• Indications for surgery:
• Were primarily optic neuropathy and corneal exposure for many years, and these are still common indications for orbital decompression
• In the 1990s, focus shifted toward cosmetic restoration and improvement (Lyons, Ophthalmology 1994).
• Currently indications are broad, graded, and individualized (Kikkawa, Ophthalmology 2002).
• If indicated, decompression is performed first, before other surgeries such as strabismus, and correction of eyelid retraction (Shorr, Ophthalmology 1986).
• There are 5 areas where orbital decompression can be achieved:
• Fat compartment
• Floor
• Medial wall
• Lateral wall (including body of the zygoma)
• Roof

• Described by Olivari in early 1990s, also by Trokel and Kazim (Trokel, Ophthalmology 1993)
• Used as primary and adjunctive technique
• Conceptually, procedure intended to remove fat from the orbit, decreasing orbital pressure and apical compression while also reducing proptosis
• Fat compartment can be approached transconjunctivally or transcutaneously
• Intraconal and/or extraconal removed

Incisions

• Transcutaneous
• Upper eyelid: blepharoplasty incision, +/- skin removal
• Lower eyelid: blepharoplasty incision, subciliary with myocutaneous flap
• Pass through orbicularis
• Remove fat from the preaponeurotic plane
• Dissection further between superior oblique and medial rectus for intraconal fat
• Laterally, retrolacrimal fatty tissue also removed
• Transconjunctival typically for the lower quadrants of the orbit.
• Swinging eyelid or closed canthal incisions have been described

Fat removal

Compartments

• Orbital fat divided into intraconal and extraconal compartments
• Some dispute importance of this distinction (Prat OPRS 2015)
• Original technique by Olivari:
• Resection of all extraconal fat + some intraconal fat in the inferolateral region with total fat volume removed in the range of 5.5–6.5 cc (Richter, Plast Reconstr Surg 2007)
• Surgeons can be reluctant to remove all extraconal fat, and cosmesis can be improved with preservation of some anterior orbital fat in the area of the central lower eyelid
• Techniques attempting to focus more on intraconal fat typically remove less: range of 3.5–4.5 cc (Liao, AJO 2011, Wu AJO 2008, Prat OPRS 2015, Kazim BJO 2000)

Quadrants

• Fat not distributed equally:
• Greater volume inferiorly, particularly lateral
• Most fat excision described in inferior orbit, laterally greater than medially (Prat, OPRS 2015; Richter, Plast Reconstr Surg 2007; Ben Simon, Arch Ophth 2005)
• Some described
• Superolateral: lacrimal nerve and artery can be encountered in this region
• Superomedial: less volume is typically resected and ethmoidal and supratrochlear neurovascular structures are carefully avoided.
• Inferiorly, are fewer critical structures, making surgery theoretically safer
• No comparisons of complication rates with different approaches

Proptosis reduction

• Proptosis reduction: range of 3.5–5.9 mm
• Generally good linear correlation (Pearson's r of 0.4–0.5) between volume of fat resection and proptosis reduction (Liao AJO 2011; Prat OPRS 2015)
• Subtypes:
• Proptosis reduction is similar in orbits with predominantly fat expansion or predominantly muscle enlargement (Prat OPRS 2015)
• Inferomedial wall adjunctive decompression not found to add significantly to proptosis reduction (Chang, Graefe's 2013)

Intraoperative and early postop complications

• Many suggest control of intra-operative bleeding is vital
• Accomplished via bipolar cautery or "Clamp-cut-cautery" (Li, Internat Ophthalmol 2014) or other techniques
• Suction excision techniques with very little cautery under local anesthesia have also been described (Ben Simon, Arch Ophthalmol 2005)
• Early postoperative complications uncommon (Richter, Plast Reconstr Surg 2007):
• Infection (< 1%)
• Hemorrhage (< 1%)
• Avoid critical structures anteriorly such as:
• Lacrimal nerve
• Supraorbital nerve
• Inferior oblique
• Apical fat:
• Some suggest excising
• Others suggest avoiding due to risk of morbidity and vision loss (Frankel, Plast Reconstr Surg 2008)

Postoperative complications: diplopia and strabismus

• New onset diplopia: range of 15%–25% (Richter, Plast Reconstr Surg 2007; Stark, Eur J Plast Surg 1996; Chiarelli, J Plast Reconstr Aesth Surg 2010)
• Some reports lower: 0$–3% (Wu, AJO 2008; Prat OPRS 2015; Chang, Graefe's 2013, Li, Internat Ophthalmol 2014)
• Improvement has been noted
• Rates variable: some authors suggest up to a 90% resolution of diplopia in primary position (Richter, Plast Reconstr Surg 2007)
• More modest estimates by other groups: range of 20%–30% (Wu, AJO 2008; Prat OPRS 2015)
• Late complications can be partially related to technique
• Olivari's group report elevated incidence of supraorbital anesthesia at 1.5%–6%
• This might be reduced by avoiding superomedial dissection
• Transcutaneous approaches with extraconal fat removal associated with eyelid retraction or ectropion (Chiarelli, J Plast Reconstr Aesth Surg 2010)

• Many techniques
• Few, if any, of these reports considered level 1 or 2 evidence (Boboridis, Cochrane Collaboration 2011)
• Thus can summarize techniques, rather than compare in most cases
• 4 bony walls can be decompressed corresponding to the 4 walls of the orbit:
• Floor
• Medial wall
• Lateral wall
• Roof
• Virtually all have all been described individually and in combination

• Floor is rarely decompressed in isolation: usually combined with medial wall as inferomedial decompression
• Approaches to floor and medial wall similar and are grouped together for discussion

Incisions and approaches

Transcutaneous lower eyelid incision

• Two options after skin incision:
• Skin-muscle flap:
• Orbicularis is traversed below the lid margin (typically leaving 2–3 mm of pretarsal orbicularis inferior to skin incision)
• Septum then followed to orbital rim and opened at arcus marginalis
• Skin flap:
• Faise skin flap below incision to the level of the orbital rim
• Then incise orbicularis and the septum together at rim
• Skin flap approach noted to have higher incidence of ectropion relative to skin-muscle approach, thus latter is preferred (Pospisil, Br J Oral Maxillofac Surg 1984)
• Other transcutaneous options (Bahr, Plast Reconstr Surg 1992; Holtmann, Plast Reconstr Surg 1981; Wray, Br J Plast Surg 1977):
• Direct approach: incision over orbital rim through skin, orbicularis, and septum simultaneously
• Mid eyelid or subtarsal approach:
• Incision of skin and orbicularis below the tarsus
• Follow the orbital septum to rim, and enter orbit there
• Scars more notable than subciliary, thus subciliary the preferred transcutaneous approach

Transconjunctival incision

• Incision on palpebral conjunctival surface of lower eyelid below tarsus
• Incision can vary in placement: some suggest higher incision at 3–4 mm below the tarsus (Barkhuysen, J Craniomaxillofac Surg 2009; O'Malley OPRS 2008), some suggest lower in the fornix (McCord, Ophthalmology 1981)
• Selection of incision position can be related to plane of approach:
• Superior incision typically access to the preseptal plane (Tessier, J Maxillofac Surg 1973)
• Preseptal requires entry to orbit at inferior rim, through arcus marginalis and orbital septum
• Inferior incision typically access to the postseptal plane (Converse, Plast Reconstr Surg 1973)
• Postseptal enters orbit directly, carrying dissection between orbital fat and septum
• Not much literature comparing efficacy and safety of these two planes and choice is based on surgeon preference
• Both can be performed without opening lateral canthus
• If canthus opened: "swinging eyelid" (McCord, Ophthalmology 1981)
• Might increase exposure to the floor and inferolateral wall

Comparisons of transcutaneous and transconjunctival incisions are typically in reference to orbital floor fracture repair, but can be considered:

• Retroseptal transconjunctival and subciliary skin flap:
• Found incidence of ectropion higher with subciliary (Wray, Br J Plast Surg 1977)
• Comparison of preseptal transconjunctival and subciliary skin-muscle flap approaches:
• Incidence of transient ectropion higher in subciliary group at 12% relative to 0% in transconjunctival (Appling, Arch Otolaryngol Head Neck Surg 1993)
• They also noted > 1 mm of scleral show at 3 months in 28% of transcutaneous and 3% of transconjunctival cases
• Meta-analysis of pooled transconjunctival, subciliary and mid eyelid (Ridgway, Plast Reconstr Surg 2009):
• Highest incidence of
• Ectropion in subciliary (14%)
• Entropion in transconjunctival (0.7%)
• Hypertrophic scars in mid eyelid (3.4%)
• Photographic analysis in post fracture patients of transcutaneous versus transconjunctival:
• Incidence of lower eyelid retraction significantly greater with transcutaneous approach, independent of fracture type (Raschke, Clin Oral Invest 2013)
• Transorbital medial wall

Transcutaneous medial canthus incision

(Lynch, Laryngoscope 1921)

• Incision midway between the medial canthus and the nasal bridge
• Periosteum exposed and subperiosteal plane developed
• Might involve disinsertion of the trochlea, cauterization of the ethmoidal bundles and/or reflection of medial canthal tendon and the lacrimal sac
• Scar and webbing can occur and thus not performed widely today; Z-plasty can be used to repair (Esclamado, Laryngoscope 1989)

Coronal incision

(Mourits, Ophthalmology 1990)

• Extended post-hairline incision over course of scalp and developing complex flap to expose orbit
• Supraorbital nerve freed
• Ethmoidal neurovascular bundles cauterized
• Morbidity of this approach is significant (Baldeschi, Orbit 2010):
• Frontal bossing
• Skin necrosis
• Alopecia
• Anesthesia
• Effective direct approaches are common (Cruz, OPRS 2003) thus coronal decompression is rarely performed today

Transcaruncular incision

(Perry, OPRS 2003)

• Initial incision is usually between the caruncle and plica semilunaris
• Incision carried inferiorly and superiorly to the mid orbit
• Can be combined with transconjunctival or swinging eyelid for access to the floor and inferolateral wall (Shorr, Ophthalmology 2000)
• Posterior to caruncle dissection follows plane between Horner's muscle and the orbital septum
• Access to posterior lacrimal crest and medial orbit
• Avoid damage to the lacrimal sac by direct visualization

Transantral incision via superior gingival sulcus

As described by Ogura and Walsh (Ogura, Laryngoscope 1962):

• Access maxillary sinus via Calwell-Luc antrostomy.
• Incision made in buccogingival sulcus above the canine fossa
• Leave cuff of tissue above gingiva to suture closed
• Periosteum elevated to infraorbital nerve
• Maxillary sinus entered and osteotomy enlarged
• Position of entry into maxillary sinus selected to avoid infraorbital and superior alveolar nerves
• Suggest making antrostomy in the mid-pupillary line at the floor of the nasal vestibule (Robinson, Laryngosocpe 2005)
• Mucosa stripped as necessary from the roof of the sinus
• Ethmoid air cells can be removed medial to the orbit, exposing the medial orbital wall which can then be removed, together with the floor of the orbit medial to the infraorbital nerve (often with Takahashi and Kerrison rongeurs)
• Removal of the medial wall and floor might result in loss of the orbital strut, with increased risk of consecutive diplopia
• Does not produce an external scar
• Complications:
• Paresthesias and anesthesia in almost all patients immediately postoperatively (Weisman, Arch Otolarynol 1994)
• Long-term anesthesia close to 10%
• Oroantral and gingivolabial fistula (about 1% each)
• Devitalized teeth 0.5% of cases (DeFreitas, Laryngoscope 1988)

Transnasal endoscopic incisions

• Endoscopic decompression pioneered in the early 1990s (Kennedy, Archives of otolaryngology--head & neck surgery 1990)
• Variable technique, with general elements:
• Entry into anterior ethmoidal air cell via, classically, an uncinectomy and excision of ethmoid bullae (Kennedy, Arch Otolaryngol 1985)
• Dissection proceeds posteriorly or can be posterior to anterior
• Medial wall of orbit is identified
• Remaining septae removed to anterior wall of sphenoid sinus
• Key anatomic features to be aware of:
• Anterior and posterior ethmoidal neurovascular bundles (Han, Annals Oto Rhino Laryngol 2008)
• Enter nose laterally at the frontoethmoidal suture.
• Anterior ethmoidal in region of the basal lamella of the middle turbinate
• Posterior complex immediately anterior to anterior wall of the sphenoid sinus
• Intraoperative control of bleeding in endoscopic surgery:
• Pledgets soaked in vasoconstricting substances (e.g., oxymetazoline)
• Gentle cautery
• Rarely, major vessel might require endovascular embolization (Isenberg, Otolaryngol Head Neck Surg 1994)
• Topical hemostatic agents: active and passive
• Active: activate biologic clotting system and help form new clots (Gabay, Pharmacotherapy 2013)
• EVICEL Fibrin Sealant (Ethicon, Cincinnati, Ohio)
• TISSEEL (Baxter International Inc., Deerfield, IL)
• Passive: provide template for platelet aggregation and activation (Emilia, Transfus Apheresis Sci 2011)
• Collagen: surgiflo (Ethicon US, LLC) and floseal (Baxter Healthcare Corporation)
• Gelatin: gelfoam (Pfizer Inc) and surgifoam (Ethicon US, LLC)
• Cellulose: surgicel (Ethicon US, LLC)
• Structures to be aware of:
• Basal lamella of the middle turbinate: disinsertion can destabilize the turbinate and exposes internal maxillary vessels
• Fovea ethmoidalis and skull base
• Potential complications:
• Skull base and orbit:
• Orbit:
• Damage to the recti, intraorbital hemorrhage and vision loss are critical complications (Dutton, OPRS 1986)
• Lacrimal sac might be damaged as well (Seiff, AJO 1988)
• Skull base:
• Perforation into cranial cavity superiorly along the low-lying fovea ethmoidalis and cribriform plate can lead to catastrophic complications (Manigilia, Laryngoscope 1981; McCormick, OPRS 2004)
• Small dural leaks can be patched with a number of substances including nasal mucosa, temporalis fascia, fat, muscle, and acellular dermal grafts
• Sphenoid sinus:
• Injury to carotid artery
• Requires immediate control of hemorrhage and rapid transfer for angiographic balloon occlusion (Isenberg, Otolaryngol Head Neck Surg 1994)
• Anatomical knowledge vital, intra-operative image guidance can be useful in preventing problems (Dubin, Annals Oto Rhino Laryngol 2008)

Comparison of incisions and approaches to the medial wall and floor

• Orbital decompression efficacy primarily related to the bone or fat resection:
• Irrespective of incision or approach
• Morbidities can be related to incisions and approaches
• Two studies investigating coronal vs direct approaches to medial wall and floor:
• Gorman et al. compared 10 transantral to 9 transfrontal
• Increased hospitalization, requirement for head shaving and large scar disadvantages of transfrontal
• Lip anesthsia and contraindication in sinusitis disadvantages of transantral (Gorman, NEJM 1974)
• Cruz et al. compared 49 transconjunctival cases with 45 coronal cases
• Morbidity of coronal as per Gorman + described 1 case of vision loss
• Anesthesia of infraorbital nerve noted in transorbital + 1 case of eyelid retraction
• Conclusion was that a coronal flap is unnecessary in most cases (Cruz, OPRS 2003)
• Review papers suggest that coronal approach can involve unique complications (Baldeschi, Orbit 2010; Mourits, BJO 2009):
• Dysesthesia
• Bossing
• Temporalis paralysis
• Flap necrosis
• As compared to periorbital that might have complications related to eyelid malpositions
• Few groups report persistent use of the coronal approach the inferomedial orbit
• Direct comparisons between transorbital, transantral and/or transnasal approaches are uncommon
• Systematic review by Leong et al. (Leong, Laryngoscope 2009), found these rates of complications:
• Transantral 15.6%
• Transnasal 5.2%
• Transorbital:
• Transconjunctival 4.2%
• Transcaruncular 5.8%
• Transcutaneous 12.8%
• Types and severity of the complications are not reported
• It's difficult to draw firm conclusions from data, however, there is a suggestion that transconjunctival/caruncular approaches perform similarly to endonasal, whereas transantral, transcutaneous and coronal might have higher rates of incision-related complications.

Bone removal strategies

Orbital floor

• Any of the above-described approaches provide access to floor and medial wall
• The extent of bone removal varies widely in the literature, as does the treatment of the periosteum, orbital fat and adjacent neurovascular bundles
• Original descriptions floor decompression involve removal of entire floor:
• Posterior to anterior
• Medial and lateral to the infraorbital nerve
• Some cases nerve removed (Moran, Plast Reconstr Surg 1972)
• Modifications later adopted to reduce hypoglobus, strabismus, and numbness:
• Bone removed only medial to the infraorbital nerve
• Anteriorly some suggest leaving 10 mm of bone under globe to prevent hypoglobus or not opening the periorbita (Mainville, OPRS 2014)

Medial orbital wall

Many variations in removal of lamina papyracea have been described:

• Anterior extent:
• Maximal anterior extent is typically the posterior lacrimal crest
• Some described mobilizing lacrimal sac and dissecting anterior to this (Weisman, Arch Otolaryngol 1994)
• Others suggest not to extend anteriorly beyond anterior ethmoidal foramen (Goldberg, Expert Techniques 2015)
• Posterior extent:
• Typically to anterior wall of sphenoid sinus
• Can extend as far as optic canal, some describe canal decompression as part of surgery for dysthyroid optic neuropathy (DON) (Schaefer, Laryngoscope 2003)
• Evidence is not compelling that this is necessary for effective surgical treatment of DON
• In some cases, anterior wall of sphenoid might extend anteriorly and require removal for decompression to annulus of zinn (Gormley, Eye 1997)
• Superior extent:
• Most describe dissection to frontoethmoidal suture.
• At this level, inadvertent entry into cranial cavity through fovea ethmoidalis has been reported (Badilla, Orbit 2008; McCormick, OPRS 2004)
• Ethmoidal neurovascular bundles serve as landmarks for this position
• Inferior extent
• Inferomedial orbital strut separates medial and inferior wall
• Authors have argued for removing this strut in maximal decompression (McCord, Ophthalmology 1981)
• Others suggest leaving the strut to avoid hypoglobus and diplopia (Goldberg, OPRS 1992; Wright, J Otolaryngol 1999)
• Inferomedial posterior:
• Orbital process of palatine bone
• Removal allows for connection of inferior and medial dissections
• Some suggest important in decompression for DON (Goldberg, Expert Techniques 2015)
• Superomedial posterior nasal cavity:
• About 11%–18% of people will have an Onodi cell (Meloni, Surg Rad Anat 1992; Arslan, Auris Nasus Larynx 1999)
• Might be > 50% in Asian populations (Thanaviratananich, Ear Nose Throat J 2003)
• Posterior projection of posterior ethmoid along superiomedial orbital wall and into sphenoid sinus
• Typically abut the optic nerve in this position
• Can extend into orbital apex and can cause apex syndrome when inflamed (Chee, Orbit 2009)
• Decompression for DON might require removal of Onodi cells in some cases
• Preoperative analysis of imaging studies can be helpful

Management of periosteum

• Periosteum will minimize prolapse of tissue after decompression unless opened (Harvey, OPRS 1989).
• Many variations in opening:
• Some suggest opening completely (Perry, OPRS 2003).
• Others suggest cross-hatching (Ogura, J Laryngol Otol 1978) or linear incisions (Platt, Facial Plast Surg 2009).
• Extensive opening of periosteum has been associated with greater rates of postoperative strabismus (Mainville, OPRS 2014).
• Modifications proposed to decrease diplopia:
• Inferiorly: Leave a cuff of periosteum under globe (Seiff, OPRS 2000) or under the inferior rectus (Leone, Arch Ophthalmol 1980).
• Medially: Leave a strip of periosteum medial to the medial rectus (Metson, Laryngoscope 2002).

Management of neurovascular bundles

• Infraorbital nerve options:
• Remove bone only medial to the nerve (most common) (Baylis, Ophthalmology 1980)
• Skeletonize nerve and leave as a hammock (Leone, Arch Ophthalmol 1980)
• Leave bony canal and dissect on either side (Hurwitz, Arch Ophthalmol 1985)
• Can be removed, but will cause significant permanent anesthesia and rarely performed
• Ethmoidal neurovascular bundles:
• Cauterize and clip one or both (Chang, Plast Reconstr Surg 2003)
• Leave both undisturbed (Hurwitz, Arch Ophthalmol 1985)

Proptosis reduction

• Floor alone:
• Average proptosis reduction about 4 mm (Leone, Arch Ophthalmol 1980)
• Inferomedial alone:
• Widely variable effect, dependent on the extent of bony removal, management of the periosteum and adjunctive fat decompression
• Methodological variability makes direct comparison difficult
• Transantral and transorbital: pooled data from multiple centers (Mourits, BJO 2009) and meta-analysis (Leong, Laryngoscope 2009; Borumandi, BJO 2011) suggest:
• Proptosis reduction: 4–5 mm
• Transnasal endoscopic suggest slightly less:
• Proptosis reduction: about 3.5 mm (Mourits, BJO 2009; Leong, Laryngoscope 2009)

Complications: diplopia and strabismus

• Transantral approach:
• Garrity et al. (n = 428) (Garrity, AJO 1993) removed bone medial to infraorbital nerve with crosshatching of the periobita.
• Reported new onset diplopia in 62% of patients
• Other results included mean proptosis reduction: 4.7 mm and improvement or resolution of optic nerve edema and visual field defects in 94% and 91% of patients respectively
• Other studies of transantral technique report similar rates of new onset or worsening diplopia: in the range of 45% to 75% (Tallstedt, Acta Ophthalmol Scand 2000; Fatourechi, Ophthalmology 1994; Warren, Laryngoscope 1989)
• Transnasal and transorbital approaches:
• New onset and worsening diplopia typically less common than transantral
• Many studies with varying technique describe rates in range of 10%–35%.
• Reviewed extensively in multiple publications (Paridaens, Eye 2006; Borumandi, BJO 2011; Leong, Laryngoscope 2009)
• Modifications of transorbital and transnasal proposed to reduce diplopia:
• Bone: some suggest leaving the inferomedial strut intact and thereby reduce globe dystopia (Goldberg, OPRS 1992) and diplopia (Jordan, OPRS 2000; Wright, J Otolaryngol 1999).
• Periosteum:
• No opening of periosteum: no new onset diplopia in a small series (Harvey, OPRS 1989)
• Leave 10–15 mm of periobita intact along floor: no new onset diplopia in a small series (Seiff, OPRS 2000)
• Longitudinal slit versus periosteal excision might reduce new-onset diplopia (May, Otorhinolaryngology 2001).
• Selective periosteal sling over medial rectus also reported to reduce new onset diplopia (Jimenez-Chobillon, Eur Ann Otorhinolaryngol 2010)
• However, note that decreasing periosteal release might lessen proptosis reduction effect.
• Balance competing priorities of diplopia prevention and proptosis reduction.
• Although not a surgical technique issue, it is noteworthy that patients with preoperative motility restriction ("type II" patients) might be more likely to develop new onset or worsening diplopia after decompression (Nunery OPRS 1997) regardless of technique.

Other complications

Complications (uncommon, < 1%) include

• CSF leak
• Epistaxis
• Eyelid and conjunctival swelling
• Sensory anesthesia
• Orbital hemorrhage
• Infection
• Sinusitis
• Vision loss is rare (Garrity, AJO 1993)

Incisions and approaches

• Kronlein credited with first direct approach to lateral orbit in 1889 using a large curvilinear incision convexly running towards lateral canthus from hairline to level of tragus
• Modified by Stallard and Wright who described incision running through eyebrow, laterally into the crow's feet (Stallard, Trans Ophth UK 1973)
• Berke in 1953 (Berke, Trans Am Ophth Soc 1953) described access via canthal splitting lateral linear incision
• Coronal flap might be attributed to Bonavolonta in 1982 (Stewart, Arch Ophthalmol 1988)
• Lateral eyelid crease gained popularity in 1990s (Harris OPRS 1999) and widely utilized today
• All provide access and differ mostly in esthetic implications

Management of lateral orbital rim

• For access to the lateral wall, some advocate marginotomy (subtotal removal of the orbital rim) while others do not
• One study (n = 47 orbits) compared deep lateral decompression with and without marginotomy (Kakizaki, Clin Ophthalmol 2011)
• Found decompression with marginotomy led to significantly greater proptosis reduction at 5.7 mm as compared to without marginotomy achieving 4.1 mm.
• Some advocate management of the lateral rim as a primary strategy for decompression.
• Techniques described:
• Advancement of orbital rim laterally (Wulc, Ophthalmology 1990; Gilliland OPRS 2007)
• Advancement of orbital rim superolaterally (Elisevich, J Neurosurg 1994)
• Advancement of the entire orbital aperture en block (De Ponte, J Craniofac Surg 1998)
• Flaring of the lateral rim laterally (Thaller, Plast Reconstr Surg 1990)
• En bloc removal of lateral rim (Fichter, Int J Endocrinol 2015)
• En bloc removal of lateral rim and the body of zygoma (Schaaf, J Craniomaxillofac Surg 2010)
• Specific complications:
• Widening of the intrapupillary distance (Fichter, Orbit 2013)
• Temporal wasting (Fichter, Int J Endocrinol 2015)

Bone removal strategies

• A wide range of bony decompression strategies used in lateral orbit
• The lateral orbital rim originally removed en block by Dollinger in 1911, (Dtsch Med Wschr 1911) became popular in the 1950s
• Deeper bone of sphenoid originally removed via neurosurgical approach by Naffziger in 1930s (Naffziger, Ann Surg 1931 and 1938)
• The transorbital ab interno approach to deeper bone of sphenoid popularized later (Goldberg, Arch Ophthalmol 1998)
• Transorbital deep lateral decompression without marginotomy ab interno (Rootman, Orbital Surgery 2014; Goldberg, Expert Techniques 2015):
• Expose periosteum of lateral orbital rim and incise periosteum parallel to axis of the orbit.
• Elevate subperiosteal plane posteriorly to expose tip of the inferior and superior orbital fissures
• High-speed burr reduction of orbital rim around lacrimal fossa (to improve visualization and instrumentation access) and area anterior and superior to tip of inferior orbital fissure:
• Enter diploe in greater wing of sphenoid and follow superiorly to superior orbital fissure.
• Pocket of thick bone extending from tip of superior orbital fissure to frontozygomatic suture can be removed.
• Part of this might involve sections of zygomatic and/or frontal bone (Goldberg, Arch Ophthalmol 1998).
• Transorbital deep lateral decompression with marginotomy:
• With removal of lateral orbital rim (Kennerdell, Ophthalmology 1982)
• With creation of lateral orbital window as attributed to Rose (Mehta, Orbit 2011)
• Orbital rim is exposed; periorbita and temporalis are reflected medially and laterally.
• Marginotomy or window created
• Anterior portion of lateral wall exposed and removed with bony rongeur
• Diploic space of sphenoid is exposed en face
• Can then be excised with a high-speed drill or rongeurs
• Transorbital deep lateral decompression ab externo:
• Access through temporalis fossa, without a marginotomy
• Lateral orbital rim exposed
• Dissection into temporalis fossa with disinsertion of muscle
• Small amount of lateral rim can be burred to gain better access
• Groove created in greater wing of sphenoid exposing diploic space until dura of temporal cranial fossa observed
• The diploe removed from lateral side
• Thin bone overriding orbit over temporalis fossa removed from posterior margin of dura anteriorly to lateral orbital rim (Wirtschafter, Arch Ophthalmol 1988)
• This approach has been reported to produce on average 4.5 mm of proptosis reduction (Chang, Ophthalmology 2008)
• Transorbital deep lateral decompression via conjunctiva:
• Swinging eyelid incision
• Lateral wall visualized in subperiosteal plane
• Zygomaticofacial and zygomatictemporal neurovascular bundles cauterized
• Osteotome to create opening in the lateral wall
• Rongeurs applied to the bone, tracking superiorly and posteriorly to remove bone of deep sphenoid.
• This approach has been reported to achieve 5.5 mm of proptosis reduction (Paridaens, BJO 2000)
• Transorbital anterolateral decompression via conjunctiva:
• Transconjunctival incision without lateral canthotomy
• Lateral wall visualized in subperiosteal plane
• Currette or burr removal of thick portion of zygoma
• Lateral maxillary sinus unroofed
• This approach has been reported to achieve about 2.5 mm of proptosis reduction (also including fat decompression) (Ben Simon, Arch Ophthalmol 2005)
• Any of these dissections can be aided by stereotactic navigation, although no difference in the outcome has been noted (Millar, Eye 2009; Nguyen, OPRS 2014; Chu, Otolaryngol Head Neck 2009)

Proptosis reduction

• Deep lateral decompression ab interno without marginotomy:
• On average between 2.7 mm and 4.0 mm of proptosis reduction from multiple studies as quoted
• Via eyelid crease, coronal, swinging eyelid, or lateral canthal incisions
• Addition of fat removal might improve decompressive effect, closer to 4.5 mm (Sellari-Franceschini, Int J Oral Maxillofac Surg 2010).
• It has also been suggested that removing rim might improve decompression by about 1.5 mm (Kakizaki, Clin Ophthalmol 2011).
• Deep lateral decompression ab externo:
• Similar results, proptosis reduction about 4–4.5 mm (Korinth, Acta Neurochirurgica 2002)
• One study compared ab externo (sonopet) and ab interno (drill):
• Proptosis reduction same; both close to 4.0 mm (Cho, OPRS 2010).
• Transorbital lateral decompression without deep bone removal:
• Removal of lateral wall overriding temporalis muscle
• Reports typically involve multiple wall decompression and it is difficult to assess the relative proptosis reduction in these techniques.
• One study involving 3‑wall decompression suggested on average 2.3 mm of proptosis reduction effect is derived from deep lateral wall component (Baldeschi, AJO 2005).

Intraoperative complications

• Small CSF leaks: 3%–7% of cases
• Typically self-limited, can be managed with bone wax, middle turbinate flap (Nadeau, J Otolaryngol 2005), dural patching (Chang, Ophthalmology 2008), tissue glue, or by packing orbital fat into tissues
• Hemorrhage and stroke typically reported in transcranial approaches (Schick, Acta Neurochirurgica 2005; Linnet, Acta Ophthalmol Scand 2001)
• Although also reported with transorbital approach (Matton, Eur J Plast Surg 1991)
• One case of vision loss was associated with coronal 3‑wall decompression (Cruz, OPRS 2003)

Postoperative Complications

• Periorbital anesthesia is common and is often self-limited.
• The region depends on technical considerations.
• Ligation of zygomaticotemporal and zygomaticofacial neurovascular bundles produce typical distribution of anesthesia
• Supraorbital and infraorbital anesthesia both reported at rates < 1%–10%
• All rates difficult to interpret as follow up is variable and many resolve
• Motor nerve injury to CN VII typically associated with coronal or pretrichial dissections: 3%–6% (Schick, Acta Neurchirurgica 2005)
• Alacrima been reported in superolateral orbital ab interno dissection rarely (Goldberg, Ophthalmic Surg Lasers 1997)
• Meningitis (rare)
• Temporal wasting: incidence difficult to assess as reporting subject to physician and patient bias. Might be as high as 15% (Fichter, Int J Endocrinol 2015)
• Oscillopsia (Goldberg, Ophthalmic Surg Lasers 1997): up to 35% of patients
• Might persist > 2 years in about 50% of cases (Fayers, Ophthalmology 2013)
• Infection: Uncommon but reported in temporalis muscle (Cho, OPRS 2010) and surgical wounds (Chu, Otolaryngol Head Neck Surg 2009)

Diplopia and strabismus

• Lateral decompression, without floor, medial wall, or roof:
• New onset diplopia in primary position: 0%–6% (Ben Simon, Thyroid 2004)
• Motility unchanged in 2‑wall lateral decompression (Ben Simon, Ophthalmology 2006) and 3‑wall decompression (Paridaens, BJO 2000)
• Others report small change in ductions (Schaaf, J Craniomaxillofac Surg 2010).

"Balanced" decompression

• Concept often credited to Leone (Leone, AJO 1989) for decompression medially and laterally
• Aimed to eliminate complications related to floor removal: hypoglobus, muscle imbalance, hypesthesia and eyelid malposition
• Proptosis reduction:
• Between 4.0 mm and 5.5 mm (Graham, Laryngoscope 2003; Goldberg, OPRS 2000, Sellari-Francheschini, Otolaryngol Head Neck Surg 2005; Baril, Can J Ophthalmol 2014)
• Up to 6.5 mm if fat removed (Unal, OPRS 2003)
• Technique dependent: some report 2.5 mm of proptosis reduction (Alsuhaibani, OPRS 2011)
• Postoperative diplopia
• Less common in balanced approaches than inferomedial transantral or endoscopic
• Range: 11%–16% in most reports; although, some rates of > 30% (Baril, Can J Ophthalmol 2014; Alsuhaibani, OPRS 2011) reported
• Comparisons of balanced and lateral decompression have been made (Goldberg, OPRS 2000):
• Goldberg et al. compared 25 balanced decompressions (13 patients) to 38 lateral‑only decompressions (19 patients)
• Balanced decompression: 3 out of 9 (33.3%) with postoperative strabismus within 20^o of fixation
• Lateral only: 1 out of 14 (7.1%) patients developed strabismus
• Proptosis reduction: not significantly different between groups (4.5 mm)
• The authors concluded lateral wall decompression is as effective as balanced decompression with lower rates of new onset strabismus

Inferomedial versus lateral decompression

Inferomedial decompression has been compared to lateral decompression (Choe, OPRS 2011):

• In this study, deep lateral decompression with marginotomy compared to transcaruncular transorbital decompression of floor and medial wall (including the posterior half of the inferomedial strut)
• Both effective in management of DON
• Lateral approach: greater proptosis reduction (6 mm) relative to inferomedial (3 mm)

3-wall decompression

• 3-wall decompression most commonly means decompression of the lateral, medial and floor.
• With some difficulty, access can be obtained with a single incision: coronal, lateral canthal, swinging eyelid.
• Many surgeons find it more practical to employ multiple incisions that can be any combination of a lateral approaches such as coronal, eyelid crease and lateral canthal, combined with an inferomedial approach such as subciliary, swinging eyelid, lynch and/or a transnasal approach
• Proptosis reduction:
• Range: 4.5–7.5 mm
• New onset diplopia in primary position:
• Typical range of 10%–15%
• Has been reported as high as 60%–70% (Unal, OPRS 2003; Nadeau, J Otolaryngol 2005)

2‑wall versus 3‑wall decompression

Multiple studies have compared various different 2‑ and 3‑wall approaches:

• Unal et al. compared transorbital deep lateral wall combined with transnasal medial to lateral, medial and floor (Unal, OPRS 2003):
• Similar proptosis reduction: 6.5 mm in 2‑wall and 6.9 mm in 3‑wall
• Addition of floor decompression (3‑wall): significantly higher incidence of new onset diplopia at 57%, relative to without at 0%
• Another group described similar findings for diplopia (Nadeau, J Otolaryngol 2005):
• New onset diplopia: addition of floor decompression (3‑wall) (70%) versus balanced medial and lateral approach (2‑wall) (16.6%)
• Did not report on proptosis reduction
• Another group compared 2‑wall inferomedial by combined transantral and endoscopic approaches with 3‑wall that added transorbital deep lateral with marginomy and lag screw fixation (Cansiz, J Oral Maxillofac Surg 2006):
• Found that addition of the lateral wall increased proptosis reduction from 4.7 mm to 7.6 mm, with little difference in new onset diplopia (both groups with very low incidence)
• Another group compared inferomedial transorbital decompression (2‑wall) to coronal inferomedial + anterior lateral wall decompression without marginotomy (3‑wall) (Cruz, OPRS 2003):
• Found addition of lateral wall significantly increased proptosis reduction at 5.8 mm relative to 4.4 mm with inferomedial alone
• No difference in incidence of new onset diplopia: both groups close to 15%
• Another group found little difference between 2‑ and 3‑wall decompression (Silver, Otolaryngol Head Neck Surg 2006):
• Found that adding floor decompression (3‑wall) to medial and lateral (2‑wall) resulted in similar proptosis reduction (about 4.5 mm) and incidence of new onset diplopia (about 12%) among both groups
• Another group compared balanced inferomedial, lateral and fat decompression (3‑wall + fat) been compared to transnasal inferomedial decompression (2‑wall) (Chu, Otolaryngol Head Neck Surg 2009):
• Found the addition of lateral wall and fat produced greater proptosis reduction at 5.9 mm, relative to 1.9 mm
• New onset diplopia was rare: 9% in transnasal group
• Overall conclusions from these studies
• Addition of floor to balanced medial and lateral decompression:
• No change in proptosis reduction
• Might increase incidence of new onset diplopia
• Addition of lateral wall (+/- fat) to inferomedial:
• Might significantly increase proptosis reduction
• Might not increase incidence of new onset diplopia

4‑wall decompression

Few reports of 4‑wall decompression:

• Transorbital 4‑wall decompression involving posterolateral roof been described with 10 mm in proptosis reduction (Kennerdell, Ophthalmology 1982)
• One study looked at the addition of transcranial orbital roof decompression for patients failing steroid, irradiation and 3‑wall decompression (Bingham, OPRS 2014):
• Almost complete resolution of optic neuropathy in all 8 orbits
• One complained of orbital pulsation.
• Another study of 10 patients found 70% response to superolateral decompression via a transfrontal approach after failure of inferomedial decompression (Fatourechi, Mayo Clin Proc 1993) and concluded that it might be useful in recalcitrant cases.

• Optic neuropathy was classically the primary indication for decompression and improvement has been documented by various techniques
• Early studies on pressure changes and decompression suggest medial wall decompression most appropriate for DON (McCann, AJO 2006; McCord, OPRS 1985)
• Anatomically, the annulus of Zinn slightly more posterior medially and hence greater potential for compression posterior to the extent of lateral decompression
• Caveat: definition and measurement of DON widely variable in the literature
• Reported rates of improvement DON: 75%–90% with inferomedial decompression by various approaches including: Transcaruncular transorbital Transcutaneous transorbital, Medial transcutaneous transorbital, Transantral, Endonasal, Fat decompression, Lateral decompression, Floor decompression, Transcranial 4‑wall
• Note: DON can persist and/or recur, and not all are completely corrected surgically (Carter, Ophthalmology 1991)
• Comparison of surgical treatment for DON:
• Choe et al. (OPRS 2011) compared lateral and medial decompression for DON for 18 medial and 10 lateral orbits and found no difference in compressive optic neuropathy score between two groups,
• Medical therapy in DON is usually considered as first line therapy using high dose steroids (Day, Arch Ophthalmol 1968; Werner, Lancet 1966)
• Small randomized trial for DON: Wakelkamp et al. (Clin Endocrinol 2005)
• Decompression vs methylprednisolone as first treatment for DON
• Both effective and often required further therapy:
• 4/9 in methylprednisolone group required decompression
• 5/6 in decompression group required postoperative steroids for median 11 weeks.
• Both groups had similar outcomes and 5/9 methylprednisolone did not require decompression.
• They concluded that IV methylprednisolone is a good first line agent

• 1889: Kroenlein first described lateral approach to orbit
• 1890: general surgeon Julius Dollinger first decompression (Alper, Documenta Ophthalmologica 1995)
• 1929: Viennese otolaryngologist Oskar Hirsch first floor decompression
• 1831: American Neurosurgeon Howard C. Naffziger described a superior decompression
• 1939: medial wall first removed following an ethmoidectomy by Kistner
• Late 1950s: Walsh and Ogura pioneered combined medial and floor transantral approach (Walsh and Ogura, Laryngoscope 1957)
• 1990: medial endoscopic described by Kennedy (Kennedy, Archives of otolaryngology--head & neck surgery 1990)
• 1980s: ophthalmic trained physicians performing orbital decompression
• First via Ogura technique (Baylis, Ophthalmology 1980)
• Then via transorbital approaches to the floor and medial wall (Anderson, Archives of Ophthalmology 1981)
• Early 1990s: transorbital decompression of the deep lateral wall popularized by Goldberg (Shorr, Ophthalmology 2000)
• Combined the transorbital approach with the sphenoid decompression developed by MacCarty (Mayo Clin Proc 1970), without a craniotomy
• Early 1990s: Orbital fat decompression, first by Olivari, then Trokel and Kazim (Ophthalmology 1993)

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