Original Investigation
Simultaneous Versus Staged Balanced Decompression for Thyroid-Related Compressive Optic Neuropathy Chris Y. Wu, M.D., Andrew W. Stacey, M.D., M.S., and Alon Kahana, M.D., Ph.D. Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, U.S.A. Purpose: To compare the visual and exophthalmometry outcomes of simultaneous versus staged balanced decompression in patients with thyroid-related compressive optic neuropathy (CON). Methods: All consecutive patients who underwent simultaneous or staged balanced decompressions for clinically diagnosed thyroid-related CON performed by 4 surgeons at the Kellogg Eye Center of the University of Michigan between 1999 and 2014 were included in the study. Demographic, medical, and surgical covariates were collected. Orbits were stratified by decompression technique. Primary outcomes were improvement in CON score (which quantifies visual dysfunction using logarithm of the minimum angle of resolution, color vision, and Humphrey visual field mean deviation), and improvement in proptosis. The authors performed univariate and descriptive statistics to identify baseline differences and covariates associated with the outcomes of interest; multivariate mixed linear regression models (to adjust for interorbit correlation) were then constructed with inclusion of potential confounders with p value ≤0.1. Results: In total, 80 orbits of 53 patients were included in the study. Of the 80 orbits, 61% underwent simultaneous balanced decompression, and 39% underwent staged balanced decompression. Mean CON score reduction was 6.12 ± 9.7 and mean proptosis reduction was 5.63 ± 2.6 mm. Staged balanced decompression was significantly associated with greater CON score reduction (p = 0.038). However, staged (vs. simultaneous) decompression technique did not remain an independent predictor (p = 0.950) after multivariate analysis adjusted for confounders. For proptosis reduction, there were no statistically significant differences between simultaneous and staged balanced decompression on univariate (p = 0.122) or multivariate mixed linear regression models (p = 0.812). Conclusion: Simultaneous and staged balanced decompression are equally efficacious in treating visual dysfunction and exophthalmos due to thyroid eye disease in patients with clinically diagnosed CON. Patient choice should be the primary consideration and care should be individualized. Further studies validating the CON score used in the study and comparative studies individualizing surgical treatment of thyroid eye disease are warranted. (Ophthal Plast Reconstr Surg 2016;32:462–467)
T
hyroid eye disease (TED), capable of causing vision loss and severe facial disfigurement, is one of the most incapacitating manifestations of autoimmunity, occurring in up
Accepted for publication October 1, 2015. The authors acknowledge an Unrestricted Departmental Grant from Research to Prevent Blindness, Inc. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Alon Kahana, M.D., Ph.D., 1000 Wall St., Ann Arbor, MI 48105. E-mail:
[email protected] DOI: 10.1097/IOP.0000000000000593
462
to half of Graves’ disease patients.1,2 Fortunately, only 3% to 5% of Graves’ disease patients will develop compressive optic neuropathy (CON), a clinical diagnosis that occurs when pathologically enlarged extraocular muscles and voluminous orbital tissues compress the optic nerve or its blood supply, most often at the orbital apex.2–4 First-line treatment for CON involves systemic steroids; nonresponsive patients undergo orbital decompression surgery targeted at the orbital apex.4–6 A variety of decompression techniques and approaches can effectively treat CON. Medial and/or inferior decompressions are advised to target the orbital apex in patients with apical crowding, although balanced, 3-wall, deep lateral, and fat decompression also have supportive evidence.1,5,7–16 Published studies, however, have consistently been underpowered and noncomparative, and hence, decompression surgery is guided more by geography, surgeon familiarity, and institutional preferences than by evidence-based guidelines.1,17 In a recent review of decompression surgery, the authors found no convincing evidence to recommend any particular technique based on randomized clinical trials, although they did conclude that the available evidence appeared to suggest that balanced decompressions with or without fat removal appeared to be the most effective surgical method.1 At the institution, balanced decompressions are performed either in a staged approach, where the medial and lateral walls are removed in separate operations, or in a simultaneous, same-day procedure. There has not been a study comparing the outcomes of staged versus simultaneous balanced decompression for CON patients. In this study, the authors present the balanced decompression technique and compare the visual and proptosis outcomes of simultaneous versus staged balanced decompression in CON patients.
METHODS Patient Selection. The University of Michigan Institutional Review board approved this study (No. 00040783). The authors obtained all data retrospectively through review of the electronic medical record. A patient list using procedural billing codes for orbital decompression surgery was obtained from April 21, 1999 to December 21, 2014 and all consecutive patients who underwent balanced decompressions (either staged or simultaneous) for visual dysfunction related to CON performed by 4 faculty surgeons of the Eye Plastic, Orbital and Facial Cosmetic Surgery Service of the Kellogg Eye Center at the University of Michigan were included. Simultaneous balanced decompressions consisted of a medial and ipsilateral lateral wall decompression performed in the same operation, while staged balanced decompression consisted of medial and lateral wall decompression performed in separate operations
