Surgical pearls for managing thyroid eye disease

Surgical considerations remain relevant in the management of thyroid eye disease (TED) despite the success of teprotumumab, Michael Kazim, MD told the audience during a session at AAO 2022.

Below, in his own words, are surgical pearls for improved surgical success shared by Dr Kazim during his presentation.

Graded Decompressions
-“The concept of decompression should be graded with everyone looked at differently. You’re looking to see how much decompression you need.”

-“When you are looking at CT scans or MRIs…you want to look at the size of the muscle, the relative volume of orbital fat, the size and pathology that may exist in sinuses, and the size of the sphenoid bone. These are the areas that you need to focus on because it gives you some idea of how best to plan your surgery.”

-“We prefer endoscopic medial and flood decompressions because we think we can manage the sinus disease that can occur better, we can get back to the apex a bit more safely, and with better visualization.

Strabismus
-“Your orthoptist is going to be your best friend. I cannot practice without an orthoptist.”

-“You want to get some sense of intraoperative forces ductions. I use, despite the fact that there’s still controversy apparently, adjustable sutures on anything but an inferior rectus.”

-“Lateral rectus resections actually do work for residual exotropia.”

Eyelid Retraction
-“You need to assure that these people are euthyroid, cause that will throw you off.”

-“I do use posterior approaches for people with no or low lid crease and in cases where the upper lids are naturally full, I will open the septum and bring the fat down gingerly and try to keep the full upper lid.”

-“Don’t do tarsorrhaphy anymore. That’s an old school thing and it is an easy operation but it looks bad. The phimosis it produces is undesirable.”

Reference
Kazim M, et al. Surgery for Thyroid Eye Disease. Presented at: AAO 2022.