The recent publication by Richter et al. in this Journal1 updates the experience of their group with the Olivari technique of decompression in Graves ophthalmopathy. While a superficial reading of their article seems to indicate that this publication is a continuation of all their previous works, a closer perusal reveals some important questions that the authors should answer.
The authors base their indications for fat orbital decompression on the modified Werner classification. Of their cases, 94 percent were based primarily on grade III (protrusion), with some (20 percent) also having grade IV and V involvement. If reduction of fat protrusion ameliorates extraocular muscle or corneal factors, it is by virtue of the fat realignment. Were the problem purely an extraocular muscle or a corneal problem, other types of surgery (e.g., extraocular muscle recessions and tarsorrhaphy) would be in order.
The surgical procedure is an upper and lower lid blepharoplasty with excision of extraconal and intraconal fat. This is a significant change from the previous surgical descriptions of their technique,2 where no intraconal excision of fat is described. In one of their publications they state,3 “The intraconal fat is luxated,” indicating change of position, not excision. It is even described in their textbook contribution2 as an “en bloc” dissection in each quadrant. Is this an extraconal and intraconal bloc? In another article,4 they describe fat removal from the “retrobulbar fat including that of the apical area.” As mentioned below, invasive apical orbital surgery is fraught with high morbidity and possible vision loss such that orbitologists have proscribed apical surgery.
I have followed Olivari’s work for many years. In my experience of orbital decompression surgery (85 to 100 cases), I have performed the Olivari technique (in about 20 cases) and found that when intraconal fat is excised, there is a 40 to 50 percent morbidity rate, with the main problem being postoperative motility and pupillary defects. Some of these untoward effects have been permanent. I found that the upper limit for excising intraconal fat is a minimal amount (0.25 cc) in any quadrant (for a total of 1 cc) before postoperative morbidity is noted. I am aware of optic neuropathy and anterior segment ischemic syndromes with excision of significant (>2 cc) intraconal fat. Presumably this is due to the fine arborization of blood vessels and nerve fibers within the intraconal fat. So it behooves the authors to inform us of how much intraconal fat they excised and how this change affected their results.
In distinction to intraconal fat, I have never had any such problems with the Olivari technique when only extraconal fat was excised. The problem with taking only extraconal fat is that the amounts excised rarely exceed more than 4 cc, especially if the deep retrobulbar area fat is not excised. This goes along with a generally accepted dictum that surgeons should avoid the orbital apex, especially the deeper 15-mm area. But such anterior excisions have been inadequate.
Also, if 6 cc of extraconal fat is taken periocularly, there would be inadequate cushioning for the globe, as the authors state in their surgical procedure section. Presumably this would require the prolapsing of intraconal fat to form some of the cushion effect in addition to excision of this fat. Does this result in morbidity postoperatively?
Further, another subgroup would be those patients with grade III and VI involvement (sight loss). How many of those patients had adequate resection with extraconal as opposed to extraconal and intraconal excision? Of my own patients, at least 50 percent are in this grade category. I have many patients with relatively pure grade VI-type changes with only visual field loss and very little protrusion. What is their procedure for these patients?
Another issue they need to clarify is their separation of diplopia from strabismus cases and results. What is the meaning of having a class of diplopia cases and a class of strabismus cases? On what basis do they distinguish diplopia from strabismus? Are these individuals who have subjective complaints of diplopia with no objective motility disorder? Are the authors then stating that these cases can be alleviated by fat decompression alone?
Joshua Frankel, M.D.
Department of Ophthalmology
University of South Carolina School of Medicine
4 Medical Park Road
Columbia, S.C. 29203
1. Richter, D. F., Stoff, A., and Olivari, N. Transpalpebral decompression of endocrine ophthalmopathy by intraorbital fat removal (Olivari technique): Experience and progression after more than 3000 operations over 20 years. Plast. Reconstr. Surg.
120: 109, 2007.
2. Stark, B., and Olivari, N. Orbital decompression by removal of fat. In J. C. van der Meulen and J. S. Gruss (Eds.), Color Atlas and Text of Ocular Plastic Surgery.
London, Baltimore: Mosby-Wolfe, 1996. Pp. 123–129.
3. Eder, E. F., Richter, D. F., and Olivari, N. The technique of the transpalpebral decompression. According to Olivari: Operative Techniques in Oculoplastic, Orbital and Reconstructive Surgery
2: 96, 1999.
4. Olivari, N. Thyroid-associated orbitopathy: Transpalpebral decompression by removal of intraorbital fat. Exp. Clin. Endocrinol. Diabetes
107(Suppl.): S208, 1999.
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