Postoperative Care of the Endoscopic Orbital Decompression Patient

Postoperative treatment of patients undergoing endoscopic orbital decompression (EOD) shares many similarities with that of patients who have standard functional endoscopic sinus surgery. Important distinctions that must be accounted for relate to the herniation of orbital contents into the nose and specific potential complications. Potential orbital complications include corneal abrasion, epiphora, new or worsening diplopia, worsening vision, and vision loss. Potential sinus complications include postoperative hemorrhage, obstructive sinusitis, nasal obstruction, anosmia, infraorbital nerve hypoesthesia, and cerebrospinal fluid (CSF) leak. An understanding of these possible sequelae is essential to treating these patients postoperatively.

Perioperative considerations, postoperative management, and the rate of complications are influenced by the indication for EOD. The majority of decompressions are performed for the sequelae of Graves ophthalmopathy, including proptosis with aesthetic concerns, exposure keratitis, strabismus/diplopia, and compressive optic neuritis (CON). Other indications include orbital cellulitis/abscess, retrobulbar hematoma/hemorrhage, and traumatic optic neuropathy. These patients are best managed through a multidisciplinary approach consisting of otolaryngology, ophthalmology, and endocrinology specialists. The goals of surgery, expected outcomes, and risks for short- and long-term complications are determined based on the extent of disease and the indication for the procedure.

Perioperative

Preoperative

A baseline preoperative assessment of corrected visual acuity, pupillary examination, ocular motility, intraocular pressure, fundus examination, and Hertel exopthalmometry is required to compare postoperative vision status and orbital outcomes. A comprehensive assessment of sinonasal history, examination, and imaging is essential. The presence or history of sinonasal disease is associated with an increased likelihood of developing postoperative obstructive sinusitis.

The preoperative period represents an opportunity to counsel patients regarding their specific surgical indication and to guide patient expectations for the postoperative course. The goal of EOD for proptosis is to improve cosmesis without causing diplopia, requiring a more balanced and less aggressive approach. Patients with preoperative diplopia/strabismus should be counseled that this may worsen, remain the same, or improve postoperatively. The chance of requiring future strabismus surgery is higher in this population.

Patients undergoing EOD for exposure keratitis require a greater degree of orbital regression, elevating their risk for postoperative diplopia. Continued conservative management of their exposure keratitis is required in the initial postoperative period until orbital swelling resolves. A temporary tarsorrhaphy may be required in these cases.

EOD for CON focuses on decompressing the posterior lamina papyracea and orbital apex. These patients have less orbital regression and are less likely to develop postoperative diplopia. The risks of worsening vision, vision loss, and CSF leak are higher in these patients, particularly if optic nerve decompression is performed. CON patients require a multidisciplinary team to provide comprehensive medical management, including the optimization of postoperative steroid and thyroid disease management.

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