Although statistically significant, the effect of orbital decompression on Graves’-associated upper eyelid retraction does not appear have clinical implications.

Although statistically significant, the effect of orbital decompression on Graves’-associated upper eyelid retraction (GAUER) does not appear to be clinically significant, coauthors Ahsen Hussain, MD, FRCOphth, and fourth-year medical student Mohammad Al-Qadi report in Orbit.

GAUER, the most common manifestation of orbitopathy in adults, is typically managed with a 3-step surgical approach that begins with orbital decompression, the authors write.

“As clinicians, we hold many assumptions, mainly through training or indoctrination over time,” Dr. Hussain says. “One such assumption is the need to stage surgical procedures in patients with thyroid eye disease.”

Evidence Backs Up Clinicians’ Experience

“We have assumed that orbital decompression may influence upper eyelid retraction and affect how we perform retraction repair,” he adds. “Clinical experience, however, tells us that orbital decompression rarely affects upper eyelid retraction sufficiently to prevent surgical correction becoming necessary. This study provides evidence for the clinical experience that many of us have with our patients.”

Dr. Hussain and Mr. Al-Qadi performed a systematic review and meta-analysis that included 20 years of studies in appearing in PubMed that assessed the effects of orbital decompression on GAUER in adult patients with Graves’ orbitopathy. The 10 studies that met the researcher’ inclusion criteria comprised 688 orbits in a diverse global population of patients. The average decrease in marginal reflex distance 1 (MRD-1: distance between the corneal light reflex and the upper lid margin) in these studies was 0.40 mm.

Six of the studies involved 472 orbits and provided sufficient information to enable a random-effect meta-analysis that found the average postoperative change in MRD-1 to be 0.35 mm (P=0.007; 95% CI, 0.08-0.63), “which although statistically significant, represents a meager change in clinical practice,” the authors write.

The study team also found a considerable range in pre- and post-orbital decompression MRD-1, with preoperative values between 3.7 mm and 7.2 mm and postoperative values between 3.5 mm and 5.3 mm.

Keeping the distinction between statistical and clinical significance in mind is important when caring for patients, the authors note.

“We have seen this to be the case in the clinical care of our thyroid eye disease patients,” Dr. Hussain says. “It was important to do this study to provide evidence that orbital decompression does not result in a clinically significant change in upper eyelid position (retraction) in Graves orbitopathy.”

These findings can help surgeons counsel patients and manage their expectations of orbital and eyelid surgical procedures, the authors write. The findings also support the potentially more efficient option of combining decompression with strabismus surgery, eyelid surgery, or both in a single procedure instead of using the traditional 3-step protocol.

Unanswered Questions and Further Research

“Further prospective cohort studies are needed to better understand the effects of orbital decompression on upper eyelid retraction depending on the surgical approach, as well as to evaluate the viability of single-step approaches,” the authors suggest.

Dr. Hussain would also like to learn more about the influence of orbital decompression on lower eyelid retraction and whether combining decompression, strabismus, and eyelid procedures in one sitting may lead to better patient outcomes.

Key Takeaways:

• Graves’-associated upper eyelid retraction (GAUER) is the most common manifestation of orbitopathy in adults.
• While orbital decompression may have a statistically significant effect on GAUER, the clinical significance of this impact is limited.
• Future research is needed to understand the effect of orbital decompression on upper eyelid retraction based on surgical approach.