Austin McCormick

                                                  Consultant Ophthalmic and Oculoplastic Surgeon MBChB, FRCOphth

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Tel: 01517098442                             Fax: 01517097509                                Email:                               Address:  86 Rodney Street  L1 9AR UK

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Orbital Decompression

Click here to see before and after photographs                                                                 Orbital-decompression-photo.html

What is orbital decompression?

  1. The orbit is the bony eye socket that contains the eyeball, eye muscles and lacrimal gland. There are also nerves, arteries, veins and orbital fat.

  2. People who have thyroid eye disease may experience a problem called proptosis. This is when the eyeball protrudes forwards out of the eye socket.

  3. Orbital decompression is an operation to remove fat from around the eye and to increase the space inside the orbit to allow the eyeball to move back into place.

  4. The space is increased by drilling away bone from the walls of the orbit and creating windows in the bony walls, into the air filled nasal sinuses so that orbital tissues may fill this extra space.

  5. It is usually carried out routinely to improve symptoms of pressure behind the eye, exposure of the surface of the eye and the unsightly staring appearance.

  6. It is rarely carried out as an emergency to save eyesight if the inflammatory phase of thyroid eye disease has not responded to steroid treatment and the nerve of vision is threatened.

What symptoms and signs may improve with orbital decompression surgery?

  1. Symptoms of pressure behind the eye, discomfort on eye movement and dry eye should improve with this operation.

  2. The protrusion (proptosis) of the eye should improve as it moves back into the eye socket. Initially this may not be noticeable due to swelling in the orbit caused by the operation itself. After 3 months there should be a noticeable improvement but the eye can continue to move back for up to a year after surgery.

  3. When the eye moves back the eyelids may move back into position and reduce the amount of white of the eye that is visible. This is not always completely resolved and some people require eyelid retraction surgery at a later date.

  4. Double vision is not usually improved with this operation but in some cases it may be. The operation itself carries a small risk of creating or worsening double vision. For this reason it is good practice to carry out orbital decompression surgery before any double vision surgery.

  5. The eyeball will be less exposed. In other words the ability of the eyelids to move over the eye, close and distribute tears should improve. This improves the symptoms of dry eye: burning, grittiness, dryness, photophobia.

What are the risks and possible complications of surgery?

  1. All surgery caries a risk of bleeding and infection, both are fortunately uncommon in this operation.

  2. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics.

  3. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding.

  4. A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department where Mr. McCormick or an On Call Ophthalmologist will attend to you.

  5. Any orbital surgery carries a very small risk of permanent loss of vision. This could be due to damage to the nerve of vision during the procedure or bleeding after the operation.

  6. Any orbital surgery carries with it a risk of double vision. In most cases, if this occurs, it is temporary but rarely it is permanent. Permanent double vision may be corrected with surgery or prisms in spectacles.

  7. Sensory loss (numbness) may be a temporary problem after surgery affecting the cheek, side of nose, upper lip and upper teeth. This is due to swelling of a nerve that travels in the bone of the floor of the orbit close to where bone is removed. In rare cases the nerve is permanently damaged and if so the numbness will not improve.

  8. Whenever the skin is incised a scar may form. Every attempt is made by Mr. McCormick to minimise and hide scars but sometimes they can be visible. 

  9. You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.

What will happen before surgery?

  1. Before the operation you will be seen in the clinic by Mr. McCormick.

  2. He will ask you about the orbital problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you).

  3. He will examine your eyes.

  4. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia.

  5. You will be asked to read and sign a consent form after having the opportunity to ask any questions.

  6. You will need to have a CT scan of the orbits. This will be booked by Mr. McCormick if it has not already been carried out as part of your trauma assessment.

  7. You will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise when you need to starve before the operation. 

What should I do about my medication?

  1. Mr. McCormick will want to know all the medication that you take and about any allergies you have.

  2. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery.

  3. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual.

  4. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.

What should I expect after surgery?

  1. Usually a pad will be placed on the eye, which will remain until the following day when you can remove it.

  2. In some cases your eye will be examined at regular intervals after surgery to make sure there are no signs of post-operative bleeding.

  3. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls.

  4. After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks.

  5. It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve.

  6. Usually the skin sutures used are dissolvable and will be left to fall out by themselves.

  7. The time when you can return to normal activities varies from person to person. For some it is 1 week, others 2 weeks.

Postoperative Instructions

  1. If an eye pad is placed it should remain until the next morning when you may remove it

  2. For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls.

  3. Chloramphenicol ointment to the eye and wound, three times a day for 2 weeks

  4. Lacrilube ointment four times a day for 4 weeks, applied to the lower eyelid to aid upward massage of the lower eyelid. This is to counter lower lid retraction and should begin at day 7.

  5. Oral antibiotic for 5 days

  6. Oral steroid (prednisolone) 60mg 2 days, 40mg 2 days, 20mg 2 days, 10mg 2 days then stop.

  7. No nose blowing for 6 weeks

  8. No hot drinks for 48 hours

  9. Sleep propped up at 45 degrees for 48 hours

  10. Follow up appointment 1 week later.

The left medial orbital wall is marked with the arrow. The bone in the medial wall is very thin. The area of bone removal is shaded red.

The right lateral orbital wall is marked with the arrow. The bone for removal is shaded in red.