur. Further, if eyelid surgery is done prior to decompression, eyelid position would change after decompression and the eyelid surgery may need to be repeated. If blepharo­plasty is performed prior to eyelid repositioning, the sur­gical options for the repositioning technique would be limited and made more difficult by the prior surgery. Therefore, it is critical that the surgeries be considered in an appropriate order.

Patients with dysthyroid ophthalmopathy are fre­quently devastated by the extreme changes in their self image and appearance. It has been our experience that when a "master plan" is explained to these patients, they are encouraged and have a set series of goals to achieve. However, they are, hopefully, realistic in their expectations that their appearance may not be completely as they re­member it, but will be cosmetically acceptable.

The concept of orbital decompression to replace the eyes to their normal anatomic position is controversial due to the possible complications of the procedure, some of which are described in this paper. Patients, however, feel that this procedure is the most important part of their rehabilitation and the staged approach gives an appro­priate opportunity to deal with the most common com­plication, diplopia, in a very rational manner.

It should not be interpreted that the increased incidence of diplopia after transantral vs. transconjunctival orbital decompression represents a greater problem with one procedure than the other. It should be noted that preop­erative incidence of diplopia was 66% for the transantral orbital decompression patients and only 29% for the transconjunctival cases. Also, more diplopia was induced in previously "straight" eyes with the transantral approach than with the transconjunctival procedure. This likely represents the surgeon's bias for performing transantral orbital decompressions for the more restricted and prop-

482

totic cases. Either procedure can be used in most cases with similar results if appropriately aggressive operations are done. However, it is recommended that the transantral approach be used for compressive optic neuropathy.6

The extraocular muscle surgery has been extremely successful in restoring useful single vision to these patients. The adjustable suture technique has been very useful and patients are very receptive to this concept when placed in the context of the overall staged approach.

Multiple procedures have been described for correcting

Table 5. Initial Stage Three Procedure for Eyelid Malpositions

Location

Upper eyelid Retraction

Anterior recession

Posterior recession

Temporalis fascia

Nasal cartilage Eye bank sclera

Ptosis Levator repair

Lower eyelid Entropion

Rotation suture Four snip

Retraction Eye bank sclera Ear cartilage Primary

retractor recession

Lateral canthus Canthal

malposition Lateral canthal

resuspension

Performed

50

17

3 2 1

4

2 2

16 15

6

10

Repeated

8

3

2 0 1

0

0 0

0 2

% Repeated

16

18

66 0

100

0

0 0

0 13

17

10

SHORR AND SEIFF • DYSTHYROID OPHTHALMOPATHY REHAB

Fig 4. Leji, prior to open sky blepharoplasty. Right, after open sky blepharoplasty.

eyelid malpositions. The data here reflect only one ex­perience. Each surgeon must find what works best for him but it is important to correct these eyelid malpositions prior to proceedings with stage four.

It should be reeniphasized that restoration of the struc­tural integrity of the. soft tissues of the mid-face is critical in dysthyroid ophthalmopathy patients prior to blepharo­plasty. The ravages of this disease cause extensive laxity of mid-face tissues; and simple excision of skin and fat will often give a less than optimal result. Eyebrow and forehead procedures should be done without hesitation when indicated. When blepharoplasty is ultimately per­formed, the open sky technique is recommended.8

Patients are generally very anxious to proceed to stages three and four, as these are "the finishing touches" of restoring their self-image. It has been interesting to note that the two women who desired face lifts and blepharo­pigmentation commented that this was their opportunity to enhance their -self-esteem beyond their pre-" dysthyroid" condition.

This staged approach to the surgical rehabilitation of the patient with dysthyroid ophthalmopathy provides a systematic approach to the treatment of these patients. It is effective in organizing the surgeon's plans and offers the patient a set of reassuring, realistic goals. Its general use should be encouraged.

REFERENCES

1. McCord CD Jr. Current trends in orbital decompression. Ophthal­mology 1985; 92:21-33.

2. Hurwitz JJ, Birt D. An individualized approach to orbital decompression in Graves' orbitopathy. Arch Ophthalmol1985; 103:660-5.

3. Shorr N, Failor M. Cosmetic orbital decompression. In: Ward PH, Ber­man WE, eds. Plastic and Reconstructive Surgery of the Head and Neck. St Louis: CV Mosby, 1984; 1150-3.

4. Baylis HI, Call NB, Shibata CS. The transantral orbital decompression (Ogura technique) as performed by the ophthalmologist; a series of 24 patients. Ophthalmology 1980; 87:1005-12.

5. Shorr N, Neuhaus RW, Baylis HI. Ocular motility problems after orbital decompression for dysthyroid ophthalmopathy. Ophthalmology 1982; 89:323-6.

6. DeSanto L. Transantral orbital decompression. In: Gorman CA, Waller RR, Dyer JA, eds. The Eye and Orbit in Thyroid Disease. New York: Raven, 1984; 231-51.

7. Putterman AM, Urist M. Surgical treatment of upper eyelid retraction. Arch Ophthalmol1972; 87:401-5.

8. Chalfin J, Putterman AM. MOiler's muscle excision and levator recession in retracted upper lid; treatment of thyroid-related retraction. Arch Ophthalmol1979; 97:1487-91.

9. Shorr N, Failor MK. Cosmetic upper eyelid blepharoplasty. Adv Ophthalmic Plastic Reconstr Surg 1983; 2:31-42.

10. Rees TO. Blepharoplasty: surgical procedures. In: Rees TO, ed. Aes­thetic Plastic Surgery. Philadelphia: WB Saunders, 1980; 470-524.

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