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Spontaneous medial orbital decompression associated with medial wall remodeling in Graves' orbitopathy.

To the Editor: The correction of exophthalmos or compressive optic neuropathy in Graves’ orbitopathy (GO) associated with extraorbital muscle enlargement may require bone removal orbital decompression (BROD). Various techniques have so far been described for BROD, including transnasal, transconjunctival, or transcutaneous approaches for the removal of 1 or more orbital walls. Previous studies have proposed the “balanced” orbital wall removal for the medial and lateral orbital walls to reduce the possibility of diplopia by creating an equal distribution of forces along the horizontal orbital axis. However, medial wall removal may be technically challenging and require the cooperation with an ear, nose, and throat (ENT) surgeon if a transnasal approach is selected. We present a case of GO patient with massive medial rectus muscle enlargement displacing medially the medial wall and thus creating an effective medial wall decompression (Fig. 1). This 52-year-old man presented with Hertel exophthalmometry readings of 25 mm (OD) and 30 mm (OS) and marked left esotropia and hypotropia (Fig. 1A,B). Best-corrected visual acuity was 20/30 (OD) and 20/200 (OS) due to concomitant nuclear cataract (more pronounced at the OS). The optic discs had clear margins, and color perception was normal in OU (Ishihara scale), thus excluding the presence of compressive optic neuropathy. A CT scan revealed an enlargement of the bellies of all extraocular muscles, much more pronounced for the OS (Fig. 1C,D). It is interesting to note that the left medial orbital wall appeared so deformed by the apposition of the massively enlarged left medial rectus belly, that expanded medially, occupying a large part of the adjacent nasal cavity (Fig. 1C,D). Based on these imaging findings, we decided to perform lateral wall decompression without medial wall decompression, which improved the left exophthalmos to 26 mm without affecting hypotropia or esotropia (scheduled to be corrected at a second stage) (Fig. 2). We believe that a degree of “spontaneous” medial wall decompression may possibly be present in a subgroup of GO patients with pronounced medial rectus muscle enlargement due to bone remodeling of the medial orbital wall. This hypothesis, that is, the spontaneous medial decompression, may also explain the absence of left compressive optic neuropathy in this patient, despite the massive muscle enlargement, entrapping the optic nerve. The fact that a significant nasal shift of the globe position has recently been reported following balanced decompression complies with the hypothesis that the medial wall may already be partially decompressed in some patients, in whom bone removal from that wall may actually not be required. If this assumption Efstathios T. Detorakis, M.D., Ph.D. Viktor Haniotis, M.D. Ioannis Mavrikakis, M.D., Ph.D. Eleni E. Drakonaki, M.D., Ph.D.