Surgical treatment of TED
Surgical treatment is started when the disease is stable. TED surgery is used to correct the proptosis, ocular exposure, double vision and periocular and orbital bulging and eyebags.
Surgery is performed in the following order:
- Orbital decompression to correct eye protrusion and orbital bulging.
- Eye muscle surgery is performed to correct double vision.
- Eyelid surgery is performed to correct eyelid retraction.
- Augmented blepharoplasty to reduce eyebags and decompress orbital soft tissue.
Balanced Orbital Decompression Surgery in TED
Orbital decompression surgery reduces exophthalmos. This involves removing bone to enlarge the orbit. After decompression, the orbital contents expand inside the orbit. The floor of the orbit is preserved in order to avoid causing double vision, this is called a balanced orbital decompression. This is called a balanced orbital decompression. Orbital decompression allows the eye to sink back into the socket and resume a more normal appearance. Decompression also helps resolve optic nerve compression and restore normal visual function.
Orbital decompression surgery is done one side at a time under general anaesthetic by an oculoplastic surgeon. The incision to access the outer orbital wall is done in the upper eyelid, well hidden in the skin creases, extending a little beyond the eyelid. This results in a very natural looking scar that is barely visible. It enables the outer orbital wall to be drilled deeply and allow optimum decompression.
The balanced inner wall decompression into the ethmoid sinus is done via a small incision inside the eyelid which is called a trans-caruncular approach and does not leave a visible scar.
Inner wall decompression can also be done endoscopically via the nose by an experienced ENT sinus surgeon. This is a particularly useful approach for relieving optic nerve compression with reduced visual function.
Additonally, orbital decompression surgery often has a positive effect on eyelid retraction, meaning additional retraction surgery is less frequently required.
Eye Muscle Surgery for TED (Squint or Strabismus Surgery)
The small muscles that move the eyes may become enlarged as a result of TED. This can impede eye movement and cause double vision.
Squint surgery (strabismus surgery) is performed to reposition the eye muscles to provide the best possible field of single vision, allowing the eyes to function near normally. Squint surgery is only done once the thyroid eye disease activity and double vision measurements have stabilised. Whilst waiting for the double vision to stabilize a small plastic prism (Fresnl prism) can be placed on the back surface of glasses, to temporarily correct symptoms.
Squint surgery is performed under general or local anaesthestic and the eye muscles that are most scarred are delicately detached from the eyeball and reattached a few millimetres back using a small suture which can be adjusted as necessary wihthin the first 24 hours.
After surgery the eye may be patched for 24 hours and then a course of eye drops started for 3 – 4 weeks.
Eyelid surgery to correct eyelid retraction in TED
The eyelids can be repositioned to correct the eyelid retraction, making the eyes more comfortable and resulting in improved cosmetic appearance.
The upper eyelids are lengthened by the oculoplastic surgeon under local anaesthetic. To lenghten the lower lid it may be necessary to use a small tissue graft taken from the hard palate of the mouth or synthetic collagen (Alloderm® or Surederm®). If a hard palate graft is used, the surgery is best done under general anaesthetic.
Despite orbital decompression, patients with TED may be left with baggy eyelids and residual periocular and orbital swelling. A soft tissue decompression or augmented blepharoplasty can be done, where fat and a small amount of skin is removed.
Filler (hyaluronic acid gel, eg. Restylane®, Perlane®) is injected into the cheek to camouflage deep tear trough holllowing and malar atrophy. This helps improve cosmetic appearance and is done after the above functional surgeries.
General post-operative instructions:
- The eye is padded for 24 hours.
- The vision is checked a couple of hours after surgery and the eye is re-padded.
- Systemic steroid and antibiotic tablets are prescribed for between 5 – 10 days after orbital decompression.
- Topical eye drops are prescribed 4 times a day for up to three weeks.
- Ice packs are recommended to reduce swelling after orbital decompression and blepharoplasty.
- You should not drive for 48 hours after surgery. You should have someone accompany you home.
- You may require up to three weeks off work or “down time” to recover as the orbit is likely to be swollen and bruised for 10–21 days after decompression surgery. The recovery time after squint surgery is 7–10 days and 7–14 days after blepharoplasty surgery.
- You should not swim for three weeks.
- Follow-up is between 5–10 days after surgery when the vision and eye movements will be checked and sutures removed.