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Surgical Management of Temple-Related Problems Following 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
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