Combined Orbital Decompression and Strabismus Surgery in Thyroid Eye Disease

Abstract

In 1986, Shorr and Seiff1 described a staged approach for surgical rehabilitation for the treatment of patients with thyroid eye disease (TED). They suggested a 4-stage surgical strategy, where each specific surgical intervention was performed sequentially: (1) orbital decompression; (2) strabismus surgery; (3) surgical correction of eyelid malposition; and (4) upper and/or lower blepharoplasty. The rationale for this specific stepwise protocol is to allow the surgeon to adequately address any potential alterations induced from previous surgical interventions. For example, orbital decompression is recommended before strabismus surgery due to the risk of new onset or worsening diplopia following decompression surgery. Furthermore, this strategy suggests addressing strabismus before eyelid recession surgery. This is especially important in the lower eyelid due to possible impact on lower eyelid positioning resulting from the confluence of the inferior rectus muscle and inferior retractor complex. Although this staged treatment strategy has been widely adopted and followed by orbital surgeons over the last 35 years, several studies have demonstrated satisfactory outcomes when these rehabilitative procedures are performed simultaneously, potentially challenging the stepwise, single procedure approach in some situations.2–5 This article highlights important considerations for orbital decompression and strabismus surgeries in TED rehabilitation. Furthermore, this work discusses the potential advantages and nuances associated with combined surgical interventions, simultaneously treating both proptosis and strabismus.