Orbital Decompression: Graded Surgical Approach

  • Kyle J. Godfrey
  • Christine C. Annunziata
  • Bobby S. Korn
  • Don O. KikkawaEmail author


Orbital decompression is an effective surgical intervention for the treatment of thyroid eye disease and other conditions causing expansion of orbital soft tissue volume. Indications for surgery include disfiguring proptosis, compressive optic neuropathy, exposure keratopathy, orbital congestion, and reduction of proptosis in preparation for strabismus surgery. The primary goals of orbital decompression are to expand orbital capacity through bony decompression and reduce orbital soft tissue volume through orbital fat decompression. The amount of decompression performed should be tailored to the individual patient based on the severity of proptosis, with the goal of returning the patient to their pre-disease state. Our preferred progression for graded proptosis reduction is fat decompression, followed by lateral wall, then medial wall, then orbital floor, and then lateral orbital rim removal, as needed. However, in cases of optic neuropathy, maximal apical expansion is created with medial, floor, and lateral decompression. Careful patient selection and improved surgical technique have led to a broadening of the indications for this traditionally rare operation.


Orbitopathy Exophthalmos Proptosis Thyroid eye disease Graves’ disease Orbital decompression 

Supplementary material

419986_5_En_50_MOESM1_ESM.mp4 (214.9 mb)
Video 50.1 Left lateral orbital decompression. Courtesy of Richard C. Allen, MD, PhD, FACS. (MP4 220034 kb)
419986_5_En_50_MOESM2_ESM.mp4 (163.7 mb)
Video 50.2 Right lateral orbital decompression. Courtesy of Richard C. Allen, MD, PhD, FACS. (MP4 167671 kb)
419986_5_En_50_MOESM3_ESM.mp4 (168.3 mb)
Video 50.3 Left medial orbital decompression. Courtesy of Richard C. Allen, MD, PhD, FACS. (MP4 172301 kb)
419986_5_En_50_MOESM4_ESM.mp4 (48.8 mb)
Video 50.4 Right medial orbital decompression. Courtesy of Richard C. Allen, MD, PhD, FACS. (MP4 49980 kb)
419986_5_En_50_MOESM5_ESM.mp4 (81.6 mb)
Video 50.5 Right orbital floor decompression. Courtesy of Richard C. Allen, MD, PhD, FACS. (MP4 83600 kb)


  1. 1.
    Kim N, Hatton MP. The role of genetics in graves’ disease and thyroid orbitopathy. Semin Ophthalmol. 2008;23:67–72.CrossRefPubMedGoogle Scholar
  2. 2.
    Kazim M, Goldberg RA, Smith TJ. Insights into the pathogenesis of thyroid associated orbitopathy. Arch Ophthalmol. 2002;120:380–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Farling PA. Thyroid disease. Br J Anaesth. 2000;85:15–28.CrossRefPubMedGoogle Scholar
  4. 4.
    Boulos PR, Hardy I. Thyroid-associated orbitopathy: a clinicopathologic and therapeutic review. Curr Opin Ophthalmol. 2004;15:389–400.CrossRefPubMedGoogle Scholar
  5. 5.
    Fayers T, Barker LE, Verity DH, Rose GE. Oscillopsia after lateral wall orbital decompression. Ophthalmology. 2013;120(9):1920–3.CrossRefPubMedGoogle Scholar
  6. 6.
    Bartalena L, Baldeschi L, Dickinson AJ, Eckstein A, Kendall-Taylor P, Marcocci C, European Group on Graves’ Orbitopathy (EUGOGO), et al. Consensus statement of the European group on Graves’ orbitopathy (EUGOGO) on management of Graves’ orbitopathy. Thyroid. 2008;18(3):333–46.CrossRefPubMedGoogle Scholar
  7. 7.
    McCracken MS, del Prado JD, Granet DB, Levi L, Kikkawa DO. Combined eyelid and strabismus surgery: examining conventional surgical wisdom. J Pediatr Ophthalmol Strabismus. 2008;45(4):220–4.CrossRefPubMedGoogle Scholar
  8. 8.
    Shorr N, Seiff SR. The four stages of surgical rehabilitation of the patient with dysthyroid ophthalmopathy. Ophthalmology. 1986;93:476–83.CrossRefPubMedGoogle Scholar
  9. 9.
    Cho RI, Elner VM, Nelson CC, Freuh BR. The effect of orbital decompression surgery on lid retraction in thyroid eye disease. Ophthal Plast Reconstr Surg. 2011;27(6):436–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Garrity JA, Fatourechi V, Bergstralh EJ, Bartley GB, Beatty CW, DeSanto LW, et al. Results of transantral orbital decompression in 428 patients with severe Graves’ ophthalmopathy. Am J Ophthalmol. 1993;116(5):533–47.CrossRefPubMedGoogle Scholar
  11. 11.
    McCord CD Jr. Current trends in orbital decompression. Ophthalmology. 1985;92:21–33.CrossRefPubMedGoogle Scholar
  12. 12.
    Kahaly GJ, Petrak F, Hardt J, et al. Psychosocial morbidity of Graves’ orbitopathy. Clin Endocrinol. 2005;63:395–402.CrossRefGoogle Scholar
  13. 13.
    Lyons CJ, Rootman J. Orbital decompression for disfiguring exophthalmos in thyroid orbitopathy. Ophthalmology. 1994;101:223–30.CrossRefPubMedGoogle Scholar
  14. 14.
    Fatourechi V, Garrity JA, Bartley GB, Bergstralh EJ, DeSanto LW, Gorman CA. Graves ophthalmopathy: results of transantral orbital decompression performed primarily for cosmetic indications. Ophthalmology. 1994;101:938–42.CrossRefPubMedGoogle Scholar
  15. 15.
    Wickwar S, McBain H, Ezra DG, Hirani SP, Rose GE, Newman SP. The psychosocial and clinical outcomes of orbital decompression surgery for thyroid eye disease and predictors of change in quality of life. Ophthalmology. 2015;122:2568–76.CrossRefPubMedGoogle Scholar
  16. 16.
    Goh MSF, McNab AA. Orbital decompression in Graves’ orbitopathy: efficacy and safety. Intern Med J. 2005;35:586–91.CrossRefPubMedGoogle Scholar
  17. 17.
    Kalmann R, Mourits MP, van der Pol JP, Koornneef L. Coronal approach for rehabilitative orbital decompression in Graves’ ophthalmopathy. Br J Ophthalmol. 1997;81:41–5.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kulwin DR, Cotton RT, Kersten RC. Combined approach to orbital decompression. Otolaryngol Clin N Am. 1990;23:381–90.Google Scholar
  19. 19.
    Seiff SR, Tovilla JL, Carter SR, Choo PH. Modified orbital decompression for dysthyroid orbitopathy. Ophthal Plast Reconstr Surg. 2000;16:62–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Baily KL, Tower RN, Dailey RA. Customized, single-incision, three-wall orbital decompression. Ophthal Plast Reconstr Surg. 2005;21(1):1–10.CrossRefGoogle Scholar
  21. 21.
    Leone CR Jr, Piest KL, Newman RJ. Medial and lateral wall decompression for thyroid ophthalmopathy. Am J Ophthalmol. 1989;108:160–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Goldberg RA, Kim AJ, Kerivan KM. The lacrimal keyhole, orbital door jamb, and basin of the inferior orbital fissure: three areas of deep bone in the lateral orbit. Arch Ophthalmol. 1998;116:1618–24.CrossRefPubMedGoogle Scholar
  23. 23.
    Shephard KG, Levin PS, Terris DJ. Balanced orbital decompression for Graves’ ophthalmopathy. Laryngoscope. 1998;108:1648–53.CrossRefGoogle Scholar
  24. 24.
    Rao R, MacIntosh PW, Yoon MK, Lefebvre DR. Current trends in the management of thyroid eye disease. Curr Opin Ophthalmol. 2015;26:484–90.CrossRefPubMedGoogle Scholar
  25. 25.
    Carrasco JR, Castillo I, Bilyk JR, Pribitkin EA, Savino PJ. Incidence of infraorbital hypesthesia and sinusitis after orbital decompression for thyroid-related orbitopathy: a comparison of surgical techniques. Ophthal Plast Reconstr Surg. 2005;21:188–91.CrossRefPubMedGoogle Scholar
  26. 26.
    Kikkawa DO, Pornpanich K, Cruz RC Jr, Levi L, Granet DB. Graded orbital decompression based on severity of proptosis. Ophthalmology. 2002;109(7):1219–24.CrossRefPubMedGoogle Scholar
  27. 27.
    Olivari N. Transpalpebral decompression of endocrine ophthalmopathy (Graves’ disease) by removal of intraorbital fat: experience with 147 operations over 5 years. Plast Reconstr Surg. 1991;87:627–41.CrossRefPubMedGoogle Scholar
  28. 28.
    Trokel S, Kazim M, Moore S. Orbital fat removal decompression for Graves’ orbitopathy. Ophthalmology. 1993;100:674–82.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Kyle J. Godfrey
    • 1
  • Christine C. Annunziata
    • 2
  • Bobby S. Korn
    • 3
  • Don O. Kikkawa
    • 3
    Email author
  1. 1.Department of OphthalmologyUC San Diego, Shiley Eye InstituteLa JollaUSA
  2. 2.Metrolina Eye AssociatesMatthewsUSA
  3. 3.Department of Ophthalmology, Division of Oculofacial Plastic Surgery and Department of Surgery, Division of Plastic SurgeryUC San Diego and the Shiley Eye InstituteLa JollaUSA

Personalised recommendations