Surgical treatment of thyroid orbitopathy Review article
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Published:
Sep 30, 2023
Keywords:
thyroid orbitopathy, eye surgery, strabismus, Graves’ Disease
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Abstract
Thyroid Orbitopathy is manifestation of Grave’s Disease that affects eyes and orbital area. It occurs in the active and inactive phase, during which different signs are presented. When Thyroid Orbitopathy reaches its advanced phase it should be operated, to avoid complications like proptosis or optic nerve neuropathy. Usually, the first choice is orbital fat decompression. However, it is often not enough and bony decompression is necessary. Surgery of the strabismus is also crucial for patient’s quality of life. Its aim is to restore visual field as wide as it is possible. Last step in surgical interventions is eyelid correction to prevent keratopathy and improve esthetic aspects.
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1.
Zabochnicki M, Szaraniec W, Pojda-Wilczek D. Surgical treatment of thyroid orbitopathy. Ophthatherapy [Internet]. 2023Sep.30 [cited 2024Dec.22];10(3):222-30. Available from: https://journalsmededu.pl/index.php/ophthatherapy/article/view/2870
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Surgery and laser therapy
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Copyright: © Medical Education sp. z o.o. License allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Address reprint requests to: Medical Education, Marcin Kuźma (marcin.kuzma@mededu.pl)
References
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3. Bartalena L, Kahaly GJ, Baldeschi L et al. The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy. Eur J Endocrinol. 2021; 185: G43-67.
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6. Wiersinga WM. Quality of life in Graves’ ophthalmopathy. Best Pract Res Clin Endocrinol Metab. 2012; 26: 359-70.
7. Kahaly GJ, Petrak F, Hardt J et al. Psychosocial morbidity of Graves’ orbitopathy. Clin Endocrinol. 2005; 63: 395-402.
8. Hall AJ, Topliss DJ. Medical and Surgical Treatment of Thyroid Eye Disease. Intern Med J. 2022; 52(1): 14-20.
9. Wiersinga WM. Advances in treatment of active, moderate-to-severe Graves’ ophthalmopathy. Lancet Diabetes Endocrinol. 2017; 5: 134-42.
10. Weiler DL. Thyroid eye disease: a review. Clin Exp Optom. 2017; 100: 20-5.
11. Taylor PN, Zhang L, Lee RWJ et al. New insights into the pathogenesis and nonsurgical management of Graves orbitopathy. Nat Rev Endocrinol. 2020; 16: 104-16.
12. Antonelli A, Fallahi P, Elia G et al. Graves’ disease: Clinical manifestations, immune pathogenesis (cytokines and chemokines) and therapy. Best Pract Res Clin Endocrinol Metab. 2020; 34: 101388.
13. Boddu N, Jumani M, Wadhwa V et al. Not All Orbitopathy Is Graves’: Discussion of Cases and Review of Literature. Front Endocrinol. 2017; 8: 184.
14. Vehof J, Utheim TP, Bootsma H et al. Advances, limitations and future perspectives in the diagnosis and management of dry eye in Sjögren’s syndrome. Clin Exp Rheumatol. 2020; 38: 301-9.
15. Marinò M, Ionni I, Lanzolla G et al. Orbital diseases mimicking graves’ orbitopathy: a long-standing challenge in differential diagnosis. J Endocrinol Invest. 2020; 43: 401-11.
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31. Seibel I, Hofmann VM, Sönmez H et al. Medial and mediolateral orbital decompression in intractable Graves’ Orbitopathy. Auris Nasus Larynx. 2017; 44: 428-34.
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33. Hsieh M-W, Hsu C-K, Kuo P-C et al. Factors Predicting the Success of Combined Orbital Decompression and Strabismus Surgery in Thyroid-Associated Orbitopathy. JPM. 2022; 12: 186.
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35. Świerkot M, Kulawik G, Sarnat-Kucharczyk M et al. Long-term remission of steroid-resistant Graves’ orbitopathy after administration of anti-thymocyte globulin. Endokrynol Pol. 2020; 71: 2.
36. Vandewalle J, Luypaert A, De Bosscher K et al. Therapeutic Mechanisms of Glucocorticoids. Trends Endocrinol Metab. 2018; 29: 42-54.
37. Marcocci C, Kahaly GJ, Krassas GE et al. Selenium and the Course of Mild Graves’ Orbitopathy. N Engl J Med. 2011; 364: 1920-31.
38. Hamed-Azzam S, Mukari A, Feldman I et al. Fornix triamcinolone injection for thyroid orbitopathy. Graefes Arch Clin Exp Ophthalmol. 2015; 253: 811-6.
39. Lee SJ, Rim THT, Jang SY et al. Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections. Graefes Arch Clin Exp Ophthalmol. 2013; 251: 261-70.
40. Khong JJ, McNab A. Medical treatment in thyroid eye disease in 2020. Br J Ophthalmol. 2021; 105: 299-305.
41. Ruchała M, Hernik A, Zybek A. Orbital radiotherapy in the management of Graves’ orbitopathy – current state of knowledge. Endokrynol Pol. 2014; 65: 388-96.
42. Nowak M, Nowak W. Treatment of moderate to severe and active thyroid orbitopathy during SARS-CoV-2 pandemic. Ophthalmol J. 2022; 7: 94-102.
43. Zhou X, Zhou D, Wang J et al. Treatment strategies for Graves’ ophthalmopathy: a network meta-analysis. Br J Ophthalmol. 2020; 104: 551-6.
44. Smith TJ, Kahaly GJ, Ezra DG et al. Teprotumumab for Thyroid-Associated Ophthalmopathy. N Engl J Med. 2017; 376: 1748-61.
45. Ostrowski RA, Bussey MR, Shayesteh Y et al. Rituximab in the Treatment of Thyroid Eye Disease: A Review. Neuroophthalmology. 2015; 39: 109-15.
46. Perez-Moreiras JV, Gomez-Reino JJ, Maneiro JR et al. Efficacy of Tocilizumab in Patients With Moderate-to-Severe Corticosteroid-Resistant Graves Orbitopathy: A Randomized Clinical Trial. Am J Ophthalmol. 2018; 195: 181-90.
47. Goldberg RA. The Evolving Paradigm of Orbital Decompression Surgery. Arch Ophthalmol. 1998; 116: 95-6.
48. Kotwal A, Stan M. Current and Future Treatments for Graves’ Disease and Graves’ Ophthalmopathy. Horm Metab Res. 2018; 50: 871-86.
49. Burch HB, Perros P, Bednarczuk T et al. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J. 2022; 11: e220189.
50. Ben Simon GJ, Schwarcz RM, Mansury AM et al. Minimally Invasive Orbital Decompression: Local Anesthesia and Hand-Carved Bone. Arch Ophthalmol. 2005; 123: 1671.
51. Willaert R, Maly T, Ninclaus V et al. Efficacy and complications of orbital fat decompression in Graves’ orbitopathy: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2020; 49: 496-504.
52. Naik M, Nair A, Gupta A et al. Minimally invasive surgery for thyroid eye disease. Indian J Ophthalmol. 2015; 63: 847.
53. Eckstein A, Schittkowski M, Esser J. Surgical treatment of Graves’ ophthalmopathy. Best Pract Res Clin Endocrinol Metab. 2012; 26: 339-58.
54. Al-Sharif E, Alsuhaibani AH. Fat-removal orbital decompression for thyroid associated orbitopathy: The right procedure for the right patient. Saudi J Ophthalmol. 2017; 31: 156-61.
55. Jefferis JM, Jones RK, Currie ZI et al. Orbital decompression for thyroid eye disease: methods, outcomes, and complications. Eye. 2018; 32: 626-36.
56. Sellari-Franceschini S, Lenzi R, Santoro A et al. Lateral wall orbital decompression in Graves’ orbitopathy. Int J Oral Maxillofac Surg. 2010; 39: 16-20.
57. Kitaguchi Y, Takahashi Y, Kakizaki H. Computed Tomography-Based Prediction of Exophthalmos Reduction After Deep Lateral Orbital Wall Decompression for Graves’ Orbitopathy. Graefes Arch Clin Exp Ophthalmol. 2019; 257: 2759-67.
58. Parrilla C, Mele DA, Gelli S et al. Multidisciplinary approach to orbital decompression. A review. Acta Otorhinolaryngol Ital. 2021; 41: S90-101.
59. Spalthoff S, Jehn P, Zimmerer R et al. Modified lateral orbital wall decompression in Graves’ orbitopathy using computer-assisted planning. Int J Oral Maxillofac Surg. 2018; 47: 167-74.
60. Tavassol F, Kokemüller H, Müller-Tavassol C et al. A Quantitative Approach to Orbital Decompression in Graves’ Disease Using Computer- Assisted Surgery: A Compilation of Different Techniques and Introduction of the “Temporal Cage.” J Oral Maxillofac Surg. 2012; 70: 1152-60.
61. Sagiv O, Satchi K, Kinori M et al. Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease. Graefes Arch Clin Exp Ophthalmol. 2016; 254: 791-6.
62. Hernández-García E, San-Román JJ, González R et al. Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves’ orbitopathy. Acta Otolaryngol. 2017; 137: 1183-7.
63. Ong AA, DeVictor S, Vincent AG et al. Bony Orbital Surgery for Graves’ Ophthalmopathy. Facial Plast Surg. 2021; 37: 692-7.
64. Clarós P, Waląg A, López-Fortuny M et al. Impact of the ethmoid volume on endoscopic medial wall decompression outcomes in Graves’ orbitopathy. Acta Otolaryngol. 2020; 140: 948-53.
65. Thakar A, Tandon N, Lal P. Endoscopic orbital decompression for Graves’ orbitopathy. Indian J Endocr Metab. 2013; 17: 265.
66. Fabian ID, Rosen N, Ben Simon GJ. Strabismus After Inferior-Medial Wall Orbital Decompression in Thyroid-Related Orbitopathy. Curr Eye Res. 2013; 38: 204-9.
67. Cubuk MO, Konuk O, Unal M. Orbital decompression surgery for the treatment of Graves’ ophthalmopathy: comparison of different techniques and long-term results. Int J Ophthalmol. 2018; 11: 1363-70.
68. Korkmaz S, Konuk O. Surgical Treatment of Dysthyroid Optic Neuropathy: Long-Term Visual Outcomes with Comparison of 2-Wall versus 3-Wall Orbital Decompression. Curr Eye Res. 2016; 41: 159-64.
69. Cheng S-N, Yu Y-Q, You Y-Y et al. Comparison of 2-wall versus 3-wall orbital decompression against dysthyroid optic neuropathy in visual function: A retrospective study in a Chinese population. Medicine. 2021; 100: e24513.
70. Jellema HM, Saeed P, Mombaerts I et al. Objective and subjective outcomes of strabismus surgery in Graves’ orbitopathy: a prospective multicentre study. Acta Ophthalmol. 2017; 95: 386-91.
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2. Patel A, Yang H, Douglas RS. A New Era in the Treatment of Thyroid Eye Disease. American Journal of Ophthalmology 2019; 208: 281-8.
3. Bartalena L, Kahaly GJ, Baldeschi L et al. The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy. Eur J Endocrinol. 2021; 185: G43-67.
4. Barrio-Barrio J, Sabater AL, Bonet-Farriol E et al. Graves’ Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management. J Ophthalmol. 2015; 2015: 1-16.
5. Genere N, Stan MN. Current and Emerging Treatment Strategies for Graves’ Orbitopathy. Drugs. 2019; 79: 109-24.
6. Wiersinga WM. Quality of life in Graves’ ophthalmopathy. Best Pract Res Clin Endocrinol Metab. 2012; 26: 359-70.
7. Kahaly GJ, Petrak F, Hardt J et al. Psychosocial morbidity of Graves’ orbitopathy. Clin Endocrinol. 2005; 63: 395-402.
8. Hall AJ, Topliss DJ. Medical and Surgical Treatment of Thyroid Eye Disease. Intern Med J. 2022; 52(1): 14-20.
9. Wiersinga WM. Advances in treatment of active, moderate-to-severe Graves’ ophthalmopathy. Lancet Diabetes Endocrinol. 2017; 5: 134-42.
10. Weiler DL. Thyroid eye disease: a review. Clin Exp Optom. 2017; 100: 20-5.
11. Taylor PN, Zhang L, Lee RWJ et al. New insights into the pathogenesis and nonsurgical management of Graves orbitopathy. Nat Rev Endocrinol. 2020; 16: 104-16.
12. Antonelli A, Fallahi P, Elia G et al. Graves’ disease: Clinical manifestations, immune pathogenesis (cytokines and chemokines) and therapy. Best Pract Res Clin Endocrinol Metab. 2020; 34: 101388.
13. Boddu N, Jumani M, Wadhwa V et al. Not All Orbitopathy Is Graves’: Discussion of Cases and Review of Literature. Front Endocrinol. 2017; 8: 184.
14. Vehof J, Utheim TP, Bootsma H et al. Advances, limitations and future perspectives in the diagnosis and management of dry eye in Sjögren’s syndrome. Clin Exp Rheumatol. 2020; 38: 301-9.
15. Marinò M, Ionni I, Lanzolla G et al. Orbital diseases mimicking graves’ orbitopathy: a long-standing challenge in differential diagnosis. J Endocrinol Invest. 2020; 43: 401-11.
16. Mombaerts I, Ramberg I, Coupland SE et al. Diagnosis of orbital mass lesions: clinical, radiological, and pathological recommendations. Surv Ophthalmol. 2019; 64: 741-56.
17. Subekti I, Pramono LA. Current Diagnosis and Management of Graves’ Disease. Acta Med Indones. 2018; 50: 6.
18. Phelps PO, Williams K. Thyroid eye disease for the primary care physician. Dis Mon. 2014; 60: 292-8.
19. Hoang TD, Stocker DJ, Chou EL et al. 2022 Update on Clinical Management of Graves Disease and Thyroid Eye Disease. Endocrinol Metab Clin North Am. 2022; 51: 287-304.
20. Dave TV, Natarajan R, Reddy RU et al. Choroidal Thickness in Thyroid Eye Disease: Comparison With Controls and Application in Diagnosing Non-Inflammatory Active Disease. Cureus 2021; 13(11): e19779.
21. Dave TV, Jonnadula GB, Lanka P et al. Choroidal vascularity index in thyroid eye disease: comparison with controls and application in diagnosing non-inflammatory active disease. Orbit. 2022; 41: 89-96.
22. Bartalena L, Piantanida E, Gallo D et al. Epidemiology, Natural History, Risk Factors, and Prevention of Graves’ Orbitopathy. Front Endocrinol. 2020; 11: 615993.
23. Cao J, Su Y, Chen Z et al. The risk factors for Graves’ ophthalmopathy. Graefes Arch Clin Exp Ophthalmol. 2022; 260: 1043-54.
24. Tabriz N, Gruben A, Uslar V et al. Risk factors for Graves’ Orbitopathy in surgical patients – Results of a 10‐year retrospective study with review of the literature. Endocrinol Diab Metab. 2021; 4(1): e00210.
25. Khong JJ, Finch S, De Silva C et al. Risk Factors for Graves’ Orbitopathy; the Australian Thyroid-Associated Orbitopathy Research (ATOR) Study. J Clin Endocrinol Metab. 2016; 101: 2711-20.
26. Bartley GB. Rundle and His Curve. Arch Ophthalmol. 2011; 129: 356-8.
27. Menconi F, Profilo MA, Leo M et al. Spontaneous Improvement of Untreated Mild Graves’ Ophthalmopathy: Rundle’s Curve Revisited. Thyroid. 2014; 24: 60-6.
28. Bahn RS. Graves’ Ophthalmopathy. N Engl J Med. 2010; 362: 726-38.
29. Drui D, Du Pasquier Fediaevski L, Vignal Clermont C et al. Graves’ orbitopathy: Diagnosis and treatment. Ann Endocrinol (Paris). 2018; 79: 656-64. http://doi.org/10.1016/j.ando.2018.08.005.
30. Imburgia A, Elia G, Franco F et al. Treatment of exophthalmos and strabismus surgery in thyroid-associated orbitopathy. Int J Oral Maxillofac Surg. 2016; 45: 743-9.
31. Seibel I, Hofmann VM, Sönmez H et al. Medial and mediolateral orbital decompression in intractable Graves’ Orbitopathy. Auris Nasus Larynx. 2017; 44: 428-34.
32. Li X, Bai X, Liu Z et al. The Effect of Inferior Rectus Muscle Thickening on Intraocular Pressure in Thyroid-Associated Ophthalmopathy. J Ophthalmol. 2021; 2021: 1-5.
33. Hsieh M-W, Hsu C-K, Kuo P-C et al. Factors Predicting the Success of Combined Orbital Decompression and Strabismus Surgery in Thyroid-Associated Orbitopathy. JPM. 2022; 12: 186.
34. Rootman DB. Orbital decompression for thyroid eye disease. Surv Ophthalmol. 2018; 63: 86-104.
35. Świerkot M, Kulawik G, Sarnat-Kucharczyk M et al. Long-term remission of steroid-resistant Graves’ orbitopathy after administration of anti-thymocyte globulin. Endokrynol Pol. 2020; 71: 2.
36. Vandewalle J, Luypaert A, De Bosscher K et al. Therapeutic Mechanisms of Glucocorticoids. Trends Endocrinol Metab. 2018; 29: 42-54.
37. Marcocci C, Kahaly GJ, Krassas GE et al. Selenium and the Course of Mild Graves’ Orbitopathy. N Engl J Med. 2011; 364: 1920-31.
38. Hamed-Azzam S, Mukari A, Feldman I et al. Fornix triamcinolone injection for thyroid orbitopathy. Graefes Arch Clin Exp Ophthalmol. 2015; 253: 811-6.
39. Lee SJ, Rim THT, Jang SY et al. Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections. Graefes Arch Clin Exp Ophthalmol. 2013; 251: 261-70.
40. Khong JJ, McNab A. Medical treatment in thyroid eye disease in 2020. Br J Ophthalmol. 2021; 105: 299-305.
41. Ruchała M, Hernik A, Zybek A. Orbital radiotherapy in the management of Graves’ orbitopathy – current state of knowledge. Endokrynol Pol. 2014; 65: 388-96.
42. Nowak M, Nowak W. Treatment of moderate to severe and active thyroid orbitopathy during SARS-CoV-2 pandemic. Ophthalmol J. 2022; 7: 94-102.
43. Zhou X, Zhou D, Wang J et al. Treatment strategies for Graves’ ophthalmopathy: a network meta-analysis. Br J Ophthalmol. 2020; 104: 551-6.
44. Smith TJ, Kahaly GJ, Ezra DG et al. Teprotumumab for Thyroid-Associated Ophthalmopathy. N Engl J Med. 2017; 376: 1748-61.
45. Ostrowski RA, Bussey MR, Shayesteh Y et al. Rituximab in the Treatment of Thyroid Eye Disease: A Review. Neuroophthalmology. 2015; 39: 109-15.
46. Perez-Moreiras JV, Gomez-Reino JJ, Maneiro JR et al. Efficacy of Tocilizumab in Patients With Moderate-to-Severe Corticosteroid-Resistant Graves Orbitopathy: A Randomized Clinical Trial. Am J Ophthalmol. 2018; 195: 181-90.
47. Goldberg RA. The Evolving Paradigm of Orbital Decompression Surgery. Arch Ophthalmol. 1998; 116: 95-6.
48. Kotwal A, Stan M. Current and Future Treatments for Graves’ Disease and Graves’ Ophthalmopathy. Horm Metab Res. 2018; 50: 871-86.
49. Burch HB, Perros P, Bednarczuk T et al. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J. 2022; 11: e220189.
50. Ben Simon GJ, Schwarcz RM, Mansury AM et al. Minimally Invasive Orbital Decompression: Local Anesthesia and Hand-Carved Bone. Arch Ophthalmol. 2005; 123: 1671.
51. Willaert R, Maly T, Ninclaus V et al. Efficacy and complications of orbital fat decompression in Graves’ orbitopathy: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2020; 49: 496-504.
52. Naik M, Nair A, Gupta A et al. Minimally invasive surgery for thyroid eye disease. Indian J Ophthalmol. 2015; 63: 847.
53. Eckstein A, Schittkowski M, Esser J. Surgical treatment of Graves’ ophthalmopathy. Best Pract Res Clin Endocrinol Metab. 2012; 26: 339-58.
54. Al-Sharif E, Alsuhaibani AH. Fat-removal orbital decompression for thyroid associated orbitopathy: The right procedure for the right patient. Saudi J Ophthalmol. 2017; 31: 156-61.
55. Jefferis JM, Jones RK, Currie ZI et al. Orbital decompression for thyroid eye disease: methods, outcomes, and complications. Eye. 2018; 32: 626-36.
56. Sellari-Franceschini S, Lenzi R, Santoro A et al. Lateral wall orbital decompression in Graves’ orbitopathy. Int J Oral Maxillofac Surg. 2010; 39: 16-20.
57. Kitaguchi Y, Takahashi Y, Kakizaki H. Computed Tomography-Based Prediction of Exophthalmos Reduction After Deep Lateral Orbital Wall Decompression for Graves’ Orbitopathy. Graefes Arch Clin Exp Ophthalmol. 2019; 257: 2759-67.
58. Parrilla C, Mele DA, Gelli S et al. Multidisciplinary approach to orbital decompression. A review. Acta Otorhinolaryngol Ital. 2021; 41: S90-101.
59. Spalthoff S, Jehn P, Zimmerer R et al. Modified lateral orbital wall decompression in Graves’ orbitopathy using computer-assisted planning. Int J Oral Maxillofac Surg. 2018; 47: 167-74.
60. Tavassol F, Kokemüller H, Müller-Tavassol C et al. A Quantitative Approach to Orbital Decompression in Graves’ Disease Using Computer- Assisted Surgery: A Compilation of Different Techniques and Introduction of the “Temporal Cage.” J Oral Maxillofac Surg. 2012; 70: 1152-60.
61. Sagiv O, Satchi K, Kinori M et al. Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease. Graefes Arch Clin Exp Ophthalmol. 2016; 254: 791-6.
62. Hernández-García E, San-Román JJ, González R et al. Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves’ orbitopathy. Acta Otolaryngol. 2017; 137: 1183-7.
63. Ong AA, DeVictor S, Vincent AG et al. Bony Orbital Surgery for Graves’ Ophthalmopathy. Facial Plast Surg. 2021; 37: 692-7.
64. Clarós P, Waląg A, López-Fortuny M et al. Impact of the ethmoid volume on endoscopic medial wall decompression outcomes in Graves’ orbitopathy. Acta Otolaryngol. 2020; 140: 948-53.
65. Thakar A, Tandon N, Lal P. Endoscopic orbital decompression for Graves’ orbitopathy. Indian J Endocr Metab. 2013; 17: 265.
66. Fabian ID, Rosen N, Ben Simon GJ. Strabismus After Inferior-Medial Wall Orbital Decompression in Thyroid-Related Orbitopathy. Curr Eye Res. 2013; 38: 204-9.
67. Cubuk MO, Konuk O, Unal M. Orbital decompression surgery for the treatment of Graves’ ophthalmopathy: comparison of different techniques and long-term results. Int J Ophthalmol. 2018; 11: 1363-70.
68. Korkmaz S, Konuk O. Surgical Treatment of Dysthyroid Optic Neuropathy: Long-Term Visual Outcomes with Comparison of 2-Wall versus 3-Wall Orbital Decompression. Curr Eye Res. 2016; 41: 159-64.
69. Cheng S-N, Yu Y-Q, You Y-Y et al. Comparison of 2-wall versus 3-wall orbital decompression against dysthyroid optic neuropathy in visual function: A retrospective study in a Chinese population. Medicine. 2021; 100: e24513.
70. Jellema HM, Saeed P, Mombaerts I et al. Objective and subjective outcomes of strabismus surgery in Graves’ orbitopathy: a prospective multicentre study. Acta Ophthalmol. 2017; 95: 386-91.
71. Quaranta-Leoni FM, Di Marino M, Leonardi A et al. Single-stage Orbital Decompression, Strabismus and Eyelid Surgery in Moderate to Severe Thyroid Associated Orbitopathy. Orbit. 2021: 1-9.
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