Endoscopic Orbital and Optic Nerve Decompression

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Graves' orbitopathy (dysthyroid orbitopathy)

Graves' disease is an autoimmune disorder that affects primarily the thyroid and the orbit. Thyroid manifestations are characterized by the production of autoantibodies to the TSH receptor with subsequent hyperstimulation and resultant hyperthyroidism. The thyroid manifestations of Graves' disease an be treated with thyroid-suppressive medications, radiation (I131), or surgery.

The orbital manifestations of Graves' disease, known as dysthyroid orbitopathy, also represent an autoimmune process

Medical treatment of dysthyroid orbitopathy

Local measures such as lubrication, eyelid taping, and patching for patients with dryness and diplopia represent initial conservative treatment approaches. More aggressive treatments include the use of systemic corticosteroids and orbital radiation. Both of these treatments appear to be most effective during the acute phase of the disease. Systemic corticosteroid treatment usually results in marked improvement, but the symptoms generally recur following discontinuation of steroid treatment.

Endoscopic orbital decompression

The endoscopic technique allows for unmatched visualization of critical anatomic regions including the skull base and orbital apex and avoids external or sublabial incisions. The entire medial orbital wall as well as the medial portion of the orbital floor is removed with endoscopic decompression (Fig. 1).

Optic nerve decompression

Historically the most common, and perhaps most controversial, indication for optic nerve decompression has been traumatic optic neuropathy (TON). The efficacy of decompression in this setting remains unclear. Endoscopic and nonendoscopic techniques of optic nerve decompression have also been used for a variety of nontraumatic causes of compressive optic neuropathy such as benign tumors and inflammatory or fibroosseus lesions [20]. It is in these patients with nontraumatic, compressive optic

Endoscopic optic nerve decompression

Traditional surgical approaches for optic nerve decompression include transorbital, extranasal transethmoid, transantral, intranasal microscopic, and craniotomy approaches. Endonasal endoscopic decompression of the optic nerve offers many advantages over these approaches, including excellent visualization, preservation of olfaction, rapid recovery time, a lack of external scars, and less operative stress in patients who may be suffering from multisystem trauma.

Summary

With excellent visualization of the orbital apex and optic canal, the endoscopic transnasal approach is well suited for both orbital and optic nerve decompression. This operation is an advanced endoscopic technique, and should be performed only by surgeons experienced in endoscopic nasal surgery. Although the indications and expected results for orbital decompression are well established, those for optic nerve decompression continue to evolve.

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