The influence of previous orbital irradiation on the outcome of rehabilitative decompression surgery in graves orbitopathy.

PURPOSE: To investigate whether orbital irradiation influences the outcome of decompression surgery in Graves orbitopathy. DESIGN: Retrospective, comparative case series. METHODS: The medical records of all the patients with Graves orbitopathy treated with a three-wall orbital decompression through a coronal approach at our institution between January 1, 1990 and December 31, 2000 were reviewed. Only patients who underwent bilateral surgery for aesthetic rehabilitation, without preoperative diplopia, and who, in the active phase of the disease, had received orbital radiotherapy alone (20 Grays (Gy) in 10 daily fractions of two Gy over a period of two weeks; group R), systemic glucocorticoids alone (daily administration for more than three months independently from the dosage; group G), or both radiotherapy and glucocorticoids (group RG) were selected. Groups were compared for demographics, smoking habits, preoperative characteristics, and surgical outcome (mean reduction of exophthalmos, reduction of lid retraction, persistence of periorbital swelling requiring cosmetic eyelid surgery, onset of diplopia within 20 degrees of the central position of gaze, and variations in the peripheral field of diplopia). RESULTS: Sixty-one of 376 patients were selected for this study. There were no differences between group R (n=29), group G (n=15), and group RG (n=17) with respect to demographics or predecompression characteristics, whereas the number of smokers was significantly greater in group RG (P=.019). We could not find differences in surgical outcome by comparing the three groups. CONCLUSIONS: The total radiation dose, fraction size, and irradiated volume commonly used to treat active Graves orbitopathy do not adversely interfere with the outcome of rehabilitative decompression surgery.

The removal of the deep lateral wall in orbital decompression: its contribution to exophthalmos reduction and influence on consecutive diplopia.

PURPOSE: To evaluate the contribution of maximal removal of the deep lateral wall of the orbit to exophthalmos reduction in Graves' orbitopathy and its influence on the onset of consecutive diplopia. DESIGN: Case-control study. METHODS: The medical records of two cohorts of patients affected by Graves' orbitopathy with exophthalmos > or = 23 mm, without preoperative diplopia, were retrieved at random from the pool of patients decompressed for rehabilitative reasons at our institution (01/1990 to 12/2003), and retrospectively reviewed. They had been treated with an extended (cases, group 1, n = 15) or conservative (controls, group 2, n = 15) 3-wall orbital decompression performed through a coronal approach. The deep portion of the lateral wall had been removed in the extended decompression group while preserved in the conservative decompression group. Demographics, preoperative characteristics, and surgical outcome were compared. The difference in mean exophthalmos reduction between groups 1 and 2 was considered to be the contribution of the deep lateral wall to reduction of exophthalmos. RESULTS: Groups 1 and 2 were drawn from a pool of 37 and 335 patients, respectively. Demographics and preoperative characteristics of the two groups were not significantly different. The mean contribution of the deep lateral wall to exophthalmos reduction was 2.3 mm. The onset of consecutive diplopia was not significantly different between the two groups (case n = 2/15, controls n = 5/15; P = .203). Diplopia resolved spontaneously in all the patients of group 1, while all the patients of group 2 required surgery. CONCLUSIONS: Removal of the deep lateral orbital wall as part of a coronal-approach, 3-wall decompression, enhances the degree of exophthalmos reduction without increasing the risk of consecutive diplopia.

The length of unsutured mucosal margins in external dacryocystorhinostomy.

PURPOSE: To compare the extent of mucosal margins remaining unsutured at the end of external dacryocystorhinostomy (DCR) using single or double flap techniques and to evaluate the influence on outcome. DESIGN: Prospective, consecutive case series. METHODS: The number and length of mucosal margins remaining unsutured at the end of external DCR were evaluated in 64 patients. Mucosal anastomosis was performed using either a conservative (group 1) or extended (group 2) double flap, or a single flap (group 3) dissection. Patients were selected for group 1 if the regional anatomy permitted the desired dissection. All other patients were randomized to group 2 or 3. The mean length of unsutured mucosal margins was calculated for each group. Subjects were followed up to 12 months, with final success rate recorded. RESULTS: In groups 1, 2, and 3 respectively: 11, 24 and 29 patients were recruited; four, 12, and 10 mucosal margins remained unsutured; and the mean length of unsutured mucosal margins was 16.36 mm (SD = 2.8), 70.66 mm (SD = 9.3), and 62.00 mm (SD = 6.0). The mean length of unsutured mucosal margins was significantly different, although groups 1 and 2 collectively did not have a significantly different mean length of unsutured mucosal margin from group 3. Mean follow-up was 11 months (SD = 2.2), 63 patients (98.43%) had a successful outcome with no significant difference among groups (P = .429). CONCLUSION: Different patterns of mucosal dissection in external DCR create a different number and extent of unsutured mucosal margins which do not appear to adversely affect the success rate of external DCR.

Impact on quality of life of botulinum toxin treatments for essential blepharospasm.

PURPOSE: To determine the impact on quality of life of Botulinum toxin therapy for essential blepharospasm. METHODS: A cross-sectional study was undertaken using the Glasgow Benefit Inventory, in the form of a postal questionnaire, to assess the subjective patient benefit of Botulinum toxin treatments for essential blepharospasm in 44 consecutive patients attending a specialist Botulinum toxin clinic. (The Glasgow Benefit Inventory generates a score from -100 (maximum harm) through 0 (no effect) to +100 (maximum benefit) for the intervention under investigation.) The Wilcoxon signed-ranks test was used to test the significance of the total scores and subdomain scores. RESULTS: A high response rate of 36 out of 44 (81.8%) was achieved. The median total benefit score was +29.2 (97.1% CI = 16.7 to 38.9, p < 0.0001). The median subdomain scores were: general +43.8 (97.1% CI = 20.8 to 54.2, p < 0.0001), social 0.0 (97.1% CI = 0.0 to 16.7, p = 0.0019) and physical 0.0 (97.1% CI = 0.0 to 0.0, p = 0.4810). CONCLUSIONS: This study demonstrates significant quality of life benefit from Botulinum toxin therapy for essential blepharospasm, and justifies continued treatment.