A chief morbidity of Graves eye disease is eyelid retraction and exophthalmus. Transpalpebral orbital fat removal
accomplished with full thickness anterior blepharotomy was performed in 4 patients (5 orbits). Preoperative and postoperative
ocular exposure symptoms, visual acuity, upper eyelid retraction and proptosis were evaluated. In all 5 operated
orbits preoperative symptoms resolved; good results were achieved from the functional and cosmetic point of view.
Full-thickness anterior blepharotomy combined with fat decompression is a safe and effective surgery for patients with
upper eyelid retraction and exophthalmus due to enlarged orbital fat compartment

Dean Šarić

Eugenia Tedeschi-Reiner

Katia Novak-Lauš

Renata Iveković

Sanja Masnec-Paškvalin

Zdravko Mandić

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Coll. Antropol. 29 (2005) Suppl. 1: 33–36UDC 617.77-089:616.441-008.61Original scientific paperFull-Thickeness Anterior Blepharotomy andTranspalpebral Fat Decompression in Graves’OrbitopathyRenata Ivekovi}, Katia Novak-Lau{, Eugenia Tedeschi-Reiner, Sanja Masnec-Pa{kvalin, Dean [ari}and Zdravko Mandi}University Department of Ophthalmology, Clinical Hospital »Systers of Mercy«, Zagreb, CroatiaA B S T R A C TA chief morbidity of Graves eye disease is eyelid retraction and exophthalmus. Transpalpebral orbital fat removalaccomplished with full thickness anterior blepharotomy was performed in 4 patients (5 orbits). Preoperative and post-operative ocular exposure symptoms, visual acuity, upper eyelid retraction and proptosis were evaluated. In all 5 oper-ated orbits preoperative symptoms resolved; good results were achieved from the functional and cosmetic point of view.Full-thickness anterior blepharotomy combined with fat decompression is a safe and effective surgery for patients withupper eyelid retraction and exophthalmus due to enlarged orbital fat compartment.Key words: Graves’ orbitopathy, blepharotomy, fat decompressionIntroductionGraves’ ophthalmopathy appears to be an organicspecific autoimmune disorder. A still unidentified pa-thogenic process induces swelling, lymphocytic infiltra-tion and later fibrosis and contractures that restrict thenormal function of extraocular muscles. Graves’ oph-thalmopathy also expands soft tissue within the bonyorbital volume. Typically orbital signs and symptomslike proptosis, chemosis, congestion of blood vessels,limitation of extraocular muscles motility as well aspain can be present. Treatment of Graves’ ophthal-mopathy can be either non-surgical or surgical. Uppereye-lid retraction is a common symptom. The Muellermuscle is involved in the inflammation and on thehistopathologic inspection, fibrosis, fatty infiltrationand increased mast cells presence can be find in it. Thesurgery is required but there is no agreement about thebest operative technique to correct retraction of uppereyelids. In our patients also proptosis due to expansionof orbital fat was present. Therefore we have combinedtwo techniques: full-thickness anterior blepharotomyand orbital fat decompression.Subjects and MethodsBetween January 2003 and January 2004 orbital fatdecompression combined with full-thickness anteriorblepharotomy was performed in 5 orbits of 4 patientswith Graves’ ophthalmopathy at the University Depart-ment of Ophthalmology »Sestre milosrdnice«. The surgi-cal treatment was recommended because of proptosis’increasing, upper eye lid retraction and presence of ex-posure keratitis. The patients have shown no responseon previous conservative treatment with corticosteroidsorally or in mega-dosis infusions. One patient had previ-ously experience with transconjuctival application ofbotulinum toxin injection in July 2003. All patientswere clinically and biochemically euthyroid and all signsand symptoms of Graves’ disease have been stable for atleast 6 months.Preoperative and postoperative examinations includ-ed Snellen visual acuity, examination of the eyelids andcornea, ocular motility, Hertel exophthalmometry, ap-planation tonometry, computed perimetry. The preoper-ative and postoperative position of the upper eyelid wasmeasured in millimetres from the pupil to the upper33Received for publication January 20, 2005U:\coll-antropolo\coll-antro-okultni\Ivekovic.vp02. svibanj 2005 14:47:12Plate: 1 of 4Color profile: DisabledBlack  150 lpi at 45 degreeseyelid margin with the eye in primary gaze and with co-ronal plane of the patient’s head perpendicular to thefloor.Eyelid retraction was measured in millimetres,inthe primary position without accommodation. The eye-lid retraction was considered when »scleral show« waspresent. Compressive optic neuropathy was not pres-ent in our patients.All patients were operated in endotracheal anaesthe-sia. After marking for symmetric upper eyelid crease in-cision, the subsequent dissection through orbicularisoculi muscle was made and levator aponeurosis exposed(Figure 1a). The levator aponeurosis, Müller muscle andconjunctiva were incised at the superior border of thetarsal plate. The dissection was extended from centralthird of eyelid medially and laterally along the superiortarsal border (Figure 1b). Limited bipolar cautery wasused for hemostasis. After opening the orbital septumwith Westcott scissors, prolapsing orbital fat was identi-fied (Figure 1c). Anterior orbital fat was removed usingblunt surgical dissection and unipolar electrocautery.Dissection extended deep into the orbit. Traction su-tures on the rectus muscles aided in the identification ofthe muscles during deep dissection.Attention was paidto avoid damage on the globe, nerves, muscles andtrochlea in superonasal dissection. Inferior orbital fatdissection was made through inferotemporal approachof the inferior eyelids. Slight pressure on the globehelped fat move into surgical field. Dissection in thesuperonasal space required greater attention and he-mostasis because of numerous dilated veins and theconfluence of muscles and nerves. The surgical fieldswere inspected for bleeding and irrigated with saline.The skin incision was closed with 6-0 nylon suturewhich was removed on fifth postoperative day. The pati-ents were admitted for 2 days of observation for postope-rative hemorrhage and ice packs were applied for 24hours.The outcome of surgery was evaluated 14 days, 1month and 3 months after the operation by measuringthe eyelid aperture and the lid-limbus distance in theprimary position. Corneal staining was performed dur-ing slit lamp examination.ResultsWe report our results after 5 operated orbits in 4 pa-tients (two female and two man) (Figures 2 and 3) In onepatient both orbits were operated (Figure 4). All operatedpatients suffered from proptosis and eyelid retractiondue to Graves’ orbitopathy. Preoperative superficialmild punctate keratitis was present in all patients. Af-ter operation there was no signs for keratitis. The uppereyelid height was improved by surgery in all operatedeyelids immediately after operation as well as after 3months. Proptosis reduction was achieved postopera-tively. In all patient more than 6 cm3 of fat was removedfrom operated orbits – only in one case 5 cm3 of fat wasremoved (case No2., Table 1)R. Ivekovi} et al.: Blepharotomy and orbital decompression, Coll. Antropol. 29 (2005) Suppl. 1: 33–3634Fig. 2. a) patient No.1 before operation – rightsided exophthalmos and upper eyelid retracted, b) five days after operation, c) 3months after operation.Fig. 3. a) patient No. 2 before operation – rightsided exophthalmos and upper eyelid retraction, b) 3 days after operation, c) 1 monthafter operation.Fig. 1. a) Upper eyelid crease incision and dissection through orbicularis oculi muscle, b) The dissection extend from central third ofupper eyelid medially and laterally, c) Prolapsing orbital fat.a) b) c)a) b) c)a) b) c)U:\coll-antropolo\coll-antro-okultni\Ivekovic.vp02. svibanj 2005 14:47:13Plate: 2 of 4Color profile: DisabledBlack  150 lpi at 45 degreesNo complications occurred during operations. No pa-tient developed wound infection or complained of post-operative ocular surface irritation.DisscusionA chief morbidity of Graves’ eye disease is upper eye-lid retraction that results in exposure keratopathy andcosmetic deformity and proptosis1. The aim of correctionis disappearance of keratopathy, complete relief of ocu-lar discomfort and complete restoration of pre-illnessappearance. In some cases exposure keratopathy canlead to corneal ulcer inert to conservative treatment. Insuch cases together with correction of eyelid amnioticmembrane has to be applied2.Eyelid retraction can not be treated successfully bymedications. Transitory effects can be achieved by ap-plication of botullinum toxin subconjunctival in the eye-lid, but permanent or longer lasting effect has only sur-gery. Henderson has 1965. modified the first surgicalmethods for the treatment of retracted eyelids in Gra-ves’ disease3. Olver revisited this method and find outunder-correction and lateral temporal flare to be com-mon4. Numerous modification of Handerson’s techniquehave been described. Most of these technique use eithertransconjunctival Müller muscle myotomy or excision ortranscutaneous levator aponeurotomy or myotomy withor without Müller muscle myotomy or excision with ad-ditional modifications4–7. Postoperative clinical risk is lowin comparison with the functional and cosmetic resultsof procedure but some complications have been reportedlike dry eye8. None of the reported surgical methods usea full-thickness technique presented by Koorneef inJune 1999 at the University of Michigan including theskin and conjunctiva9,10. The anterior blepharotomypermits better control of eyelid contour and height be-cause the eyelid is not deformed by inversion or stretch-ing during operation10.Our results in 5 operated eyelids support this thesis.In all patients we have achieved good results in func-tional and cosmetic point of view in all operated eyesscleral show was no more present immediately after op-eration as well as after 6 months. Our results confirmthesis from Elner et al. which explained Koorneef, thatdissection through eyelid essential part of the surgeryand that leaving conjunctiva unsutured doesn’t lead toits shortening and recurrence of eyelid retraction10.Graves’ orbitopathy expands also soft tissue withinthe fixed bony orbital volume. Fat decompression re-duces exophthalmos, eliminate orbital pain and reducecongestion11,12. Nowadays some authors have shownthat this technique can be successfully used for treatingoptic neuropathy as a result of Graves’ orbitopathy13.They report that removal of 4–6 ml of anterior andmid-orbital fat was sufficient to relieve optic neuropa-thy even in the cases in which orbital muscles were en-larged.All patients involved in this study have suffered fromexophthalmos and retraction of upper eyelid. Thereforewe decided to combine two techniques mentioned above.Full thickness blepharotomy was performed in last fewyears in our department for reduction of »scleral show«in patients with Graves’ disease. Orbital decompressionis known to reduce exophthalmos: bony or transpal-pebral fat decompression. Endonasal endoscopic orbitaldecompression is nowadays standard bony decompres-sion14. Transpalpebral decompression as Olivari des-cribed is one of standard method to reduce exophthalmosat our department. Olivari reported about simultane-R. Ivekovi} et al.: Blepharotomy and orbital decompression, Coll. Antropol. 29 (2005) Suppl. 1: 33–3635TABLE 1SYMPTOMS OF GRAVES’ DISEASE AND EFFECT OF BLEPHAROTOMY COMBINED WITH ORBITAL FAT DECOMPRESSIONEye Gender ageEyelid HeightExposurekeratitisVisual acuityIntraocularpressureDiplopiaHertel exoph-thalmometryPreop. Postop. Preop. Postop. Preop. Postop. Preop. Postop. Preop. Postop. Preop. Postop.1. Right Male 46 7 3 no no 1.0 1.0 16 14 no no 22 192. Right Female 78 8 4 mild no 0.8 0.7 19 19 no no 20 183. Left Male 52 10 3 mild no 1.0 1.0 15 18 no no 25 224. Right Female 44 8 3 mild no 1.0 1.0 21 17 no no 23 19Left Female 44 9 4 no no 1.0 1.0 19 18 no no 24 19preop. – preopetrative, postop. – postoperativeFig. 4. patient No.4 – exophthalmos and eyelid retraction on bothside and c) 5 days after operation on both eyes.a)b)c)U:\coll-antropolo\coll-antro-okultni\Ivekovic.vp02. svibanj 2005 14:47:14Plate: 3 of 4Color profile: DisabledBlack  150 lpi at 45 degreesously performed fat decompression and levator apo-neurosis and Müller muscle lengthened15. We have com-bined transpalpebral fat decompression with »open sky«blepharotomy and achieved good results even 6 monthsafter operations were done. Visual acuity was stabile,intraocular pressure after operation was lower andthere was no new-onset diplopia. The advantage of thisprocedure are avoiding bone removal, one anaesthesia,less stress for patient and better cosmetic and func-tional results than in cases where either decompressionor blepharotomy was done.ConclusionIn conclusion, we believe that two described tech-niques can bring benefits to patients. Benefits includednot only reductions of proptosis but also improved eyelidposition at the same time. The cases are presented to il-lustrate an alternative successful surgical treatment inselected cases of Graves’ orbitopathy. Limitations of thisstudy are small number of cases and the nonmaskedmeasurements.R E F E R E N C E S1. BARTLEY, G. B., Trans. Am. Ophthalmol. Soc., 92 (1994) 477. —2. PETRIC,I., R. IVEKOVI], E. TEDESCHI-REINER, K. NOVAK-LAU[,V. LACMANOVI]-LON^AR, M. BRADI]-HAMMOUD, Coll. Antropol.,26 (2002) 621. — 3. HENDERSON, J. W., Tr. Am. Ophthalmol. Soc., 63(1965) 70. — 4. OLVER, J. M., P. FELLS, Eye, 9 (1995) 467. — 5. MOU-RITS, M. PH., I. V. SASIM, Br. J. Ophthalmol., 83 (1999) 81. — 6. LIN-DEMAN, V., W. LIEB, G. KAHALY, F. GREHN, Ophthalmologe, 92 (1995)359. — 7. CEISLER, E. J., J. R. BILYK, P. A. D. RUBIN, Ophthalmology,102 (1995) 483. — 8. GEORGE, J. L., M. E. TERCERO, K. ANGIOI--DUPREZ, T. MAALOUF, Orbit, 21 (2002) 19. — 9. CLAUSER, L., M.GALIE, E. SARTI, Plast. Reconstr. Surg., 108 (2001) 1880. — 10. EL-NER, V. M., A. S. HASSAN, B. R. FRUEH, Arch. Ophthalmol., 122 (2004)55. — 11. OLIVARI, N., Plast. Reconstr. Surg., 87 (1991) 627. — 12. TRO-KEL, S., M. KAZIM, S. MOORE, Ophthalmology, 100 (1993) 674. — 13.KAZIM, M., L. TROKEL, G. ACAROGLU, A. ELLIOT, Br. J. Ophthal-mol., 84 (2000) 600. — 14. STIGLMAYER, N., R. MLADINA, M. TOMI],M. TOJAGI], J. JURI, N. BUBA[, V. MRAZOVAC, CMJ, 45 (2004) 318.— 15. OLIVARI, N., Exp. Clin. Endocrinol. Diabetes., 5 Suppl. (1999) S208.R. Ivekovi}University Department of Ophthalmology, Clinical Hospital »Systers of Mercy«, Vinogradska 29, 10000 Zagrebe-mail: renata.ivekovic@zg.htnet.hrBLEFAROTOMIJA U PUNOJ DEBLJINI VJE\E I TRANSPALPEBRALNA MASNOTKIVNADEKOMPRESIJA KOD GRAVESOVE BOLESTIS A @ E T A KGlavni znakovi Gravesove bolesti na o~ima su retrakcija vje|a i egzoftalmus. Kod 4 bolesnika (5 orbita) odstra-njeno je masno tkivo kroz vje|u i blefarotomija u punoj debljini vje|e. Prije i nakon operacije pra}eni su znakoviizlo`enosti o~ne jabu~ice, vidna o{trina, retrakcija gornje vje|e i proptoza. Kod svih 5 operiranih orbita preoperativnisimptomi su nestali; postignuti su dobri funkcionalni i kozmetski rezultati. Blefarotomija pune debljine vje|e kom-binirana s masnotkivnom dekompresijom orbite sigurna je i u~inkovita operacija za bolesnike s retrakcijom gornjevje|e i egzoftalmusom uslijed pove}anja orbitalnog masnog tkiva.R. Ivekovi} et al.: Blepharotomy and orbital decompression, Coll. Antropol. 29 (2005) Suppl. 1: 33–3636U:\coll-antropolo\coll-antro-okultni\Ivekovic.vp02. svibanj 2005 14:47:14Plate: 4 of 4Color profile: DisabledBlack  150 lpi at 45 degrees

Full-Thickeness Anterior Blepharotomy and Transpalpebral Fat Decompression in Graves’ Orbitopathy

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