Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science Surgical management of temple-related problems following lateral wall rim-sparing orbital decompression for thyroid-related orbitopathy We Fong Siah,1 Bhupendra CK Patel,2 Raman Malhotra1

1Corneoplastic Unit, Queen ABSTRACT a thin rim of lateral wall bone23and those that Victoria Hospital NHS Trust, Aim To report a case series of patients with persistent create a bony window. The latter technique can be East Grinstead, UK 4 2 temple-related problems following lateral wall rim- achieved by a lateral orbitotomy approach, en bloc Division of Facial and Orbital 5 Cosmetic & Reconstructive sparing (LWRS) orbital decompression for thyroid-related resection of the lateral orbital wall with or Surgery, Moran Eye Center, orbitopathy and to discuss their management. without the rim,67temporal fossa approach8 and University of Utah, Methods Retrospective review of medical records of coronal approach.9 Salt Lake City, Utah, USA patients referred to two oculoplastic centres While literature is in abundance regarding the Correspondence to (Corneoplastic Unit, Queen Victoria Hospital, East occurrence of postoperative strabismus after orbital Dr We Fong Siah, Grinstead, UK and Moran Eye Center, University of Utah, decompression, other ocular morbidities are under- Corneoplastic Unit, Queen Salt Lake City, USA) for intervention to improve/alleviate reported. Recently, Fayers et al10 reported the inci- Victoria Hospital NHS Trust, temple-related problems. All patients were seeking dence of masticatory oscillopsia following a lateral East Grinstead RH19 3DZ, UK; [email protected], treatment for their persistent, temple-related problems wall rim-sparing (LWRS) where the temporalis [email protected] of minimum 3 years’ duration post decompression. muscle had been elevated and a bony window The main outcome measure was the resolution or created. In this present study, we highlight add- Received 4 August 2015 improvement of temple-related problems. itional complications associated with this surgical Revised 22 September 2015 Results Eleven orbits of six patients (five females) with approach and discuss the corrective interventions Accepted 21 October 2015 – Published Online First a median age of 57 years (range 23 65) were included that were carried out when problems persisted and 13 November 2015 in this study. Temple-related problems consisted of remained bothersome. This is the first paper to cosmetically bothersome temple hollowness (n=11; report on the management of this debilitating com- 100%), masticatory oscillopsia (n=8; 73%), temple plication after LWRS orbital decompression. tenderness (n=4; 36%), ‘clicking’ sensation (n=4; 36%) and gaze-evoked ocular pain (n=4; 36%). Nine orbits METHODS were also complicated by proptosis and exposure This is a retrospective review of consecutive cases keratopathy. Preoperative imaging studies showed the of patients with thyroid-related orbitopathy absence of lateral wall in all 11 orbits and evidence of referred to the authors (RM and BCKP), at the prolapsed lacrimal gland into the wall defect in four Queen Victoria Hospital (QVH), East Grinstead, orbits. Intervention included the repair of the lateral wall UK and the Moran Eye Center (MEC), University defect with a sheet implant, orbital decompression of Utah, USA, respectively, for management of involving fat, the medial wall or orbital floor and temple-related problems that had developed follow- autologous fat transfer or synthetic filler for temple ing LWRS orbital decompression. All patients had hollowness. Postoperatively, there was full resolution of persistent and bothersome temple-related signs and masticatory oscillation, temple tenderness, ‘clicking’ symptoms of at least 3 years’ duration, and were sensation and gaze-evoked ocular pain, and an keen to have intervention. Preoperative imaging improvement in temple hollowness. Pre-existing diplopia studies, standard preoperative and postoperative in one patient resolved after surgery while two patients photographs and medical records were reviewed. developed new-onset diplopia necessitating strabismus The presence of temple-related signs/symptoms and surgery. clinical outcomes following corrective intervention Conclusions This is the first paper to show that were documented. This study was conducted in persistent, troublesome temple-related problems accordance with the Declaration of Helsinki, and following LWRS orbital decompression can be surgically was approved by the local institutional review corrected. Patients should be counselled about the boards. potential risk of these complications when considering LWRS orbital decompression. RESULTS A total of 11 orbits of six patients (five females) were included in this study; four patients were INTRODUCTION treated at QVH and the other two patients at Lateral orbital wall decompression alone has MEC. Median age was 57 years (range 23–65). become increasingly popular as the first choice of Preoperative imaging studies showed the absence of surgery for the management of proptosis in a lateral wall in all 11 orbits (figure 1). Table 1 thyroid-related orbitopathy. Current surgical arma- summarises patient demographics and their pre- To cite: Siah WF, mentarium revolves around deep lateral wall operative morbidity and table 2, the management Patel BCK, Malhotra R. Br J decompression where potential space can be of temple-related problems and clinical outcomes. Ophthalmol created to allow good orbital expansion.1 Largely, Cosmetically bothersome ipsilateral temple hol- – 2016;100:1144 1150. this can be differentiated by those that leave behind lowness was present in all 11 orbits and a

1144 Siah WF, et al. Br J Ophthalmol 2016;100:1144–1150. doi:10.1136/bjophthalmol-2015-307600 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science

DISCUSSION There is a paucity of information in the literature on the risk of temple-related complications following LWRS orbital decom- pression. In this retrospective review, we highlighted a series of patients with persistent, bothersome temple-related signs and symptoms of at least 3 years’ duration following LWRS orbital decompression carried out elsewhere. Following corrective intervention at the QVH and the MEC, respectively, all our patients’ temple-related problems were either alleviated or improved. To the best of our knowledge, this is the first case series reporting persistent, troublesome temple-related compli- cations following LWRS orbital decompression along with suc- cessful outcomes following intervention. Mehta et al6 reported a mean reduction in proptosis of 4.81 mm±1.23 (SD) following LWRS orbital decompression and did not report any temple-related complications in his retro- spective series. In contrast, Fayers et al10 conducted a retrospect- ive telephone interview on 98 patients who had undergone LWRS orbital decompression (46 patients with lateral decom- Figure 1 CT orbit showing the absence of the lateral orbital wall in a pression alone and 52 patients had decompression of the lateral subject with previous bilateral lateral wall rim-sparing orbital and 1–2 other walls) and reported the incidence of post- decompressions. operative oscillopsia to be as high as 35% (n=34 patients): 29 during chewing and in eight, on walking. It highlighted a sur- complaint in all six patients, ranging from mild to severe. prisingly high discordance of self-reported oscillopsia compared Although subject 2 only suffered from mild left temple hollow- with that recorded in documentation by the ophthalmologist. ness as the only temple-related complication, she was very Unless patients are specifically questioned about such symptoms, unhappy with the aesthetic appearance given the obvious asym- these complications may potentially be under-recognised and metry between the two sides (figure 2). Patients 2 and 5 (n=4 under-reported. Furthermore, this problem may not be easily orbits, 36%) had severe temple hollowness with a skeletonised detected on clinical examination, another reason why the appearance (figures 3A and 4, respectively). Two patients pre- surgeon may have missed it. Fayers et al10 found that mastica- sented with temple tenderness in four (36%) orbits. Evidence of tory oscillopsia resolved within 1 year in 15 patients while 16 prolapsed lacrimal gland into the wall defect and vicinity of ten- still had mild symptoms at 2 years or more and one (1%) had derness was present in all of these cases. Two patients (n=4 persistent, bothersome masticatory oscillopsia 2 years after orbits, 36%) presented with a ‘clicking’ sensation that was preci- surgery. To date, there has been no report in the literature on pitated by blinking or eye movement; one patient described this the management of patients with persistent bothersome mastica- symptom akin to a ‘leaky tap’. Four patients (n=8 orbits, 73%) tory oscillopsia after lateral orbital wall decompression. experienced persistent, bothersome masticatory oscillopsia of The bony orbital walls have a role in providing a stable and which two patients (n=4 orbits, 36%) also presented with enclosed environment for the eyeball and its adjacent structures. gaze-evoked ocular pain and temple tenderness. All four of Goldberg et al1 had previously encountered one patient who these patients required repair of the lateral wall defect with a had developed masticatory oscillopsia following a lateral wall MEDPOR implant (figure 5). At the time of the surgery, the decompression and advocate leaving a thin layer of bone over prolapsed orbital lobe of the lacrimal gland was found to be the temporalis muscle to prevent this complication. In another adherent to the temporalis muscle in one patient (subject 2). study of 18 patients who had en bloc resection of the lateral Those with residual proptosis also underwent orbital decom- wall including the rim, one patient experienced masticatory pression with four patients (n=7 orbits) having combined pos- oscillopsia, which was apparently not distressing.5 One case of terior orbital fat excision and medial wall decompression of oscillopsia during chewing or clenching of the jaw occurred in which one patient (n=2 orbits) also required additional orbital a patient who had an epidermoid cyst within the temporalis floor decompression. Following revision surgery, there was muscle that had caused extensive erosion of the temporal bone resolution of masticatory oscillation, temple tenderness, ‘click- and lateral wall.11 These cases, together with that described by ing’ sensation and gaze-evoked ocular pain in all cases. Temple Fayers et al10 and those found in this case series, all suggest hollowness improved in all cases (figure 3B). Although subject that any undue anterior fenestration of the lateral orbital wall 5 had remarkable proptosis, orbital decompression was not allows the transfer of forces from the contracting temporalis performed to prevent worsening of her skeletonised appear- muscle to the orbital tissue with a resultant masticatory ance. She had refused further surgical intervention and under- oscillopsia. went Radiesse (Merz Aesthetics, San Mateo, California, USA) The cause of temple hollowness can be multifactorial. It is a injection to the temples. Subject 2 underwent autologous common complication in coronal approach surgeries where the abdominal fat grafting to the temples to address temple hollow- anterior and lateral craniofacial skeleton had to be exposed.12 A ness (figure 3C). One patient (subject 4) developed a left direct injury to the temporalis muscle may precipitate temple orbital cellulitis that was successfully treated with intravenous hollowing.8 The temporalis muscle has a superficial temporal fat antibiotics a week following surgery. One patient (subject 1) pad (Yasargil’s fat pad)13 overlying it, and any trauma to this with pre-existing strabismus had resolution of this problem structure and its neurovascular supply may result in post- after corrective surgery while two patients (subjects 3 and 4) operative temple hollowing.12 14 Temple hollowing was evident developed new-onset, persistent diplopia necessitating strabis- in all the patients in this series, ranging from mild hollowness mus surgery. present just behind the lateral orbital rim to severe concavity of

Siah WF, et al. Br J Ophthalmol 2016;100:1144–1150. doi:10.1136/bjophthalmol-2015-307600 1145 1146 lnclscience Clinical

Table 1 Patient demographics and preoperative morbidity

Subject Age (years) Sex Orbit (N=11) Side Past orbital decompression Other ocular surgery Temple-related symptoms Temple-related signs Other symptoms Other eye findings Downloaded from

1 57 F 1 L LWRS Strabismus×2 None Temple hollowness Dry eye Proptosis (20 mm) Diplopia Blink lagophthalmos Exposure keratopathy LL retraction Restricted IR on upgaze

Visible tear trough and inferior orbital rim http://bjo.bmj.com/ 2 54 F 2, 3 R, L MW+OF* Strabismus Masticatory oscillopsia Temple hollowness None L enophthalmos LWRS Temple tenderness L hypoglobus (4 mm) ‘Clicking’ sensation R+L superior sulci hollowness Gaze-evoked ocular pain Restricted upgaze R+L Restricted R abduction 3 23 F 4, 5 R, L LWRS None Masticatory oscillopsia Temple hollowness Dry eyes Proptosis (R, L 20 mm) ihWF, Siah Temple tenderness Exposure keratopathy onAugust30,2016-Publishedby Gaze-evoked ocular pain R+L UL and LL retractions 4 64 F 6, 7 R, L LWRS R+L UL and LL Bleph. None Temple hollowness Dry eyes Proptosis (R, L 20 mm) tal et L UL levator recession Blink lagophthalmos

. Exposure keratopathy rJOphthalmol J Br R+L LL retraction R+L superior sulci hollowness Asymmetrical UL pretarsal show Restricted downgaze R+L 5 57 F 8, 9 R, L LWRS+MW+OF+intraorbital fat None Masticatory oscillopsia Temple hollowness Dry eyes Proptosis (R, L 18 mm)

2016; Exposure keratopathy R+L hypoglobus 100 R+L superior sulci hollowness

:1144 6 65 M 10, 11 R, L LWRS+MW+OF None Masticatory oscillopsia Temple hollowness Dry eyes Proptosis (R, 30 mm; L, 27.5 mm) group.bmj.com ‘Clicking’ sensation Exposure keratopathy –

10 doi:10.1136/bjophthalmol-2015-307600 1150. R+L hypoglobus Restricted eye movements (all directions) R+L UL and LL retraction Lagophthalmos *Patient previously underwent combined medial orbital wall and orbital wall decompression via an endoscopic endonasal approach for management of her dysthyroid optic neuropathy. Bleph., blepharoplasty; F, female; IR, inferior rectus; L, left; LL, lower lid; LWRS, lateral wall rim-sparing; M, male; MW, medial wall; OF, orbital floor; R, right; UL, upper lid. ihWF, Siah tal et . rJOphthalmol J Br 2016; Downloaded from

100 Table 2 Management of temple-related problems and clinical outcomes

:1144 Orbit Subject (N=11) Side Procedure Temple-related signs/symptoms Other signs/symptoms Complications Further intervention – 10 o:013/jptaml21-0601147 doi:10.1136/bjophthalmol-2015-307600 1150. 1 1 L Inferior orbital fat*+MW decompressions† Temple hollowness improved Proptosis resolved (16 mm) None UL blepharotomy Debulked fat transferred to lid–cheek junction Lagophthalmos improved LL septoretractor recession LL retractor recession+lateral horn release Diplopia resolved http://bjo.bmj.com/ 2 2, 3 R, L Repair of LW defect with 2 MEDPOR implants (0.85 mm)‡ Temple hollowness improved Sup. sulci hollowness improved None Autologous fat transfer to R +L temples Prolapsed lacrimal gland replaced into orbit Temple tenderness resolved Hypoglobus improved Masticatory oscillopsia resolved Enophthalmos unchanged ‘Clicking’ sensation resolved Gaze-evoked ocular pain resolved 3 4, 5 R, L Prolapsed lacrimal gland replaced into orbit* Temple hollowness improved Proptosis improved (R, 18 mm; L, 16.5 mm) Diplopia L Levator Botox injection§ onAugust30,2016-Publishedby LW defect repaired with a MEDPOR implant (0.85 mm)* Temple tenderness resolved Lagophthalmos improved Strabismus surgery Inferior orbital fat*+MW decompressions† Masticatory oscillopsia resolved Debulked fat transferred to lateral canthi Gaze-evoked ocular pain resolved 4 6, 7 R, L Inferior orbital fat*+MW decompressions† Temple hollowness improved Lagophthalmos improved L orbital cellulitis Strabismus surgery×3 Debulked fat transferred to L cheek Worsened diplopia LL retractor recession 5¶ 8, 9 R, L LW defect repaired with a MEDPOR implant‡ Temple hollowness improved Proptosis unchanged None Radiesse filler into temples Masticatory oscillopsia resolved Lagophthalmos unchanged Hypoglobus unchanged Sup. sulci hollowness unchanged 6 10, 11 R, L LW defect repaired with a MEDPOR implant* Temple hollowness improved Proptosis improved (R, 23 mm; L, 22 mm) None R+L cheek implants Orbital fat+posterior MW+OF decompressions Masticatory oscillopsia resolved Lagophthalmos improved R+L alloderm grafts to LL MEDPOR implant to anterior OF ‘Clicking’ sensation resolved Hypoglobus improved R+L levator recession group.bmj.com *Swinging eyelid approach. †Transcaruncular approach. ‡Lateral skin crease approach. §Transconjunctival approach. ¶Orbital decompression was not performed given the presence of ‘skeletonised’ appearance. Patient had declined fat grafting to the superior sulci to improve hollowness and lagophthalmos. L, left; LL, lower lid; LW, lateral wall; MW, medial wall; OF, orbital floor; R, right; Sup., superior; UL, upper lid. lnclscience Clinical Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science

Figure 4 Preoperative photograph of subject 5. Note the skeletonised appearance (temple hollowness and deep superior sulci) and associated hypoglobus.

technique where the temporalis muscle was injured during inci- sion and cautery application. Following this finding, they had Figure 2 Preoperative photograph of subject 1 demonstrating mild avoided any cautery to the temporalis muscle and would left temporal hollowness (A); CT orbit showing corresponding left reattach the muscle to the periosteum of the orbital rim hence lateral orbital wall defect (B). eliminating the occurrence of further cases of temple hollowing. Fichter et al5 had one patient out of a series of 18 patients (30 the temporal fossa. Chang et al8 reported the findings of post- orbits), who had bothersome temple hollowing following an en operative temple hollowing in the early series of their patients bloc resection of the lateral orbital wall at 6 months postopera- who had undergone LWRS orbital decompression via a temporal tively. In contrast, Mehta et al6 did not have any case of temple fossa approach. This outcome can be explained by the surgical hollowing in their series of 21 orbits that had undergone LWRS orbital decompression. In their surgical technique, they would mobilise and reflect the periosteum-temporalis muscle as a flap to minimise damage to the muscle and future temple hollowing. The average postoperative follow-up was short at 11.8 months (range 9–12 months) and the authors did comment that the occurrence of temple hollowing, if any, is only apparent in the long term. Currently, the occurrence of temple hollowness as an undesirable aesthetic outcome following orbital decompression is under-reported. Lateral wall decompression is highly successful in addressing proptosis whether performed in isolation,6 carried out as a 3-wall decompression15 or when combined with intraorbital fat debulking.16 17 There is good evidence to support a lateral wall only decompression. Goldberg et al16 had shown a lower incidence of postoperative diplopia in an isolated lateral wall decompression compared with combination medial and lateral wall decompressions (resolution of pre-existing strabismus, 60% vs 25%; new-onset persistent postoperative strabismus, 7% vs 33%). Furthermore, a lateral wall only decompression avoids the need to violate the sinuses. However, if a significant retroplacement of the globe is necessary, instead of performing an over-aggressive removal of the deep lateral wall and risk the development of temple-related problems, a safer approach is to perform balanced lateral/medial wall decompression but with a compromise of higher postoperative diplopia risk. Additional retroplacement of the globe can be achieved by combining the latter approach with intraorbital fat decompression.18 Stereotactic-guided navigation has been shown to be an asset in achieving safe and effective decompression of the deep lateral wall but is currently limited by its cost and availability.19 20 Figure 3 Preoperative photograph of subject 2 showing skeletonised appearance (temple hollowness and deep superior sulci), hypoglobus LWRS orbital decompression is becoming popular in the man- and left enophthalmos (A); 4 months after repair of the lateral wall agement of proptosis in thyroid-related orbitopathy but the defect with MEDPOR implant (note the improvement in temple associated morbidity is under-represented. An ophthalmologist hollowness, right>left) (B); 1 week after autologous fat transfer to the should carefully tailor the choice of surgical approach to each periorbital region (note the improvement in temple hollowness) (C). individual and be mindful of all aspects, including aesthetics

1148 Siah WF, et al. Br J Ophthalmol 2016;100:1144–1150. doi:10.1136/bjophthalmol-2015-307600 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science

Figure 5 Prolapsed orbital lobe of the lacrimal gland (small arrow) and orbital fat (large arrow) through the lateral wall defect (A); lacrimal gland and orbital fat were separated from the temporalis muscle and replaced into the orbit (B and C); insertion of MEDPOR implant to repair lateral wall defect (D). outcomes, when planning the surgery. The temporalis muscle reviewed and revised the manuscript and gave final approval of the version to be should not be disrupted via the external approach especially in published. female patients as this could lead to aesthetically unacceptable Competing interests None declared. temple hollowing. We recommend leaving a thin rim of lateral Patient consent Obtained. wall behind and to refrain from disturbing the anatomy of the Ethics approval Institutional review board. temporalis muscle. In our experience, both senior authors (RM Provenance and peer review Not commissioned; externally peer reviewed. and BCKP) perform lateral orbital wall decompression via an intraorbital approach with no disruption of the peripheral peri- osteal attachments of the temporalis fascia in combination with orbital fat decompression, and, when indicated further bony REFERENCES 1 Goldberg RA, Kim AJ, Kerivan KM. The lacrimal keyhole, orbital door jamb, and decompression for the last 12 and 15 years, respectively, with basin of the inferior orbital fissure. Three areas of deep bone in the lateral orbit. no incidence of oscillopsia or temple hollowing. Arch Ophthalmol 1998;116:1618–24. We acknowledge that this case series has some limitations in 2 Unal M, Ileri F, Konuk O, et al. Balanced orbital decompression in Graves’ that our observations were retrospective in nature and the orbitopathy: Upper eyelid crease incision for extended lateral wall decompression. – number of cases was small. In contrast, all the patients in this Orbit 2000;19:109 17. 3 Vaseghi M, Tarin TT, Levin PS, et al. Minimally invasive orbital decompression for series had undergone LWRS orbital decompression via the exter- Graves’ ophthalmopathy. Ann Otol Rhinol Laryngol 2003;112:57–62. nal approach, which is traumatic to the anatomical integrity of 4 Graham SM, Brown CL, Carter KD, et al. Medial and lateral orbital wall surgery the temporalis muscle including its superficial temporal fat pad for balanced decompression in thyroid eye disease. Laryngoscope 2003;113: and neurovascular supply. This case series is not a representation 1206–9. 5 Fichter N, Krentz H, Guthoff RF. Functional and esthetic outcome after bony lateral of the true incidence of temple-related complications. Instead, wall decompression with orbital rim removal and additional fat resection in graves’ this is a skewed series of patients seeking intervention for their orbitopathy with regard to the configuration of the lateral canthal region. Orbit persistent, troublesome temple-related problems. 2013;32:239–46. This is the first paper to report on the management of this 6 Mehta P, Durrani OM. Outcome of deep lateral wall rim-sparing orbital debilitating complication of lateral orbital wall decompression. decompression in thyroid-associated orbitopathy: a new technique and results of a case series. Orbit 2011;30:265–8. The modern orbital surgeons need to be vigilant and recognise 7 Paridaens DA, Verhoeff K, Bouwens D, et al. Transconjunctival orbital these potential complications and to counsel patients prior to decompression in Graves’ ophthalmopathy: lateral wall approach ab interno. LWRS orbital decompression surgery. Where there is pre- Br J Ophthalmol 2000;84:775–81. existing temple hollowness, patients should be made aware of 8 Chang EL, Piva AP. Temporal fossa orbital decompression for treatment of disfiguring thyroid-related orbitopathy. Ophthalmology 2008;115:1613–19. the potential worsening of the problem and to involve them in 9 Koornneef L, Mourits M. Orbital decompression: for decreased visual acuity or for the decision-making of the surgery. Though rare, we report that cosmetic reasons. Orbit 1988;7:225–38. these temple-related complications can be successfully managed 10 Fayers T, Barker LE, Verity DH, et al. Oscillopsia after lateral wall orbital with corrective intervention. decompression. Ophthalmology 2013;120:1920–3. 11 Knight RT, St John JN, Nakada T. Chewing oscillopsia. A case of voluntary visual illusions of movement. Arch Neurol 1984;41:95–6. Contributors WFS, BCKP and RM contributed to the conception and design of the 12 Matic DB, Kim S. Temporal hollowing following coronal incision: a prospective, work. All the authors were involved in the acquisition of data. All the authors randomized, controlled trial. Plast Reconstr Surg 2008;121:379e–85e.

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1150 Siah WF, et al. Br J Ophthalmol 2016;100:1144–1150. doi:10.1136/bjophthalmol-2015-307600 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com

Surgical management of temple-related problems following lateral wall rim-sparing orbital decompression for thyroid-related orbitopathy We Fong Siah, Bhupendra CK Patel and Raman Malhotra

Br J Ophthalmol 2016 100: 1144-1150 originally published online November 13, 2015 doi: 10.1136/bjophthalmol-2015-307600

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