Microsurgical two-wall orbital decompression for treatment of visual impairment in patients with thyroid-associated ophthalmopathy

BackgroundDysthyroid optic neuropathy (DON) is a vision-threatening complication of thyroid-associated ophthalmopathy that may require urgent surgical intervention. We describe a microsurgical two-wall orbital decompression technique designed to achieve effective orbital and optic nerve decompression in extremely severe cases as an additional option.MethodsA frontotemporal extradural approach is used to remove the lateral orbital wall and orbital roof, with optional decompression of the optic canal. Neuronavigation guides bone removal and helps avoid violation of the frontal sinus. The surgical technique, anatomical landmarks, and perioperative considerations are described in detail, and key steps are demonstrated in an accompanying video.ResultsTwelve orbits in 7 patients (mean age 60 ± 5 years) underwent microsurgical two-wall orbital decompression for treatment of visual impairment due to DON. The technique allows controlled removal of the lateral orbital wall and orbital roof with excellent visualization of the orbit and optic canal. Adequate orbital volume expansion and optic nerve decompression can be achieved while preserving critical anatomical structures. The procedure is associated with low technical morbidity.ConclusionMicrosurgical two-wall orbital decompression appears to be a clinically applicable and feasible technique for the treatment of visual impairment due to DON. It may be considered in selected patients with severe or refractory disease and persistent visual impairment despite prior decompression.