What is the optimal timing for orbital decompression in thyroid eye disease (TED) to minimize complications and maximize outcomes?

From the Guidelines

The optimal timing for orbital decompression in thyroid eye disease is during the stable, inactive phase of the disease, typically after 6-12 months of disease inactivity, as indicated by a clinical activity score (CAS) <3 for at least 6 months 1.

Key Considerations

• Patients should ideally complete medical therapy first, including corticosteroids and possibly teprotumumab, to allow the inflammatory phase to resolve completely 1.
• Urgent decompression should be performed immediately in cases of compressive optic neuropathy or severe corneal exposure regardless of disease activity 1.
• Sequential surgical rehabilitation is recommended, with orbital decompression first, followed by strabismus surgery after 3-6 months, and eyelid surgery as the final step after another 3-6 months 1.
• The two-wall (medial and lateral) balanced decompression technique is commonly preferred for cosmetic and functional outcomes while minimizing postoperative diplopia 1.

Rationale

• Operating during active inflammation increases surgical complications, including unpredictable outcomes, persistent inflammation, and higher reoperation rates 1.
• The staged approach prevents the need to revise earlier surgeries as orbital anatomy changes with each procedure 1.
• Preserving the orbital strut may diminish the risk of new-onset strabismus 1.

Important Notes

• Patients with concurrent proptosis and significant strabismus should be considered for orbital decompression surgery prior to strabismus surgery 1.
• Strabismus repair should be delayed until after the decompression because of the likely change in ocular alignment post decompression 1.
• Displacement of the extraocular muscles and the globe into newly available space can significantly impact ocular motility 1.

From the Research

Optimal Timing for Orbital Decompression

• The optimal timing for orbital decompression in thyroid eye disease is not clearly established, as there is limited evidence on the effectiveness of different techniques and their impact on outcomes 2, 3.
• Studies suggest that the choice of surgical technique may be less important than individualizing treatment based on patient goals and preoperative factors, such as preoperative Hertel exophthalmometry measurement 4.

Factors Influencing Outcomes

• Preoperative Hertel exophthalmometry is a strong predictor of proptosis reduction following orbital decompression in thyroid eye disease 4.
• Surgical technique may influence outcomes, but the evidence is not conclusive, and more research is needed to determine the most effective approach 2, 3, 4, 5.
• Other factors, such as smoking, body mass index, orbital wall height, and TRAb level, do not appear to affect outcomes 4.

Complications and Safety

• Common complications of orbital decompression include temporary postoperative numbness and new postoperative diplopia, with varying rates depending on the surgical technique used 4, 5.
• The safety and effectiveness of orbital decompression can be achieved with careful patient selection and individualized treatment planning 5.

Future Research Directions

• There is a need for more randomized controlled trials to evaluate the effectiveness of different orbital decompression techniques and their impact on outcomes in thyroid eye disease 2, 3.
• Future studies should address the effectiveness, possible complications, quality of life, and cost of each intervention, as well as the optimal timing for orbital decompression 2, 3.