Abstract

Thyroid eye disease is an orbital inflammatory manifestation of autoimmune thyroid disease that results in orbital congestion and can lead to significant cosmetic disfigurement, diplopia, and vision loss. Typically, there is an active, inflammatory phase that transitions into a quiescent, fibrotic state. Management of this condition consists of regulation of the underlying thyroid disease, modulation of risk factors, supportive care for symptoms, and both medical and surgical treatment of ocular sequelae. Orbital decompression is generally indicated in 2 main subsets of cases: in active disease that includes ulcerative keratitis from severe corneal exposure or compressive optic neuropathy that does not resolve with high-dose corticosteroids, and in quiescent cases with persistent congestive or exposure symptoms and/or cosmetic deformity. Decompression may involve the medial wall, the lateral wall, the orbital floor, or any combination thereof, and this decision is dependent on surgeon preference and the overall goal of decompression. The medial wall is commonly selected due to the ease of approach, the potential for orbital volume expansion, and the opportunity for direct decompression of the optic nerve in cases of compressive optic neuropathy. Various surgical approaches to the medial wall have been proposed. The transcaruncular approach offers immediate access to the orbit with direct exposure, excellent visualization of the medial wall and the medial portion of the orbital floor, and the absence of cutaneous scars.