Graves eye disease, while well known, does not have one standard way that it presents itself. It is a complex eye disorder that presents with differing anatomic involvement of the periorbital tissues that varies based on the stage of the disease. But the classic findings include proptosis/exophthalmos (bulging eyes), upper eyelid retraction and restriction of eye movement. These occur because of infiltrating fibrosis and edema of all tissues surrounding the eye.
Besides the visual problems that may occur from Graves eye disease, there is also a significant associated aesthetic disfigurement as well. The bulging eye look creates a classic but unusual appearance that is socially distracting and psychologically burdensome. Fortunately once the thyroid function is under control (for at least six months), improvement in these symptoms is possible with surgery that typically includes orbital decompression and intraorbital fat reduction.
In the September 2014 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Aesthetic Refinements in the Treatment of Graves Ophthalmology’. This paper presents the addition of bone augmentation as an adjunctive technique in improving the aesthetic appearance of the eye area of the Graves patient. Through a lower eyelid approach, orbital decompression is initially performed through medial and lateral orbital wall decompression and the removal of excessive infraorbital fat.
A Medpor infraorbital rim implant was then also placed combined with a midface lift. The intent is to improve the eyeball-cheek relationship through the combination of the eye setting back into the orbit (decompression) and the infra-orbital rim/cheek implant bringing the position of the bone outward. (augmentation) Over a three year period, a total of 13 patients (26 eyes) were treated. Besides the aesthetic improvement obtained, diplopia improved in 3 patients (23%) and almost all patients (92%) discontinued the use of eye lubricants.
The addition of lower orbital bone augmentation is a logical treatment extension for the Graves eye disease problem. While Graves disease does not cause loss of bone or a weakening of the lower eye socket, it is a compensatory maneuver to help camouflage the residual eye bulging that orbital decompression alone can not completely solve. It adds little risk to the overall orbital decompression procedure. It is usually necessary to add cheek tissue suspension (midface lift) over and on top of the implant to lower the risk of lower eyelid sagging (ectropion) afterwards.
Dr. Barry Eppley
Indianapolis, Indiana