Aesthetic Refinements in the Treatment of Graves' Ophthalmopathy

Goals/Purpose: Graves’ ophthalmopathy is a chronic, multisystem, autoimmune disorder characterized by increased volume of intraorbital fat and hypertrophic extra-ocular muscles.  Clinical findings of proptosis, impaired ocular motility, diplopia, lid retraction, and impaired visual acuity are treated with orbit decompression and fat reduction.  We present the addition of skeletal augmentation to further improve periorbital aesthetics.

Methods/Technique: Through a transconjunctival with lateral canthotomy incision, a balanced orbital decompression was executed removing the medial and lateral walls, and medial floor.  Intraorbital fat was excised.  All patients underwent placement of porous polyethylene infraorbital rim implants and midface soft tissue elevation, increasing inferior orbital rim projection and improving globe-cheek relationship.  From 2009-2012, 13 patients (11 females/2 males, 26 eyes) with Graves’ ophthalmopathy underwent surgery at two institutions.  Outcomes were evaluated, specifically for improvements of proptosis, diplopia, dry eye symptoms, and cosmetic satisfaction.

Results/Complications: Postoperative follow up ranged from 0.5-3yrs (median 1.5yrs).  The mean improvement in Hertel exophthalmometer was 5.4mm.  Diplopia resolved in 3/13(23%) cases.  No patients had worsening diplopia, and 12/13(92%) discontinued use of eye lubricants.  All patients had cosmetic satisfaction.  One patient suffered temporary paresthesia to the inferior orbital nerve.  There were no infections, hematomas or ocular complications.

Conclusion: Skeletal augmentation is a useful adjunct to orbital decompression and fat excision for treating Graves’ ophthalmopathy.  Balanced orbital decompression with infraorbital rim implants are reliable, effective, and safe, with good, lasting results.  Improvements are made towards the resolution of ocular symptoms and in the patient’s personal well-being, and social life, with a high benefit–to–low-risk ratio.